More than half a million tonsillectomies are performed each year on children in the U.S. More than sixty percent of those children report significant pain in the days that follow. Acetaminophen with codeine is in widespread use for post-operative pain, but the U.S. Food and Drug Administration is now investigating the safety of codeine for post-operative pain relief in children following reports of three deaths in children related to its use after tonsil surgery.

Kids deserve pain relief, both for comfort and to speed up healing — pain negatively impacts breathing and kids are less likely to eat and drink after surgery when they are in pain, but there is no known benefit of acetaminophen with codeine over acetaminophen alone for post-tonsillectomy pain in kids.

Another option is ibuprofen, but many physicians are reluctant to recommend ibuprofen because of bleeding concerns. Interestingly, research hasn’t shown the dangers physicians fear.

Another alternative is acetaminophen with hydrocodone. It appears to be more effective and less risky than acetaminophen with codeine – especially if on a schedule, rather than waiting for pain to breakthrough.

Kids do deserve pain relief, but I see no reason to give codeine after tonsillectomy, when there are other, less risky options.

Sometimes children tumble, skin their knees, and keep right on playing happily. Other times, the slightest ‘owwie’ can cause children to dissolve in tears. Research published in the June 23, 2003 online issue of the Proceedings of the National Academy of Sciences suggests that the pain people feel is real, that the amount of pain from the same event truly differs from person to person, and that people can report their pain accurately.

In this study 17 adults were subjected to a hot prod on their right legs and asked to rate their pain. Some said the pain was severe – a nine on a ten point scale. Others felt the pain was no big deal – as low as a one on the same scale. Fascinatingly, head MRI’s said the same thing as did the study participants. Those who reported more pain showed more physical activity in the pain centers of the brain, and vice versa. Some people truly feel more pain than others.

This small study was unable to detect any difference between the way that men versus women experience pain. Earlier research suggests that the amount of pain people feel is partly genetic – related to the amount of natural painkillers, endorphins, that their brains can produce. The amount of pain from the same event can also vary from time to time in the same person.

A child is less likely to notice pain when intent on accomplishing an exciting new task (running and falling), than when experiencing disappointment (falling while a toy is being taken away). Sleep, hunger, mood, and sugar can all influence the amount of pain a child feels. None of this makes the pain children experience less real. And one of the best ways to tell if a child is hurting is to listen to him. If a newborn cries during circumcision, believe it hurts, and if a preschooler seems overly concerned about a skinned knee or tiny boo-boo, he just might be right.

Listen to kids first, and you will be wiser when you respond to their cries.

Dr. Greene’s Answer:

Usually, the peak age for crying is about 6 weeks old, so there is light at the end of the tunnel. After all of the emotions of pregnancy and anticipating a baby, this crying period can be overwhelming for parents. Different babies respond to different comforting measures. Experimenting and observing what seems to work best for your baby is the best way, through.

Some children are comforted by being held close in a dark room. Some like to be swaddled. Some like to be sung to. Some need to suck on something. Some are calmed by rocking. For many kids, car rides are settling.

Some children are intolerant to cow’s milk-based formulas. Most of them will do well on soy, but about 20 percent of them are intolerant to soy as well. Breastfeeding mothers can try a dairy-free diet. For formula-fed infants, Nutramigen or one of the other hydrolysate formulas will often do the trick. Kids may not like them, but they are almost impossible to be intolerant to.

If you are using a bottle, try switching brands. Any bottle change can produce improvement in some babies. In one clinical trial, switching to BornFree bottles with ActiveFlow made a significant difference for 80 percent of babies.

If a baby is not consolable, or if the fussiness increases after kids are 6 to 8 weeks old, it’s important to consider other causes, such as reflux. Talk to your pediatrician about possible causes and treatments.

Related concepts:

Bad Dreams

Introduction to nightmares:

Mommy, I had a bad dream…

What are nightmares?

Nightmares are unpleasant dreams that awaken a dreamer from sleep.
We’ve learned much about nightmares from traumatic events, which are known to cause a predictable pattern of nightmares: first dreams that relive the event, then dreams that relive the primary emotion of the event using different scenarios (different pictures), then dreams that incorporate aspects of the event into other parts of life.
Nightmares are an important means of addressing the normal difficult events and emotions of childhood, to weave them into the fabric of our minds in a constructive way.
Night terrors are very different from nightmares.

