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A - Z of Childhood Illnesses

A

On this page: Abdominal Pain A. Psychological Causes B. Medical Causes Worms Ascariasis lumbricoides (commonly called roundworm) Threadworms Hookworms Triburis tricbiura (whipworms) Tapeworms Bacillary dysentery Giardiasis and amoebiasis Food poisoning Sore throat Tuberculosis of the abdomen C. Surgical Causes Appendicitis Intestinal obstruction Intussusception Inguinal hernia Abrasions or Scratches Acute Glomerulonephritis Addictions Parents' role Misconceptions about addictive drugs How to suspect addiction Adenoids

Abdominal Pain

If your child has pain in the abdomen, but he looks otherwise well, you can be almost sure that the problem is not serious. If the look of him causes anxiety, you better see your doctor. Below are given some of the important causes of abdominal pain in children. Common Causes A. Psychological B. Medical Causes Worms Ascariasis lumbricoides (commonly called roundworm) Threadworms Hookworms Triburis tricbiura (whipworms) Tapeworms Bacillary dysentery Giardiasis and amoebiasis Food poisoning Sore throat Tuberculosis of the abdomen C. Surgical Conditions Appendicitis Intestinal obstruction Intussusception Inguinal hernia A. Psychological Schoolgoing children often complain of recurrent pain in the abdomen. The pain is usually located around the navel. In most cases it is not severe and the child does not complain about it if he is involved in doing something interesting. It rarely wakes him up from his sleep. He is perfectly all right in between the attacks which may last for a few moments or longer but rarely for more than half an hour. There may be a family history of similar pain in other children or in the parent(s). Usually these children are quite intelligent. A sudden change in the child's behaviour may point towards this diagnosis. It may be worthwhile to sit quietly and consider if there is any reason for the child to becoming emotionally upset. Is he being bullied in the school bus by another student? Is he afraid of his new teacher? Are the examinations causing much anxiety? Is he upset because of a quarrel between his parents? It is not always easy to probe the mind of a child and if the symptoms persist, a doctor's advice must be taken, who may even refer him to a family counsellor, psychologist or a psychiatrist. In the management of these children, it is important to remember that they should not be made to feel ashamed by parents remarking, 'You are just acting' or 'Do not try to fool us'. I believe that such children do get pain but the symptom is probably due to some, not yet fully understood mechanism or is related more to the mind, rather than body - possibly a subconscious way of attracting the parent's attention for more body contact. It is like an adult who goes to an interview for the first time. Such a person may feel like going to the toilet frequently before the interview. The bladder of such a person is normal but the urge for going to the toilet, though related to the mind, is genuine. Hence the treatment lies in understanding the child, helping him with his underlying emotional problem- if any, rather than being, harsh towards him. B. Medical Causes

