Discover 5 powerful tips to effectively manage chronic pancreatitis in children for better health and wellness.

Pancreatitis Chronic: Comprehensive Guide for Managing in Children

Introduction

Chronic pancreatitis, a long-lasting inflammation of the pancreas, is a condition that significantly impacts a child’s physical well-being and quality of life. Though more commonly associated with adults, chronic pancreatitis in children is a serious health concern that requires early recognition and diligent management.

Brief Overview of Chronic Pancreatitis and Its Effects on Children

Chronic pancreatitis occurs when the pancreas, a vital gland responsible for digestion and blood sugar regulation, undergoes continuous inflammation, leading to irreversible damage. In children, this condition can cause recurring abdominal pain, malabsorption of nutrients, and long-term complications such as diabetes or growth delays. It can also have profound emotional and social impacts, interfering with school activities, sports, and peer relationships.

Why Proactive Management is Crucial for Young Patients

Unlike adults, whose pancreatitis is often linked to lifestyle factors, children’s cases often stem from genetic mutations or underlying medical conditions. Proactive management is essential to:

• Mitigate complications such as malnutrition, infections, or diabetes.
• Alleviate debilitating symptoms like chronic pain and digestive distress.
• Ensure normal physical development and emotional well-being.

A structured, multidisciplinary approach can significantly improve children’s quality of life and reduce the impact of the disease.

What Readers Can Expect to Learn from the Article

This article delves into chronic pancreatitis as it affects children, covering essential aspects such as:

• Understanding the nature and causes of the condition.
• Recognizing symptoms and seeking timely medical care.
• Implementing actionable tips for management, including dietary strategies, pain relief methods, and regular monitoring. By the end, caregivers will gain insights into creating a supportive, health-focused environment for children battling chronic pancreatitis.

Section 1: Understanding Chronic Pancreatitis in Children

Definition and Overview

What is chronic pancreatitis?

Chronic pancreatitis is an ongoing inflammation of the pancreas that causes permanent damage to its structure and function. Unlike acute pancreatitis, which is sudden and may resolve with treatment, chronic pancreatitis is progressive and can result in long-term complications. In children, this condition often requires lifelong management and has a significant impact on overall health and well-being.

Key Differences Between Acute and Chronic Pancreatitis

Characteristic	Acute Pancreatitis	Chronic Pancreatitis
Duration	Temporary, often resolving within weeks	Persistent, with progressive damage
Symptoms	Severe, sudden pain and inflammation	Chronic, recurrent pain with digestive issues
Reversibility	Damage usually reversible	Irreversible structural and functional damage
Underlying Causes	Often lifestyle-related (e.g., alcohol, gallstones)	Often genetic or idiopathic in children

Causes in Children

Genetic Factors

• Hereditary Pancreatitis: A genetic mutation in the PRSS1 gene can predispose children to recurrent inflammation.
• CFTR Gene Mutations: Commonly associated with cystic fibrosis, these mutations can impair the pancreas’s normal functioning.
• SPINK1 Gene Mutations: Linked to increased susceptibility to pancreatitis due to insufficient pancreatic enzyme regulation.

Environmental and Lifestyle Contributors

While less common in children, certain environmental factors can also contribute to chronic pancreatitis:

• Dietary Issues: High-fat diets can sometimes exacerbate pancreatic strain.
• Medications or toxins: Exposure to certain drugs or toxins may play a role in rare cases.
• Trauma: A physical injury to the abdomen can lead to pancreatic inflammation.

Symptoms to Watch For

Caregivers should be vigilant about early signs of chronic pancreatitis to ensure timely diagnosis and management.

1. Persistent Abdominal Pain: A hallmark symptom, often centered in the upper abdomen, which may worsen after eating.
2. Digestive Issues: Chronic diarrhea, greasy or foul-smelling stools (steatorrhea), indicating fat malabsorption.
3. Nutritional Deficiencies: delayed growth, weight loss, or failure to thrive due to poor nutrient absorption.
4. Blood sugar fluctuations: an increased risk of diabetes if insulin production is compromised.
5. Fatigue and malaise: often stemming from the body’s inability to absorb essential nutrients.

