Diagnosing Puberty

picture for puberty post

About a month ago my 7 year old daughter (soon to be 8), came to me one night, with a nervous complaint of a lump behind her right nipple.  With a slight sense of unease, I got up, palpated the spot she was pointing to, and sure enough there was a hard, pea sized nodule lurking under her skin.  Thinking the lump was probably normal breast development, I sent my daughter back to bed with a kiss and an “everything is normal” hug, then immediately jumped on my computer Googling 7 year old girls with breast lumps.

To my relief, most of my research pointed me in the direction of early thelarche.   Thelarche is the development of breast tissue, otherwise known as breast buds, and is one of the signals of the onset of puberty.  According to a study in the journal Pediatrics, American girls are maturing earlier.  What was once a normal pubescent age of 10 or 11 is now being seen in 7 and 8 year olds.

However, when these signs and symptoms of puberty occur before the age of 8 in girls and 9 in boys, then precocious puberty could be to blame.  Early puberty has its problems and could lead to shorter growing times, and shorter overall height.  The psycho/social problems with early puberty could lead to poor body image and low self esteem.

Signs of precocious puberty in girls:

Breast growth
First Period
Pubic Hair
Rapid Growth

Signs of precocious puberty in boys:

Enlarged testicles/penis
Body odor
Deepening voice
Pubic Hair
Rapid Growth

The following morning I placed a call to my pediatrician, and after explaining to the nurse my daughter’s finding from the night before, I expected her to say, “That’s normal, nothing to worry about.”  Instead she said my daughter was too young for breast development, and needed to come in and see the doctor.  My stomach did a little flip as I made the appointment.  Was I missing something?  Was this normal development, or a new anxiety to keep me from sleeping at night?

My daughters experience got me thinking about my own development, or lack thereof.  I have no memory of breast bud development; I would have been horrified to touch my own growing flesh, let alone go to my mom about it.  When I was growing up girls didn’t do that sort of thing.  I was twelve when my period came, and I remember the shock and embarrassment that brought on.  I was horrified by the painful, hemorrhaging happening between my legs, and there was no way I was going to my mother.  My sister, (through my tears of objection), did it for me.

My daughter is a different breed, thank God.  She is the daughter of a nurse.  I don’t lie, or make up silly names, much to the chagrin of my husband and father.  When my daughter was three, she used to run around my parent’s house singing, “I have a vagina; I have a vagina!!”  My father, not quite understanding her sing song, turned to my smiling mother and asked, “What is she saying?”  To which my mother replied in her best sing song voice, “I have a vagina, I have a vagina!!”

There’s a look that father’s, not men, but father’s give when they hear the word vagina that makes them squirm in their seat, roll their eyes, and huff and puff a little bit as if some sort of taboo has been broken, fearing the word period, or perhaps feminism might slip out next.  This was the look my father gave that day.  It’s no wonder I was afraid to get my period.

So thankfully my daughter is comfortable in her own skin, and so far, not afraid to come to me for help.  But could she be facing puberty at age 7, when I could barely face it at age 12?

The pediatrician examined my daughter later that day, and felt the pebble like nodule of what?  She didn’t know.  “Wait three weeks, if it’s still there then I would like her to see a pediatric endocrinologist.”  Really, I thought?  Was this necessary?

With anxious weekly reminders from my daughter, we got to week three, and the lump was still present, along with what appeared to be soft breast tissue, or as my daughter likes to call it, “the hill.”  After a thorough examination by the endocrinologist, we were still no closer to an answer.   She too agreed that the lump seemed odd, but thought we should run some tests to determine if she was entering puberty.  Since when did the normal transition from child to adult become so complicated?

So what are the tests for puberty?  Here is a list of the most common ones:

  1. Blood work is first collected to test for the hormones of puberty: LH (Luteinizing Hormone), FSH (Follicle Stimulating Hormone) Estrogen Levels, and Thyroid levels, (Testosterone levels in boys).
  2. A bone X-Ray of the wrist is performed to measure the growth plates and determine bone age vs. stated age.
  3. An MRI of the brain may be done to look for any abnormalities.
  4. An ultrasound of the ovaries may be done in girls to rule out a cyst or tumor.

If the tests are positive and early puberty is diagnosed then there are treatment options which include a monthly injection of a hormone that blocks the onset of puberty.  This hormone is given until a more reasonable pubescent age and then discontinued, allowing the body to take its normal course.

This treatment option was discussed with me by the endocrinologist, and I have to say it weighed heavy on my conscience.  Medicate my child to prevent early puberty, or let nature take its course?  I was more than hesitant to have to make that decision.