Worms

We shall deal here with common worms : Ascariasis lumbricoides (commonly called roundworm), threadworms, hookworms, triburis tricbiura (whipworms) and tapeworms. The mature eggs of these worms entering the system or the penetration of the larvae of the worm into the child's skin causes the infection. Many people have a wrong notion that intake of excess sugar or sweets causes worms. Although I am against taking an excess of sugary things, worms result from causes other than ingestion of sweets. Ascariasis - Roundworm Ascariasis (infection with Ascaris lumbricoides) is quite common. The infected person passes eggs of worms in the stools. They mature in about a week's time and become infective. When swallowed, the eggs release larvae which penetrate the intestines, reach the lung, travel up the windpipe and are swallowed back into the intestines to mature into adult worms. They measure from 15-35 cms in length and are 3-4 mms in diameter. They are either passes out as worms or their eggs are excreted. If a person defecates in the open, the soil gets contaminated with the eggs. The fingers of the child can get contaminated by contact with the infected soil and infection may travel from the hand to the mouth. Alternatively, food can become infected by the excreta or by flies. Most children having ascaris do not have any complaints. Sometimes, it may cause pain in the abdomen, distention of the abdomen and even intestinal obstruction resulting in absence of stools and persistent vomiting. Although these worms may contribute towards causing malnutrition in a child, a child with significant malnutrition should also be investigated for other possible causes. Grinding the teeth while sleeping is not due to worms. Hand-washing before touching food should become a ritual with all families even if they use a spoon, knife and fork for eating. Treatment : The commonly used drug for the treatment of ascariasis is mebendazole in the dose of 100 mg twice daily (for all age-groups) for 3 days. As reinfection is possible, you may be tempted to give a course of this drug every 3 months or so. But it is better to take care of personal hygiene rather than use the drug so often. At the most, you may consider giving the drug once a year, around your child's birthday. A single dose of albendazole can also be given in place of mebendazole. Threadworms Threadworms are quite common. Rarely may they result in pain in the abdomen, when they block the appendix. Otherwise, they are more of a nuisance and do not cause any serious problem. Parents complain that the child has disturbed sleep due to itching around the anus. This happens because the threadlike, female worms measuring about 1 cm come out of the intestine at night and lay eggs on the skin around the anus. This results in scratching. The eggs are carried by the child or an adult under the fingernails or they may spread in the home through their clothing or bedding. The patient may ingest these eggs from his/her own fingernails or may infect others by contamination of food while serving/cooking. These eggs when swallowed become adult worms. Hence, it is important to treat all the members of the family, including helping-hands, with a single dose of 100 mg of mebendazole. In certain cases the treatment may have to be repeated every 3 months. Hookworms Hookworms attach themselves to the upper, small intestine and suck blood resulting in anaemia. If the worm load is heavy, it may also cause pain in the abdomen. The patient gets infected by walking barefoot on warm, damp infected soil. Larvae emerge from the eggs lying on the soil. They penetrate the skin and become adult worms inside the body. The diagnosis is made by stool examination. Anaemia is treated with iron and the patient is given mebendazole as in ascariasis. Prevention is achieved by using footwear and proper sanitation. Whipworms Whipworms (Triburis Tricbiura) infection rarely causes pain in the abdomen but it is an important, though not a common cause of prolapse of the rectum in children. Infection takes place by ingestion of eggs passed in the stool. It spreads with unclean hands and flies, which in turn contaminate water and food. The treatment is the same as for ascariasis. Tapeworms Tapeworms are several meters long. They inhabit the intestines. They have several segments which are passed into the stool as small, flat, white pieces (like seeds of a gourd or marrow, kadu and gbia) about 1 cm long. The infection stems from eating infected pork or beef which is not cooked properly. Vegetables contaminated with eggs of tapeworms may also be responsible for causing infection. Tapeworms may not cause much problem except for mild pain in the abdomen. But if the eggs from the segments are ingested by the child or the adult from his faeces by improper washing of his hands, they may form cysts in his brain. This condition is called cysticercosis which can lead to headaches, fits or even death. So those who eat meat must make sure that it is well-cooked. Of course, personal hygiene remains equally important. The drugs found useful are niclosamide for removal of adult worms and praziquantel and albendazole for the cysts affecting the brain.

Bacillary dysentery

Frequent motions (not necessarily loose) with passage of blood or mucus accompanied with gripping pain, noticed more at the time of passing a motion is mostly due to bacillary dysentery. The responsible organism is a bacteria needing drugs to control the infection. At times the child doesn't pass any faecal matter, but passes only blood and/or mucus. Unlike acute watery diarrhoea, vomiting and significant dehydration is not a common feature in dysentery. But some children can have frequent watery motions at the onset. It may also be accompanied with vomiting. Such children can become severely dehydrated and need replacement of water and salts as for acute diarrhoea. The disease is seen more during the monsoons in toddlers. But children who are also breastfed in the year of life are less prone to get the disease and even if they fall sick due to dysentery, the severity of the disease is less and they recover faster. The child can get the infection from a close contact or by taking contaminated water or food. That is why it is recommended that breastfeeding should be continued even in the second year and drinking water should be boiled. Uncovered food on the roadside should be avoided. Sugar-cane juice extracted in unhygienic surroundings can be dangerous. Adults as well as children should make a habit of washing hands before touching food or after passing motions. In serious cases high fever and convulsions may occur. A history of more than one person in the family having the above-mentioned symptoms suggests the diagnosis and treatment may be initiated. If facilities exist, a routine stool examination can be undertaken. It would show the presence of mucus, red blood cells and leucocytes. Macrophages may also be present. Stool culture, though not necessary, is sometimes asked for identifying the bacteria and the range of drugs to which these bacteria are more likely to respond. Treatment This consists of adequate hydration (see section on acute watery diarrhoea), food and drugs. The child should not be starved. Foods which are better tolerated are rice preparations like khichdi, curds, banana, patatoes, apples, pomegranate juice and coconut water. The child should not be denied any other food item that he wants to consume. For instance, I am, in general, against cold drinks, tea, and maida preparations. But if a child used to such items asks for the same, it may be worthwhile letting him have them rather than submit him to prolonged starvation. Breastfed children should be given breastmilk more often. If the child is getting ordinary milk, the same may be stopped for a day, then given in half-strength concentration for another day, and be followed with undiluted milk. Prolonged dilution is not advisable. The drugs found helpful are cotrimoxazole and nalidixic acid. Those allergic to sulpha drugs should not be given cotrimoxazole. The total course of five days must be completed even if the patient improves within a day or two. Some doctors advise a combination of nalidixic acid with metronidazole (a drug useful for amoebic infection and infection with giardia). This approach is not recommended as our investigations have shown that most cases of bacillary dysentery in children are not accompanied with amoebiasis or giardiasis. Besides adding to the cost, metronidazole has its own possible side-effects and is not advised in such combinations. Some doctors advise anti-motility drugs to reduce the frequency of motions. Such drugs, containing loperamide and diphenoxylate, are banned in liquid preparations meant for use by children. Besides prolonging the illness, such drugs can also have serious side-effects.