Section 2: Importance of Early Diagnosis and Medical Care

Role of Early Diagnosis

How It Helps Prevent Complications

Early diagnosis plays a pivotal role in managing chronic pancreatitis effectively, especially in children. By identifying the condition in its initial stages:

• Complication Prevention: Early intervention can help mitigate long-term effects such as malnutrition, pancreatic insufficiency, and diabetes. For instance, timely enzyme replacement therapy can improve nutrition absorption.
• Symptom Control: Catching chronic pancreatitis early allows caregivers and medical professionals to implement lifestyle changes and medical treatments to alleviate pain, digestive distress, and other symptoms.
• Improved Quality of Life: Early diagnosis helps children avoid prolonged discomfort and ensures they maintain normal growth and development milestones.

Diagnostic Methods

Identifying chronic pancreatitis in children often involves a combination of advanced medical testing and clinical observation.

1. Imaging Techniques:
   • Ultrasound and CT scans help visualize pancreatic inflammation or structural changes.
   • MRI with MRCP (Magnetic Resonance Cholangiopancreatography) provides detailed images of pancreatic ducts, aiding in precise diagnosis.
2. Blood Tests:
   • Tests to measure pancreatic enzyme levels (e.g., amylase and lipase). Elevated levels may indicate inflammation.
   • Assessments of nutritional deficiencies or blood sugar levels help evaluate secondary complications like malabsorption or diabetes.
3. Genetic Testing:
   • Since many pediatric cases are linked to genetic mutations, tests to identify mutations such as PRSS1, CFTR, or SPINK1 are essential. This can clarify underlying causes and inform long-term treatment planning.

Collaborative Medical Management

Importance of Working with Pediatric Gastroenterologists

Pediatric gastroenterologists are central to managing chronic pancreatitis in children. These specialists bring:

• Expertise in Pediatric Care: Their focus on children’s unique physiological needs ensures that treatments are tailored appropriately.
• Comprehensive Treatment Plans: They work to balance medication, nutritional management, and preventive care to address both symptoms and root causes.

Coordination Between Healthcare Providers, Including Nutritionists

Effective management of chronic pancreatitis often requires a multidisciplinary approach.

• Role of Nutritionists:
  • Nutritionists develop diet plans that are low in fat and easy to digest, ensuring children receive enough nutrients without exacerbating pancreatic strain.
  • They also monitor weight and growth metrics to address potential deficiencies or malnutrition.
• Involvement of Other Specialists:
  • Endocrinologists may be required if pancreatic insufficiency leads to diabetes or other hormonal imbalances.
  • Psychologists or counselors can provide emotional support to children and families coping with chronic illness.

Section 3: Tip 1: Establishing a Pancreatitis-Friendly Diet

Role of Nutrition in Managing Symptoms

Avoiding Foods That Trigger Flare-Ups

For children with chronic pancreatitis, dietary management plays a key role in minimizing flare-ups and supporting overall pancreatic health. The pancreas struggles to process high-fat or heavily processed foods, which can increase inflammation or worsen symptoms. Foods to avoid include:

• Fried and greasy foods: burgers, fried snacks, and fast food.
• Processed snacks: chips, packaged cookies, and sugary treats.
• Full-fat dairy products: Switch to low-fat milk or yogurt instead.
• Sugary or carbonated beverages: These can irritate digestion and should be replaced with water or mild herbal teas.

Educating children and their families about avoiding these triggers ensures fewer flare-ups and promotes stable digestive health.