After blood work and a wrist X-Ray, it was determined that my daughter was not in puberty; a relief on the one hand, but leaving me with the question, “Then what is that pea sized lump in her breast?”

Only an ultrasound will be able answer that question.

In the meantime I wait and I worry (a little), about what I’m putting my child through, and if I really have anything to worry about at all.

I can’t help but wonder if after all this testing, we’ll come full circle to find out her breast lump was nothing more than premature thelarche, and the premature wanderings down the inevitable path to a diagnosis of puberty.

Post Mortem Etiquette

NYPD One Police Plaza

NYPD One Police Plaza

Did you ever notice that one of the many stupid things people say when you lose a loved one includes the line, “Oh, I’m so sorry, how old were they?”  Well, since I’ve lost someone close to me, where age was never a factor in determining my level of grief, I have come to both dread and outright hate this question.  But now that it has crawled its way into my consciousness, I have no choice but to confront it head on.

The question alone ‘How old were they?’, implies that based on the answer, the questioner can either have a reaction of utter dismay or a reaction of relief, either way it leaves the person who is actually grieving unnerved.  If I respond with “three months old“: dismay, if I respond “ninety“: relief, (followed by stupid response number two: “well, they lived a long life.”)  Am I supposed to buy that line of crap?  Am I supposed to feel less sad for someone I’ve known my whole life, let’s say my grandparent, vs. someone I’ve known for only three months.

Is my grief mitigated by age?

And then there’s the middle aged dilemma, not quite too young to evoke the shock and awe response, but not too old to get that 2nd line of crap.  In fact, people here aren’t quite sure what to do.  Here’s a suggestion, stop asking the fucking question!

My father died at age sixty-seven.  It was sudden and tragic.  Is my heartache any less?  Of course not.  I didn’t see him as young or old, I only saw him as my dad.

In this I am sure I am not alone.  No one wants to measure their grief in time.  From the new mother who gives birth to a stillborn, or the daughter who loses her ninety-six year old mother, grief is grief.

So to all of those thinking about asking this question next time you are face to face with someone who has just lost a loved one, don’t do it.  Be kind, say your sorry, give and hug and move on.  I know I don’t want to be remembered for how old I was when I died, but rather how I lived.

Don’t you?

Reposted courtesy of http://www.inthepowderroom.com

Cupcake Wars; Battling Childhood Obesity One Cupcake At a Time

Spider Halloween Cupcakes by Jean James

Why is it that when America has a problem with something their only solution is declare war on it?  There’s the war on drugs, the war on guns, the war on terror, the war on women, the war on Christmas, the war on cancer, the war on job creation, the war on marriage, the war on free speech, the war on war, the war on ethics, the war on working moms, the war on murder, the war on success, the war on sugary drinks, the war on fossil fuels, the war on soda, the war on obesity and therefore the war on cupcakes.  There are so many wars going on, I’m having a hard time keeping it all straight in my head.  Maybe there should be a war on declaring war on everything!  Just saying…

So back in 2010 the Obama administration signed into law the Healthy Hunger-Free Kids Act (HH-FKA).  This was enacted to battle both hunger and childhood obesity by presenting guidelines to improve the nutritious value of school lunches, while concurrently providing accessibility to lunch programs for children who were otherwise going to school hungry.  At the helm of the battleship USS Fat and Hungry Kids, is our effervescent First Lady, Michele Obama.  I applaud her efforts for drawing national awareness to a distended obesity crisis among children, teenagers, and adults.  But as a nurse, and a bit of cynic, I also realize that the obesity epidemic is costing the U.S. government approximately 3 billion dollars a year for those children covered under Medicaid, and about 11 billion dollars a year for those privately insured.  So when big money is at stake, it’s no wonder we have to declare war on something.  And that something right now is the cupcake.

Because of this new HH-FKA law, I received a notice home from my children’s elementary school principal  informing me that the time-honored tradition of bringing in cupcakes for your kid’s birthday party at school was being eliminated.  In lieu of cupcakes the notice recommended bringing in  “goodie bags”.   It seems our principal is going all Mayor Bloomberg on our kids big, fat asses, and has decided (along with the Federal Government), that they’ve had one cupcake too many.  I have to tell you that I received this notice on the same day I picked up my kids from school, and was slammed in the face by the odor of bacon wafting down the hallway from the cafeteria…you know bacon, the other white fat!

Now I don’t know about you, but I love making cupcakes for my kid’s birthday parties at school.  Two of them have birthdays in the fall, which gives me a whole lot of creativity time making Halloween themed spooky masterpieces.  The kids mostly love to look at the cupcake designs, eat the frosting off the top, and throw the rest of the cupcake in the garbage, so I’m pretty sure the caloric intake isn’t as high as the government might think.  The goodie bags, on the other hand, are mostly filled with candy (100% ingestion rate guaranteed) and or landfill crap (cheap toys imported from China probably coated in toxic lead levels).