Giardiasis and amoebiasis

Giardiasis and amoebiasis may be suspected in children with persistent or recurrent pain in the abdomen. A stool examination of a fresh sample is asked for which confirms the diagnosis. The child is given a course of metronidazole.

Food poisoning

Food poisoning should be suspected if all those who have eaten the same food start getting abdominal pain, diarrhoea and vomiting, with or without fever. The foods which may cause this condition are salads, custards, milk, and milk products, stuffed food items, pastries with cream or custard and home-preserved food such as cheese or home-canned vegetables and fish. Food poisoning is not uncommon during the festive season when sweets made from milk and milk products bought from a particular shop sometimes results in a large number of people getting affected. Most of these cases settle within 2-3 days. Those affected with severe symptoms may need hospitalization. For prevention, children should be encouraged to avoid eating milk products outside the home. Food should be eaten the same day it is cooked. If this is not possible, the leftover items should be rapidly cooled in a cold storage or kept in the deep-freeze compartment of the refrigerator and thoroughly heated before consumption. Even the centre of the food should be heated, leaving no cool spots.

Sore throat

Sore throat with enlargement of glands in the abdomen can cause abdominal pain in children above 2 years of age. The pain disappears as the sore throat gets treated. The child may also have headaches and vomiting. Severe bouts of cough or vomiting leading to soreness of abdominal muscles may also present as abdominal pain. The remedy lies in treating the cough or vomiting.

Tuberculosis of the abdomen

Tuberculosis of the abdomen should be considered if the child having pain in the abdomen has associated features connected with a possible diagnosis of tuberculosis. These are : a history of close contact with an adult having tuberculosis, loss of appetite and weight, distension of abdomen with or without evidence of intestinal obstruction and evidence of tuberculosis elsewhere in the body. C. Surgical conditions causing pain in the abdomen

Appendicitis

Appendicitis if diagnosed properly, needs surgery. Fortunately, this condition is less common in our children when compared to children to western countries. But it does occur and must be taken seriously. Also it is uncommon under the age of 3, though it may occur also in small infants. Appendicitis refers to inflammation of the appendix- a tail-like structure connected to the caecum portion of the large intestine located in the right lower abdomen. If not detected early, an inflammed appendix may burst open, leading to a serious condition called peritonitis. This condition should be suspected in presence of persistent pain in the abdomen, often (though not always) associated with loss of appetite, vomiting and fever. The pain mostly begins around the centre of the abdomen (near the navel) and after a few hours gets localized to the right lower abdomen. The child who is otherwise active becomes quieter, resists examination of this part of the abdomen and gets even more pain when his abdomen is pressed gently over this region. Unattended peritonitis makes the abdomen feel hard like a board and pain and tenderness (pain when touched) becomes worse. A child with a possible diagnosis of appendicitis needs immediate attention of a surgeon- preferably one who deals only with children (paediatric surgeon). If the surgeon suspects appendicitis, he/she may also do a rectal examination and ask for a blood count. If the diagnosis is not clear, a plain X-ray of the abdomen in vertical position and sonography of the abdomen may be helpful. If the surgeon recommends surgery, it is advisable to go ahead with it. As the patient should be starved for sometime before surgery is undertaken, it is best not to give the child anything to eat or drink in case you suspect a surgical condition like appendicitis. If the surgeon finds that your child is running about and wants to eat, he will rule out the possibility of appendicitis. If in doubt, he will admit the child for observation, keep the child nil by mouth, give intravenous fluids and undertake routine investigations like a blood count, routine urine examination and a urine culture.