Who gets nightmares?

Birth is a wonderful and terrible experience. There is much to be happy about and much to learn about in the weeks that follow. Babies’ dreams must incorporate and address those things that bring them pleasure and those that make them cry. In all likelihood, the peak age of crying, the first 6 weeks, is also the peak age of nightmares.
These nightmares are not unsuccessful dreams. Far from it! They help babies learn and grow; nightmares may even be an important reason that crying diminishes after 6 weeks.
Stressful events, such as injections, circumcision (which should never be done without anesthesia), being left alone or dropped, or even feeling hungry, need to be learned about and integrated. Anything worth crying about is worth dreaming about.
Nightmares are most evident between the ages of 3 to 5 years — the peak age when children talk about their fears.

What are the symptoms of nightmares?

Children wake up and remember a scary or sad dream, usually in the second half of the night. They may be sad or afraid when they wake up, and are often crying. Children who are old enough will often wake their parents and tell them they had a bad dream.
Unlike with a night terror, they will recognize their parents and be comforted by their presence. In addition, unlike a night terror, they will often have trouble falling back asleep because of fear.

Are nightmares contagious?

Nightmares are a normal part of development. They are not contagious, although children will often respond to the fear and sadness of those around them.

How long do nightmares last?

Individual nightmares are brief.
Nightmares can occur throughout life, but tend to decrease with each passing year.

How are nightmares diagnosed?

Nightmares are diagnosed based on the history.
They are to be distinguished from night terrors. In pre-verbal children, they should be distinguished from ear infections, reflux, hernias, or other causes of pain.

How are nightmares treated?

An individual nightmare is treated with your reassuring presence. Holding your child and talking soothingly about the dream can diminish the fear and sadness.
If your child is old enough to tell or draw the story of the dream, it can be helpful to find a way for the story to reach a happy ending. Addressing the underlying emotions can help your child make sense of them.

How can nightmares be prevented?

Much excellent children’s literature directly addresses difficult dreams. Other books address children’s common fears and concerns. This literature, and other art, can help children do some of the integrating work of nightmares without the nightmares themselves.

Related A-to-Z Information:

Colic, Ear Infection, Gastroesophageal Reflux, Hernia (Inguinal hernia), Night Terrors, Separation Anxiety, Tantrums

Introduction to colic:

It usually strikes toward the end of a long day, when your baby is just about at the age when your sleep deprivation has really begun to set in. Your baby stops being the quiet, peaceful, miracle baby and begins screaming every evening. It is no wonder that parents become frustrated, discouraged, and depressed.

What is colic?

Almost all babies go through a fussy period. When crying lasts for longer than three hours a day, and is not caused by a medical problem (such as a hernia or an infection), it is called colic. This phenomenon is present in almost all babies, the only thing that differs is the degree.
The child with colic tends to be unusually sensitive to stimulation. Some babies experience greater discomfort from intestinal gas (and they tend to swallow even more air when they cry!). Some cry from hunger, others from overfeeding. Some breastfed babies are intolerant of foods in their mother’s diets. A few bottle-fed babies are intolerant of the proteins in formula. Fear, frustration, or even excitement can lead to abdominal discomfort and colic.
Whatever the mechanism, I believe that the fussy period exists in order to change deeply ingrained relationship habits. Even after the miracle of a new birth, many parents and families would revert to their previous schedules and activities within a few weeks – if the new baby would only remain quiet and peaceful. It would be easy to continue reading what you want to read, going where you like to go, doing what you like to do as before, if only the baby would happily comply. Instead, the baby’s exasperating fussy period forces families to leave their previous ruts and develop new dynamics that include this new individual. Colic demands attention. As parents grope for solutions to their child’s crying, they notice a new individual with new needs. They instinctively pay more attention, talk more to the child, and hold the child more – all because of the colic. Colic is a powerful rite of passage, a postnatal labor pain where new patterns of family life are born.

Who gets colic?