Look, I get it, childhood obesity is ever-expanding, but I don’t need the President, the Mayor, or my school principal telling me what I can or cannot feed my kids.  We need to look a little deeper, beyond the batter and frosting, outside the schoolyard grounds, far, far away from the White House lawn, and into the windows of the kitchens of the culprits of the cause of the obese children.  If you’re a parent that means you!

17% of children and adolescents 2-19 years old are obese in this country.  If one parent is obese then their child has a 50% chance of being obese, if both parents are obese, that risk goes to 80%. It is the personal responsibility of parents to  provide an environment of health at home for themselves and their children.  I’m a parent, I’m not obese.  I exercise regularly, I eat right, and once in a while I like to enjoy a cupcake.  This problem of obesity is self-induced and self-indulgent.  Most people are quiet aware that they are overweight.  But try telling someone they can’t have something, and all you do is make them want it more.

America has not won one war it has declared war on.  We still have a drug problem, there are way too many guns on the street, the terrorists keep terrorizing us, people are still dying from cancer, and fat people keep getting fatter.  Government intervention is never the solution to solving personal problems.  Banning cupcakes from school isn’t going to make any child thinner.

This problems run deep in the psyche of Americans.  Somewhere in the last twenty years kids stopped being kids.  Playing video games won out to playing kick the can.  Paranoia won out to trusting that kids could play outside with their friends, and if as a parent you’re so worried about them being abducted, then get YOUR fat ass off the couch and go play with them!  We’ve become a nation of instant gratification and reward.  Had a hard day…I deserve a drink; boyfriend broke up with you, have a pint of Haagen-Dazs, kid throwing a temper tantrum, give him a cookie to shut him up.  Life isn’t easy, but  we don’t have to have a treat every time the going gets tough.

I worry about the weakness of overindulgent Americans, but I worry more about our weakness to stand up and keep big brother’s hands out of our cookie jars.

Friday Funnies: Calling All Nurses!

U.S. Nurses playing cards, reading, and relaxing circa 1918.  U.S. Navy History and Heritage Command Photo.

U.S. Nurses playing cards, reading, and relaxing circa 1918. U.S. Navy History and Heritage Command Photo.



Something magical happens when nurses get together to share stories so funny they make us pee in our pants, double over in stitches, and send tears streaming down our face, as we release the tension of caring for some pretty f’d-up patients.  I have experienced this kind of laughter over the years and it’s like a great orgasm: deep, rich, and leaving you wanting more.

With that said, I would like to invite my fellow nurse readers (if I have any) to submit your funniest story, or one you’ve heard and think is worthy of retelling.  Each and every Friday I would like to post these stories to the ‘Friday Funnies’.  You can publish your story under your own name, your nom de plume, or remain anonymous. I’ll fill in my own stories if I don’t have any friday guest authors.

The only thing I ask is that you abide by the HIPPA laws, and use your artistic license to change any part of your story that might identify someone.

You can send your submissions to jeanjames@nightingalechronicles.com

Happy story telling!

Letting Go

courtesy of Asli Kutluay at aslikutluay.com

Florence Nightingale. Courtesy of Asli Kutluay at aslikutluay.com

As a critical care nurse I have had the unfortunate experience of taking care of what I tend to call ‘living corpses’.  Simply put, this is a human being, who if not for a ventilator, an intra-aortic balloon pump, a dialysis machine, at least three IV drips to maintain a blood pressure, and no hope for recovery, would not be alive.  Time and again I’m amazed at the ability of family to keep their loved one alive despite the obvious fact that the person they love and care for is nothing more than a shell of who they were.

I’m sure this sounds cruel to people who don’t work in the medical field, and familiar to those that do.  When a patient is deemed terminal the family is often the last to accept it.  (The 5 stages of grief.)  Most families eventually come around and do what’s best for their loved one, but there are those families that will never let go, and I find this disturbing.

It’s these families that would rather keep their loved ones dependent on artificial life support until the very end whether it be out of ignorance or religious belief.  I’m fascinated by the idea of people who quote religion for not removing life support as if they’re going against Gods will; however, isn’t trying to cheat death doing just that?  The term ‘artificial life’ gives rise to its unnatural state of being.