Intestinal obstruction

Intestinal obstruction is a serious surgical condition. Some of the causes are congenital obstruction (from birth), a mass of roundworms obstructing the intestines, intussusception and an obstructed inguinal hernia. (See below). The child with intestinal obstruction has pain in the abdomen, constipation, distension of abdomen and vomiting. The vomiting is projectile (shooting out of the mouth with great force). It may be green in colour (due to presence of bile) or may even contain faeces. The child wants to lie quietly in spite of pain. In such a situation the urgent care of a surgeon is needed.

Intussusception

Intussusception is a condition in which one portion of the intestine slips inside the portion next to it. The condition occurs commonly between the ages of three months and three years. There is a sudden onset of pain which lasts for two to three minutes and then occurs in repeated bouts every quarter of an hour or so. The child shrieks with pain and looks ghastly pale. Generally, a child becomes red in the face when he cries but in intussusception, the child looks pale, acutely ill, refuses to eat or drink and with continuos bouts appears to be collapsing. At such a stage, the child may pass blood in the stool. A surgical opinion is urgently needed in such a situation. Early, in the condition, the doctor may find a mass in the right upper abdomen. As the upper intestine slips more into the lower intestine, the mass may be felt in the left upper abdomen. The doctor will hospitalize the child, put him on a drip of intravenous fluids, get the operation theatre ready for an emergency surgery and ask for an X-ray of the abdomen to be taken after giving an enema of barium. Sometimes the intussusception reduces on its own while the above procedures are being attempted or it may get reduced with the barium enema. Alternatively, the child might need surgery.

Inguinal hernia

Inguinal hernia with strangulation or obstruction may present itself in an infant who starts crying suddenly and the mother notices a hard swelling in the groin (junction between the abdomen and thigh). No attempt should be made to press on this swelling and the child should be shown to your doctor. If the doctor decides that it is hernia, he may gently try and reduce it. Failing this he would hospitalize the child for surgery. The child should fast until the doctor decides whether surgery is needed or not. If unattended, obstructed inguinal hernia can present with signs of intestinal obstruction, mentioned above. If the treatment is unduly delayed, the blood vessels in the swelling get obstructed causing damage to the surrounding intestines. Mostly the inguinal hernia is noticed as a swelling in the groin or the scrotum. The swelling becomes more prominent when the child cries. It may disappear on its own or by gentle pressure when it reduces with a gurgling feel. This is not an emergency situation but as the possibility of strangulation exists, this hernia should be operated as soon as possible. But a strangulated hernia is an emergency needing urgent attention. Some children may have hernia on both sides. At times, the child has some tender glands in the groin secondary to an infection in the lower limb. This should not be confused with hernia. A hernia should also be differentiated from a congenital hydrocele with presents with swelling of the scrotum. This swelling does not change in size on crying or by pressure. It usually disappears on its own before the child is one year old.

Other less common surgical conditions.

Other less common surgical conditions with pain in the abdomen like injury to the abdomen and a stone in the urinary tract may also be kept in mind. The onset of pain with a stone is sudden. The pain is often located in the back and extends towards the groin. A dull ache persists, with outburst of shooting unbearable pain. This may be associated with passage of blood in the urine. Other possible causes of abdominal pain in children Allergy or intolerance to animal milk, colic in small infants, constipation, dietary indiscretion, abdominal epilepsy, urinary infection, referred pain from the chest in a child with pneumonia or pleural infection, hepatitis (infection of liver), malaria, and hunger with low blood sugar can also cause abdominal pain.