Importance of a High-Protein, Low-Fat Diet with Easy-to-Digest Foods

To support the pancreas and maintain essential energy levels, a high-protein, low-fat diet that is easy to digest is critical. This helps reduce strain on the pancreas while still meeting a child’s nutritional needs. Key diet recommendations include:

• Protein sources: lean meats like chicken or turkey, fish, and plant-based proteins such as tofu and lentils.
• Low-fat options: Incorporate low-fat dairy products and avoid heavy creams or fatty cheese.
• Digestible carbohydrates: Use easily digestible options like boiled rice, mashed potatoes, or steamed vegetables.
• Healthy fats: Include small amounts of healthy fats like avocado or olive oil, which are easier to digest.

Meal Plans and Examples

Balanced Meals for Children with Chronic Pancreatitis

1. Breakfast: Scrambled egg whites with whole-grain toast and a small serving of fruit (like a banana or papaya).
2. Lunch: Grilled chicken breast, steamed vegetables (zucchini, carrots, broccoli), and a portion of boiled rice.
3. Dinner: Baked salmon or grilled tofu with sweet potato mash and lightly seasoned spinach.

Snacks and Alternatives That Provide Necessary Nutrients

Healthy snacks can help maintain energy levels while avoiding pancreatic irritation.

• Fresh fruit smoothies made with low-fat yogurt and berries.
• Plain crackers with almond butter.
• Boiled eggs or steamed corn with a pinch of seasoning.
• Small handfuls of mixed nuts (if tolerated) or seeds like sunflower or pumpkin seeds.

These meals and snack options ensure children get essential nutrients while adhering to dietary guidelines for pancreatitis.

Supplements

Pancreatic Enzyme Replacement Therapy (PERT)

Children with chronic pancreatitis often suffer from pancreatic insufficiency, where the pancreas cannot produce enough digestive enzymes. PERT is a vital supplement that helps:

• Break down fats, proteins, and carbohydrates, making them easier to digest.
• Prevent malabsorption and related issues like diarrhea or nutrient deficiencies. This therapy must be prescribed and monitored by a healthcare provider to ensure the correct dosage.

Vitamins and Minerals to Address Deficiencies

Chronic pancreatitis often leads to deficiencies in fat-soluble vitamins (A, D, E, K) and other essential nutrients due to impaired absorption. Pediatricians or nutritionists might recommend:

• Vitamin D supplements for bone health and immune support.
• Multivitamins to cover broader nutritional gaps.
• Calcium and magnesium for strong bones and overall well-being.

Section 4: Tip 2: Staying Hydrated and Promoting Digestive Health

Why Hydration Matters

Impact of Dehydration on Pancreatic Health

Hydration is a cornerstone of managing chronic pancreatitis, particularly for children. The pancreas plays a critical role in producing digestive enzymes and regulating blood sugar. When the body is dehydrated, the pancreas struggles to maintain optimal functioning. Key impacts of dehydration include:

• Worsening inflammation: Insufficient hydration can exacerbate inflammation, intensifying pain and discomfort.
• Digestive Difficulties: A lack of water affects the ability of digestive enzymes to break down food properly, leading to malabsorption and bloating.
• Increased Risk of Complications: Dehydration can trigger acute pancreatitis episodes, making hydration vital for children managing the chronic form.

Encouraging Healthy Hydration Habits

Child-Friendly Strategies for Staying Hydrated

Getting children to drink enough water can be challenging, but these strategies make hydration more engaging and manageable:

1. Invest in Fun Water Bottles: Choose bottles with bright colors, favorite cartoon characters, or stickers that children can customize to make drinking water enjoyable.
2. Flavor the Water Naturally: Add slices of lemon, cucumber, or berries to the water for a refreshing taste. Herbal teas like chamomile (cooled) can also be a soothing option.
3. Set Hydration Goals: Use visual tools like a water chart or a time-marked water bottle to encourage children to meet daily hydration targets.
4. Incorporate Hydrating Foods: Offer fruits with high water content, such as watermelon, oranges, and cucumber slices, as snacks.
5. Make It a Game: Create a rewards system where they earn points or treats for reaching hydration goals consistently.

By making hydration an active and enjoyable part of their routine, children are more likely to maintain optimal fluid intake.