Almost all babies will develop a fussy period. About 20 percent of babies will cry enough to meet the definition of colic. The timing varies, but colic usually affects babies beginning at about three weeks of age and peaking somewhere between four and six weeks of age.

What are the symptoms of colic?

For most infants the most intense fussiness is in the evening. The attack often begins suddenly. The legs may be drawn up and the belly distended. The hands may be clenched. The attack often winds down when the baby is exhausted, or when gas or stool is passed.

Is colic contagious?

Colic is not contagious, but babies do respond to the emotions of those around them. When others are worried, anxious, or depressed, babies may cry more, which can make those around them more worried, anxious, or depressed.

How long does colic last?

Colic will not last forever! After about six weeks of age, it begins improving, slowly but surely, and is generally gone by twelve weeks of age. When colic is still going strong at 12 weeks, it’s important to consider another diagnosis (such as reflux).

How is colic diagnosed?

Colic is usually diagnosed by the history. A careful physical exam is wise to be sure the baby does not have a hernia, intussusception, a hair tourniquet, a hair in the eye, or another medical problem that needs attention.

How is colic treated?

Helping a child with colic is primarily a matter of experimentation and observation. Different children are comforted by different measures. Some prefer to be swaddled in a warm blanket; others prefer to be free. The process of treating colic involves trying many different things, and paying attention to what seems to help, even just a little bit.
Holding your child is one of the most effective measures. The more hours they are held, even early in the day when they are not fussy, the less time they will be fussy in the evening. This will not spoil your child. Body carriers can be a great way to do this.
Some babies are only happy when they are sucking on something. A pacifier can be like a miracle for some.
Singing lullabies to your baby can be powerfully soothing. It is no accident that lullabies have developed in almost every culture. The noise of a vacuum or of a clothes dryer is also soothing to many babies.
As babies cry, they swallow more air, creating more gas and more abdominal pain, which causes more crying. This vicious cycle can be difficult to break. Gentle rocking can be very calming (this is directly comforting and seems to help them pass gas). When you get tired, an infant swing is a good alternative for babies at least 3 weeks old with good head control.
Holding your child in an upright position may help (this aids the movement of gas and decreases heartburn). A warm towel or a hot water bottle on the abdomen can help. Some babies prefer to lie on their tummies, while someone gives them a backrub. The gentle pressure on the abdomen may help.
Some children seem to do best when they are going for a ride in the car. If your child is one of these, you might try a device developed by a pediatrician to imitate car motion and sound.
Some parents report an improvement by giving simethicone drops, a defoaming agent which reduces intestinal gas. It is not absorbed into the body and is therefore quite safe. Sometimes doctors will prescribe stronger medicines for severe colic (but this should only be done after a physical exam). If nothing else seems to work, you might try pretending your baby is sick, and taking a rectal temperature (do not use a mercury thermometer). This will often cause babies to pass gas and obtain relief.
There are many stories about foods that breastfeeding moms should avoid. Most often, I hear about abstaining from broccoli, cabbage, beans, and other gas-producing foods. The scientific evidence is strongest for avoiding stimulants such as caffeine and caffeine-related compounds (those found in chocolate). The other foods in mom’s diet that are most likely to cause a problem are dairy products and nuts. I would try eliminating these for a few weeks. Other foods may also irritate the baby. Experimentation and observation will guide you.
Switching formulas is not helpful for most babies, but is very important for some.
Taking a break is a good idea. Each of you can take charge and spell the other. Time for oneself is an important part of the new family dynamic. You will be able to pay more loving attention to your baby when you’ve had a chance to get refreshed.

How can colic be prevented?

A fussy period is likely no matter what prevention techniques are undertaken. Good feeding techniques (as advised by a lactation consultant, if appropriate), good burping, and early identification of possible allergies in the baby’s or mother’s diet may help prevent colic. Experimenting with the comfort techniques outlined above before colic develops can help you identify your baby’s needs and desires, and can help stop the fussy period from becoming so intense.

Related A-to-Z Information:

Diaper Rash, Food Allergies, Gastroesophageal Reflux, Hernia (Inguinal hernia), Intussusception, Nightmares

Dr. Greene’s Answer:

Most of us have wonderful soft-focused mental pictures of how special bath time can be. A laughing baby in the bath with shampoo piled high on his head joins other classic childhood images such as the grinning baby whose face is smeared with sweet potatoes, or a brand-new toddler taking his first steps with delight.