Abrasions or Scratches

This is an injury where the child has been scraped on the surface affecting only the epidermis or the outer layer of the skin, without any cut. Treatment This is a minor injury which needs to be cleaned properly to remove only dirt- a possible source of infection. Put the part under running tap water or pour water from a glass. Then clean the wound with soap and water after first washing your hands. There is no need for cleaning it with spirit, iodine or red medicine (mercurochrome) because no medicine is needed for a clean wound. If the child's booster dose of DPT (Triple antigen) or Dual antigen (DT) is due, give it now. If he is about ten, give an injection of tetanus toxoid. A fully immunized child does not need an extra dose of tetanus toxoid. For instance, if he has been given DPT (which contains tetanus toxoid) at the age of two and meets with an accident at three years, there is no need to give tetanus toxoid. Dressing or no dressing? I personally believe that a dressing is not needed. However, if you feel that the wound might not remain clean or flies may sit on it, you may cover it with a sterile piece of gauze available from the chemist. Keep it in place with a clean bandage or a clean piece of cloth. Check the wound daily and change the gauze. If the gauze or bandage is stuck to the wound, pour boiled and cooled water to remove it. If the wound is oozing from the beginning, do cover it with the gauze, as mentioned above. In such a case, you may even apply an antibiotic skin ointment on it and then put the gauze over it. If the ointment is not available easily, just a sterile gauze will serve the purpose. Once the scab is formed, there is no need for covering the wound any more.

Acute Glomerulonephritis

Some people also refer to this disease as acute nephritis. It is a disease of the kidney following infection of the throat or skin by a particular bacteria. A typical case usually affects a schoolgoing child. It is extremely rare in the pre-school period. About three weeks after a sore throat or skin infection, you may notice that the child is passing less urine. It is reddish in colour. On getting up in the morning the child's face is found to be puffy. The swelling is more marked below the eyes and spreads also to the lower limbs. In some cases the blood pressure goes up and the child may also get fits. Your doctor will first ask for a urine test and then may order some blood tests. Fortunately, 95 per cent of children recover completely without any damage to the kidneys. The child looks normal within 2 to 3 weeks when the urine output and colour becomes normal and swelling disappears. The urine may show the presence of red cells and albumin for a longer period. Keep in touch with your doctor. Most likely he will also reassure you and shall not prescribe any further medicine. Treatment Bed rest and certain restrictions in diet, salt and water intake will be advised by your doctor. He will also prescribe medicine for the residual throat or skin infection and for the blood pressure in case it has gone up. In the first few days, your doctor may like to check the child's blood pressure twice daily. If the blood pressure is high or the child has convulsions or marked reduction in urine output, he may wish to hospitalize the child.