I thought my father might be one of those people, who for religious reasons, had trouble with the idea of removing life support from the terminally ill.  He seemed steadfast in his position, but lacked any clinical observations to support his opinions.  When my father was faced with his own mortality three years ago, it was I who sat down with him as his stage IV lung cancer was rapidly ravaging his body and explained to him his options.  Sadly there were only two: 1.) End up on a ventilator and die anyway, or 2.) Make himself a D.N.R. (Do Not Resuscitate) and die a more peaceful death.

My dad was a very intelligent man, and still had his faculties enough to know he did not want to die with a tube shoved down his throat, connected to a machine, devoid of dignity and privacy in his final moments.

He chose option 2.

My relief was palpable, and after twelve harrowing weeks, when it came time for my father to take his final breath he did so on his own terms, surrounded by his family, comforted by a morphine drip; and as he let go of this world and slipped into the next, I felt peace.

This Really Burns Me Up!

Courtesy of Jesse Michener at lifephotographed.com

Courtesy of Jesse Michener at lifephotographed.com

Two sisters from a Washington state school suffered severe sun burn during their field day festivities due to a ridiculous policy that states sunscreen cannot be applied to children at school; it is considered a “medication”.  Only California allows children to bring sunscreen to school.  The school district forbids teachers from applying sunscreen to children for obvious reasons, but refuses to allow the children to block themselves because sunscreen use requires a physician’s prescription.  What??!!

My two kids recently had field day and I got a notice home saying the exact same thing.  I could apply sunscreen to my children before leaving for school, but any reapplication would not be available for them should their initial block wear off.  So rather than protect the children from obvious dangerous exposure to the sun (one liability), they would rather cover their own assess by doing nothing (an even worse liability).

So tell me, why do we have school nurses?  I understand not wanting teachers to reapply the sunscreen and I absolutely agree with that, but if a child is burning and is in need of medical care, isn’t it the responsibility of the school nurse to intervene at that moment.  Where was this Tacoma WA. school nurse at anyway?  And even if the nurse can’t reapply sunscreen, shouldn’t her judgement come into play here and remove the children from the unsafe environment.

I can’t tell you how many notes I get home during the school year to give my permission for the most ridiculous things, you would think perhaps that on field day schools might make it a policy to have parents sign a permission slip allowing the school nurse to reapply sunscreen in the event that their child was starting to bubble up like a hot tar blister?  Call me crazy but this country is so obsessed with liability that we feel more comfortable with apathy.

Why is it that one state out of fifty has managed to find a solution to this problem, but 49 states still have their thumb up their ass?  I understand children have a lot of allergies, got it, but if the parents are sending in a labeled bottle of sunscreen that they always use on their child, then I’m not sure I see what the big deal is.

Again, doing nothing to protect children in a dangerous situation is more of a crime to me than acting in their best interest.  Field day should be a day for tears of joy and fun and laughter, not a day for tears of pain and trips to the Emergency room.  Thankfully these girls are healing from their burns, but what will their future hold?  According to skincancer.org it only takes one blistering sunburn to more than double their risk of melanoma later in life.

I wonder how many cumulative years of graduate degrees were on that field, yet no one was smart enough to take the children out of the sun?

Expiration Date; The Souring Aspects of Growing Old

courtesy of Asli Kutluay

Florence Nightingale courtesy of Asli Kutluay aslikutluay.com

Did you ever think you’d get to a point in your life when what you have to say doesn’t matter to anyone, anymore?   Maybe you’re already there, or know someone who is.  It’s the sad side to aging when your opinion expires, and the person on the other end of your flapping gums finds you about as relevant as spoiled milk.

I used to think that old people held such great wisdom and knowledge from all the years spent prior on this planet.  I believed in looking up to your elders, anxiously awaiting some bone of advice to nibble on and regurgitate into my own life.

But as I get older, I’m realizing that this just isn’t true.  Not all old people impart wisdom.  But for the many that do, are we listening?

As a nurse of twenty plus years, the one piece of elderly advice I have heard time and again is, “Don’t get old!”  I used to laugh at this comment and brush it aside, but at forty-one, I’m kind of starting to fear this bit of Methuselahian advice.  The physical aspects of aging are scary enough without the thought of gradually being reduced to nothing more than an amorphous cluster of denture cream, depends, and dementia.

We need to respect our youthfully challenged population, for one day we will step into their orthopedics, and it will be our coke rimmed spectacle reflection staring back at us in the mirror.

There’s usually a lesson in a story, even if you’ve heard it a thousand times.  So instead of rolling your eyes and planning your escape route, sit down, pour a cup of coffee, and listen to that old codger, because that might just be the lesson we’re all missing.

I don’t want to expire before my time.  I want to age like fine wine and have that cork popped open, instead of jammed into my doddering old pie hole.  We’re all gonna get there someday…

Just ‘Don’t get old” along the way!