How disappointing that your son’s bath time has become something that you both dread! Thankfully, even an intense dislike of baths can usually be turned around. From your question it sounds as if you have done a great job with baby-bathing basics, but I will review them first (just in case one of them sparks a good idea for you):

• Use a tub that is comfortable for your baby – most babies like them to be soft (or lined with a towel) and “just right” in size.
• A couple of inches of warm (not hot) water in the tub is plenty. Babies feel both heat and cold more than we do. If you are unsure about the temperature, you can buy an inexpensive bath thermometer that changes color to indicate safe and comfortable heat levels. (Note: If you haven’t already done so, turn down your hot water heater to no higher than 120 degrees Fahrenheit for safety.)
• Babies lose body heat very quickly, so make sure the room is also warm.
• Some babies are a bit frightened of having their clothes taken off and being exposed to the air. Your soothing voice – singing or talking – will help remind him that he is safe.
• Use age-appropriate toys to engage him in the whole experience. At first this might be something as simple as giving him a clean washcloth to suck on or a rattle to hold. Later, plastic cups and bowls make excellent pouring toys.
• Be careful to use safe, gentle, hypo-allergenic, tear-free products to clean your baby’s skin and hair. The Environmental Working Group has a wonderful database, Skin Deep, that allows you to search for products for personal care and cosmetics. You can search by age group (baby), product, ingredient, or company to find the very safest products available.
• Gently wash him with a soft, warm washcloth. Admire his individual parts — all too often we bundle up our babies and never adore those precious feet.
• It’s a good idea to wash a baby’s hair near the end of bath time. This will help prevent him from losing too much body heat. Also, for babies who dislike baths, this is often the toughest part. Most babies dislike getting their eyes wet. If you tip the head back just a bit and work your way from the front to the back, you can avoid getting water in your baby’s eyes.
• Never leave your baby alone in a bath! Not even long enough to pick up the phone or turn off the iron (who has time to iron with a newborn?!). If you want to answer the doorbell, take your son out of the bath, wrap him in a towel, and take him with you. On your way back to the bath, grab a dry towel to use when his bath is complete.
• Wrap him in a warm, dry towel. Then dress your fresh, clean baby.

Most young babies who initially recoil from baths will come to enjoy them eventually. There are two good options that might help right now and also increase his long-term enjoyment: minimize the bath, or maximize the reward.

Minimal baths are sponge baths – there needn’t be a tub at all. If he likes, you can wash one area at a time and put a fresh item of clothing on as soon as an area is washed and dried. He never needs to be all the way undressed. And it isn’t necessary to bathe him daily. As long as you are spot cleaning after spit-ups, and cleaning his diaper area after bowel movements, he shouldn’t need to be bathed more often than every three or four days. Facing a small version of fears is a great way to overcome them without feeling overwhelmed. Minimal exposure is also the way to acquire new tastes.

My favorite solution, though, is to make the bath a family event in a full-size tub. You can get in the tub first, and have someone carefully hand your son to you. You can wash him with a warm hand towel while you hold him close. The reward of the skin-to-skin contact and the warmth of your presence can turn what was terrifying into a joy for both of you.

Getting stitches on the face is no fun for anyone, but it is especially frightening to young children.

A study published in the January 2001 issue of Annals of Emergency Medicine evaluated different ways to reduce distress in children needing facial laceration repair. Some of the children received a topical anesthetic alone, some received an anesthetic plus nitrous oxide (laughing gas), some received an anesthetic plus midazolam (an anti-anxiety drug, similar to valium), and some received ‘all of the above’.

Laughing gas plus a local anesthetic gave the best results — the lowest distress during cleaning, stitching, and shots, as well as the fewest side effects and the quickest recovery.

This was a happy solution for painful or frightening procedures in kids as young as age 2.

Children’s health issues are just the same as adult health issues — only smaller.  In adults, back pain is a common musculoskeletal problem.  In children, back pain should be taken seriously. 

When children under age 10 have back pain that lasts longer than 3 days, they should have an advanced imaging study of the spine.