Addictions

Addictions to alcohol, tobacco-chewing, smoking, and use of hard drugs is taking its toll of young lives all over the world. India is no exception. More and more pubs are being opened throughout the country. Hard-sell advertising of cigarettes with the eye on the youth is on the increase. Young people are still going hooked to hard drugs. Sadly, it is often young school children who fall victims to drug pushers. It is estimated that India has 10 lakh heroin addicts, out of which 1,10,000 are from Mumbai. Most became addicts while in their teens. Over 1 lakh are addicted to brown sugar. Mumbai is also reported to have 25,000 people addicted to cough syrups (quite rampant in college hostels), prescribed medication, petrol, and glue. A teenager whose body is undergoing rapid physical and harmonal changes can be under a lot of stress. He is often curious and can be tempted to experiment with new substances. Peer pressure or wanting to feel one with the group and high expectations of parents often add to the stress. Not realizing fully that alcohol is also a drug, a teenager may use it as an excuse for relaxation or from escaping from stress. But we know that the continued use of alcohol can give rise to feeling of inadequacy, lowered self-esteem, estranged relationships, impaired reasoning and judgement, dependence and gradual personality deterioration. A teenager who already has a poor image of himself runs the risk of using alcohol or drugs as a 'crutch'. Parents' role You can play an important role in curbing such dangerous trends by helping your child develop self-esteem and character from an early age. A free and open communication with children is helpful. Your youngster should be provided the necessary help to realize his inner potential. Extra-curricular activities should be encouraged. Sports can provide the right form of stimulation. Young people can be made conscious of the need to preserve their health so that they can compete favourably in sports and extra-curricular activities. In such an atmosphere, things are less likely to get out of hand. Regarding peer pressure, let me tell you about a young college student. I once asked her, 'All your friends smoke. Why don't you?' She replied, 'I have been influenced by my parents and have decided for myself not to follow the crowd blindly. I find it far more exciting to follow my conscience and be ready to differ even with my closest friend'. It is obvious that the parents of this girl had prepared her for life- to be independent in her thinking and not to be swept away by peer pressure. I suggest you read the chapter in this book which deals with behaviour at different ages. Parents who start understanding why children behave differently at different ages can find the right language (preferably the language of love and trust) to communicate with their teenagers. Also by their own example, they can show how one can remain happy and face problems without alcohol, tobacco or hard drugs. It is certainly worthwhile to make a conscious effort to find an opportunity to discuss certain misconceptions people have about such harmful agents. You may also help remove any guilt feelings that your teenager may be having in this connection. Parents who are honest and do not pose as if they were perfect are more likely to have an open relationship with their children. All of us have made mistakes in life. Children must get the message that to err is human, but it is suicidal not to learn from our mistakes. Misconceptions about addictive drugs Some people wrongly believe that experimentation with these agents always leads to dependence and disaster. While it is true that a trial puff could lead to chain-smoking, I know of young people who did indulge in these things but stopped doing so once they became conscious of the deleterious effects on their health, personality, career and relationships. However, the harsh reality can also not be set aside. Seventy-five per cent of young addicts who are hooked on drugs may never recover fully in spite of best possible treatment. It is not true that alcohol provides warmth in cold climates. In fact, alcoholics are known to die of pneumonia when they go out in cold weather. Some young and old persons are made to believe that the quantity of alcohol in beer is negligible and that it is quite safe to drink beer. I have seen teenagers admitted to hospitals with injuries due to fights and automobile accidents under the effect of beer. Beer can also impair rational thinking processes leading to an irrational behaviour. It can also be responsible for delayed reaction time which may increase the risk of automobile accidents. And then there is always a possibility of graduating from beer to harder stuff. That alcohol enhances sexual performance is another myth. Shakespeare made it clear when he said that it provokes the desire but takes away the performance. Young people may think that they may not necessarily get heart trouble or lung cancer due to smoking and wonder why they should not 'enjoy' themselves for the moment rather than worry about the future. There are hundreds of studies about the proven dangerous effects of smoking. A single cigarette is said to reduce the lifespan by 5 minutes. Even if we close our eyes to the long term dangers, what about simple effects like bad breathe and staining of teeth. This does not help in becoming popular with friends! Smoking also has an immediate effect on our lungs, resulting in frequent attacks of cough, possible wheezing, poor stamina, and an adverse effect on performance in competitive sports. How to suspect addiction Early diagnosis of addiction to drugs is important. It may save the child as well as the breakdown of the family. Counselling by parents or experts can help get rid of the habit if detected early enough. Do consider the possibility of addiction if you find that your son (or daughter) gets tired easily, has started keeping odd sleeping hours and has a poor appetite, does not care about his dress, gets easily annoyed or depressed, shuns company and keeps getting congestion or redness of the eyes. You may also start getting complaints from his school or college. In certain case, the addiction may even lead to depression and an attempted suicide. But before you start spying on your teenager, keep in mind that most of the above symptoms can also be found in growing children who either have no major problem or have some physical or behaviour problem unrelated to agents under discussion. Confirmation of addiction should be left to a doctor. As the addiction grows, withdrawal symptoms can be detected when the addict wakes up. He appears restless, has watering from the eyes and nose, complains of cramps in his abdomen and develops diarrhoea, vomiting and mental confusion. Although advanced cases are hard to treat, loving attention from parents and help from experts can lead to a satisfactory outcome.

Adenoids

What are adenoids? Most of us have experienced, at one time or other, a sore throat with high fever allowed by appearance of enlarged glands under our jaws. They feel like peas or marbles. These are called lymph glands made up of lymphoid tissue. They try to trap the germs before they get a chance to invade our whole system. Adenoids from a part of the lymphoid tissue meant to help us fight infections in our body. Adenoids lie behind the roof of our mouth cavity (the palate) where the back of our nostrils join the back of our throat. Ordinarily, they seem to do their job quietly by keeping a check the germs in our upper respiratory tract. The tonsils act likewise. At times these adenoids get enlarged and block the nasal passages causing varying degree of obstruction of breathing. In most cases, the enlarged adenoids shrink in size as the child grows older. In the past it was quite a routine practice to remove the adenoids along with the tonsils. But it is now being increasingly recognized that often both these tissues should be kept intact or only if definite indications exist should then, one or both of them may be sacrificed. Removal of adenoids thus should only be considered if the child gets recurrent ear infections, has difficulty breathing normally, breathes mostly through the mouth, or snores heavily at night with temporary stoppage of breathing for few seconds; his speech is disturbed and his voice sounds nasal, as if his nose is blocked. May I stress that in the above conditions, the removal of adenoids is to be considered but not necessarily resorted to. Mouth breathing per se is not an adequate indication. Some people do so out of habit. Also your doctor may like to treat the child with antibiotics if he suspects persistent infection or he may like to treat the child for allergies.