Results presented at the 1999 annual meeting of the Radiological Society of North America suggested that about 1/3 of these children have significant problems needing specific treatment — even though the regular x-rays were normal!

Dr. Greene’s Answer:

Even the unbridled energy of childhood can be squelched by a pounding migraine headache. As the pain mounts, a normally curious and active child will slow and then stop playing, brought down by the migraine. Migraines are not just any type of bad headaches — they are a specific condition. And they are much more common than most people suspect. Migraines are the most important and frequent type of headache in children, affecting more than one in twelve kids — yet only 20 percent of children with migraines are ever properly diagnosed and treated (Headache, May 1997).

Migraines are caused by an inherited extra-sensitivity of certain blood vessels to the nerve and chemical signals that normally cause these vessels to dilate or constrict (especially to serotonin, norepinephrine, and substance P). When these over-exuberant blood vessels expand and contract, the resulting changes in pressure produce pain (Pediatric Annals, September 1995). The medicines for migraines decrease the responsiveness of these vessels.

Migraines are defined as recurrent headaches (in which the child is well between episodes) accompanied by at least 3 of the following symptoms:

• abdominal pain
• nausea or vomiting
• throbbing headache
• specific location of pain
• sensitivity to light and sound
• associated “aura”
• relief with sleep (headaches that awaken children, or early morning)
• family history of migraines

Before puberty, migraines are more common in boys than in girls (the reverse is true afterwards). Most kids do not have an aura (changes in vision or tingling hands or feet), but most do have a throbbing or pounding headache, often at both temples, accompanied by nausea and vomiting. The headaches typically last for one to three hours — but they can last for 24 hours or longer. Kids often appear pale and are sensitive to light during a migraine. They feel crummy!

Helping kids with migraines begins with carefully observing the circumstances when the headaches begin. A big difference in kids’ lives can be made by identifying and avoiding their migraine triggers.

A number of foods have been shown to be the triggers for some individuals. The most common of these are nuts, chocolate, cola drinks, hot dogs and luncheon meats (probably the nitrates and nitrites), pepperoni and sausage (thought, perhaps, to be the spices), kippers (though I have never yet seen a kid eat kippers!), and MSG (found in Chinese food and in restaurant salads — another non-issue for most kids). Both alcohol and birth control pills are associated with migraines, but there are better reasons than headaches to avoid these in young children.

Bright flashing lights can also trigger migraines. This happened recently on a large scale to many children watching a cartoon in Japan (this cartoon also triggered seizures in many children, which of course captured more attention than the migraines).

Children who get migraines are more likely to get them when they are over-tired or have gone too long without eating. In addition to fatigue and hunger, other known triggers are sun exposure, excessive physical exertion, motion sickness, loud noises, head bumps, stress, and anxiety.

Even if the triggers can’t be avoided, children who learn what their triggers are often experience a great reduction in the number of headaches. Perhaps their brains are more ready to deal with the surges of serotonin or other substances.

Exciting new drugs have been developed for adults with migraines. These have not yet been approved for use in children, but thankfully kids are much more responsive than adults to available, gentle medicines.

Ibuprofen (Motrin or Advil) is more than twice as effective as acetaminophen (Tylenol) at stopping a migraine — but acetaminophen starts working twice as fast. I recommend giving a child a dose of both ibuprofen and acetaminophen when the headache starts, and then having him rest in a quiet, darkened room. Most kids get quite sleepy with migraines, and want to lie down. They usually awake refreshed and headache-free.

If vomiting is a major symptom, giving a prescription anti-vomiting medicine at the beginning of the headache can be the most important part of treatment.

These simple measures will give effective relief to most kids. Stronger medicines (such as ergotamine or sumatriptan) might be used if pain continues to be a problem. Multiple studies have demonstrated the safety of triptans (such as sumatriptan) in children and adolescents; only the nasal form of sumatriptan has demonstrated efficacy in adolescents. However, the triptans (as well as ergotamine) have not been approved by the FDA for pediatric use. They are usually used “off label” in consultation with a neurologist (Pediatrics in Review, February 2007).

If the migraines are very frequent, or are interfering with school, then a continuous, daily medication might be prescribed to prevent the migraines. Options for this include propranolol, phenytoin, phenobarbital, amitriptyline, cyproheptadine, and methysergide. Newer antiseizure medications are now being used for migraine prevention, such as topiramate and leviteracetam; they generally have less side effects than phenytoin or phenobarbital. Propranolol is the one most frequently used by experts in the field. These are all strong medicines with significant side effects, so I would only use them if the headaches are seriously impacting your child’s life.

I prefer teaching children either self-hypnosis or biofeedback to control their headaches. These techniques can be mastered by most kids in second grade or above. They have been shown to be even more effective than propranolol at preventing migraines (Nelson Textbook of Pediatrics, Saunders, 2004) — and without side effects! Cognitive-behavioral therapy and relaxation techniques have been shown to be effective as well (Cephalalgia, 2006).

Most children’s hospitals have experts who can teach these techniques to children. Pediatricians in behavioral pediatrics departments should be able to direct you to the appropriate people.

With the many options now available, most kids can cut down both the frequency and severity of migraines. Whatever course of treatment you choose, most children with migraines can look forward to spontaneously outgrowing them by the 10th birthday — just in time for the new challenges of puberty

Dr. Greene’s Answer:

Many of you probably remember seeing footage of the 1989 Loma Prieta earthquake. I am told that national news coverage showed three striking images over and over and over — the horrible crash on the San Francisco Bay Bridge, the fires burning out of control in the San Francisco Marina District, and the collapsed Cypress Freeway Structure in Oakland. I say, “I am told,” because I didn’t see any of the footage — I was inside the collapsed freeway.

I can not begin to tell you the horror I experienced during the next three days and nights. The top deck of the double decker freeway literally caved in on the bottom deck, which remained precariously standing. With each after shock, and it seemed there were hundreds of them, the whole structure threatened to come tumbling down. As a rescue worker, I spent most of my time crawling in and out of the area where most of the victims were trapped — the area that had once been the bottom deck of the freeway. We looked for spaces where there was room to crawl. In many places the two decks were completely merged with no hope for survivors. Once inside, it was interminably hot. There were clouds of cement dust filling the air making it almost impossible to breathe. And the sounds — car horns blaring, radios playing an eerie accounting of what I was experiencing, and occasionally moans. We longed for the moans — someone was still alive! It seemed like just about the time we would make it to someone who was still breathing, the structure would begin to sway, again, and again, and again, threatening to trap the rescue workers along with the victims.

Several months later I was on board a pleasure boat. The sea became rough and the boat began to sway. I must have turned a ghostly color as I hung onto the rail. An older woman approached me and asked if I was all right. I told her that I was having trouble because the swaying reminded me of a difficult experience. “You’ve been in an earthquake, haven’t you?” she asked. She went on to tell me that she knew that was what was going on just by looking at me. She knew because she also had been in an earthquake — almost 40 years earlier.

I tell you this story to illustrate the powerful emotional impact a catastrophic experience can have.

Even though your daughter may not have been in the eye of the storm, she came to understand firsthand how overwhelmingly powerful nature can be. This experience changed how she viewed the world. Hurricane Fran declared that no matter how hard she tried, no matter what she accomplished, no matter how good she was, she could not count on living a long, happy life. This is a difficult thing for any of us to deal with, but it is particularly hard for children.

Your daughter is entering adolescence — the age of idealism. But Fran took her toll. Because the main symbol of Fran’s power was to leave you in darkness, it is the darkness that most reminds your daughter of her loss.

The best thing you can do to help your daughter through this difficult time is to help her express her current feelings. While the deep feelings of young children can often be drawn out through story-telling and drawing, most adolescents’ deep feelings can be drawn out through literature. The most easily accessible form of literature in our culture is the movie. One current film that deals with this issue is “Phenomenon”. You might consider taking your daughter on a date to the movie. Afterwards go to a coffee house that encourages its patrons to linger and talk. Ask questions about how she felt watching the movie, listen to her fears, and help her work through her doubts. During this time share your own feelings as well, especially if you were also touched by the movie. (I’ve personally seen it twice and I rarely have time for movies these days. I will warn you, it may require several tissues!) Be careful not to try to “fix” your daughter’s fears. They are very real and she needs to face them.

What ever techniques you use to get your daughter to share her feelings with you, it is important not to short change this step. In order to fully embrace life, each person must embrace death. If not now, your daughter must one day face the fact that we will all die, and unfortunately, before death, many people do suffer. If she is able to grasp that concept now, she will achieve an incredible level of maturity. I recently heard a radio interview of a 13 year-old boy who races bicycles. The interesting thing about him was that he only has one leg. The other had been amputated, first at the knee and later at the hip, due to bone cancer. In the interview he sounded so full of energy and hope! He stated that he knew we were all going to die, but no one knew when they would die. So he figured he had better make the most of each day, and that was why he raced. I was amazed at the attitude of this young man. He was able to take what could have kept him wheel chair bound, and turned it into a motivation to live life to the fullest! Cancer had not robbed him of his leg, but given him an understanding of life (and therefore a zest for living) that far exceeded his years. This isn’t something that can be taught, but you can help your daughter come to these conclusions on her own.

You might also want to consider staying up with her one night (especially if it is not a work or school night). Turn out the lights as you normally would at bedtime, and light candles as I’m sure you did during the hurricane. Get a big cuddly comforter and curl up together under it. Make sure she feels safe in the very same atmosphere she experienced during the hurricane. Ask her how she feels. Without passing judgment on her feelings — not asking her to change them in any way — begin talking about all the things she dreams of one day doing. Encourage her to dream big! Her dreams may start as high school cheer leader. Ask her what that would be like; what she would enjoy most about it. She may dream of college and grad school or trips around the world or marriage and motherhood or all of the above. Whatever her dreams, encourage her (they will change over time, so you don’t need to worry if she dreams of riding a Harley across the country with the Hell’s Angels!). Don’t worry about being directed — just let the conversation flow. When you are done, ask her if she might like to write down some of her dreams, or tape record them, or video them. Maybe you could take a still picture of the two of you cuddled under the comforter (aren’t cameras with timers wonderful?) so she could remember this night and all her dreams.

If you find that it is difficult for your daughter to discuss her thoughts and feelings with you, consider seeking the help of a therapist such as a psychologist, psychiatrist, therapist or counselor. It is not uncommon for teenagers to have trouble expressing their fears to their parents and loved ones. Therapy can provide a wide array of benefits and may help your daughter discover ways to cope with her fears and emotions.

Anxiety (which is often brought on by a stressful event) is probably the most common cause of difficulty falling asleep. This is called “stress related insomnia.” It is a self-limited problem that usually resolves over several weeks (sometimes several months). It does not tend to turn into chronic insomnia. It might be helpful to reassure your daughter that it is normal to have difficulty falling asleep after a stressful life event, and that she can expect her situation to improve over the next several weeks. During this time period it is important to have good sleep habits:

• A consistent bedtime and a consistent rising time — 7 to 8 hours later. (You can make an exception for your late night chat.)
• Even if tired, do not “sleep in.” This could prolong the problem!
• Not reading in bed. The habit of reading in bed can give the brain mixed signals, making it even more difficult to return to normal sleep patterns.
• Refraining from daytime napping. Even if there is daytime fatigue or sleepiness, it is important not to sleep during the day in order to get the normal circadian rhythm back into step.
• Avoiding all alcohol and caffeine.
• Not using sedatives. (Although seditives have a therapeutic role in some situations, I agree that they are not best in this situation.)

If this problem doesn’t resolve within a few months, it will be important to have your daughter evaluated by a professional skilled in sleep disorders. He or she can lead your daughter through behavioral programs that can be helpful in her situation. These include relaxation techniques, meditation, guided imagery, biofeedback, systematic sleep restriction, and bright light therapy. All of these techniques should be done in conjunction with an expert in sleep. While it is tempting to jump right in and fix the sleep problems your daughter is having, if you don’t deal with the underlying issues first, you will be missing out on a golden opportunity to help her grow. Times like this are trying for parents. We don’t want our children to experience pain, much less to help them embrace pain. But what an honor it is to be able to help our children face the truly difficult issues of life, and grow into mature, well adjusted adults.