Probiotics and Gut Health

Benefits of Probiotics for Digestive Health in Pancreatitis

Probiotics, the beneficial bacteria that support gut health, are especially important for children with chronic pancreatitis. Here’s how they help:

• Enhance Digestion: Probiotics improve the breakdown and absorption of nutrients, compensating for the pancreas’s reduced efficiency.
• Reduce inflammation: Certain strains of probiotics, like Lactobacillus and Bifidobacterium, have anti-inflammatory properties that can alleviate pancreatic inflammation.
• Strengthen Immunity: A healthy gut microbiome supported by probiotics boosts overall immunity, protecting children from infections.
• Prevent Digestive Discomfort: Probiotics balance gut flora, reducing diarrhea and bloating that are common in chronic pancreatitis.

Probiotic Sources for Children

• Natural Foods: Include probiotic-rich foods like yogurt (low-fat and sugar-free), kefir, and fermented vegetables like kimchi or sauerkraut.
• Supplements: Pediatric probiotics are available in chewable, powder, or liquid forms; consult a healthcare provider to choose the best option for your child.

Section 5: Tip 3: Managing Pain and Improving Quality of Life

Addressing Pain in Children

Medications (Under Medical Supervision)

Chronic pancreatitis often causes persistent and severe abdominal pain in children, making pain management a crucial aspect of care. Medications should always be prescribed and monitored by a healthcare professional to ensure safety and effectiveness. Common approaches include:

• Over-the-Counter Pain Relievers: Mild pain may be managed with acetaminophen or ibuprofen under medical guidance.
• Prescription Medications: In more severe cases, doctors may recommend stronger pain relievers, including low doses of opioids, though these are used cautiously to avoid dependency.
• Antispasmodics: These can help reduce pancreatic spasms, providing relief from discomfort.
• Adjunctive Therapies: Medications such as antidepressants or anticonvulsants are sometimes prescribed to address nerve pain, especially in long-standing cases of chronic pancreatitis.

Non-Pharmacological Methods

Non-drug interventions can also be effective in reducing pain and improving comfort for children. These methods are often used in combination with medical treatment.

1. Heat Packs: Applying heat packs to the abdomen can help relax muscles and alleviate pain during flare-ups. Ensure the heat is moderate to prevent burns, and use for 15–20 minutes at a time.
2. Relaxation Techniques: Simple techniques such as deep breathing, progressive muscle relaxation, or guided imagery can help children manage pain by reducing stress and tension. Incorporate these practices during quiet times or before bedtime.
3. Acupuncture: While evidence is limited, some families find the treatment beneficial in relieving chronic pain and improving overall well-being.
4. Massage Therapy: Gentle abdominal massage can enhance circulation and provide some relief from discomfort, but always seek professional advice beforehand.

Mental and Emotional Support

Coping Strategies for Children and Their Families

Living with chronic pancreatitis can take a toll on a child’s emotional health and their family’s overall dynamics. Developing coping strategies is essential for fostering resilience and maintaining a positive outlook.

• Routine and Structure: Establishing a consistent daily routine around meals, medication, and rest can help children feel more in control of their condition.
• Support Groups: Engaging with pediatric support groups or online communities for chronic pancreatitis provides children and their families with a network of shared experiences, advice, and encouragement.
• Stress Management Activities: Introducing age-appropriate mindfulness exercises or creative outlets like art therapy can help children process their emotions in a healthy way.

Encouraging Open Communication About Health Challenges

Open, honest dialogue is critical for helping children understand and cope with their condition. Some practical tips include:

• Age-appropriate Conversations: Tailor explanations about chronic pancreatitis based on the child’s developmental stage. Younger children may benefit from simple analogies, while older kids can handle more detailed discussions.
• Acknowledging Emotions: Encourage children to express their feelings—be it fear, frustration, or sadness—without judgment. Let them know it’s okay to feel overwhelmed.
• Empowering the Child: Involve them in decisions about their care, such as choosing meals or tracking hydration goals, to foster independence and a sense of control.
• Family Counseling: Regular family therapy sessions can help parents and siblings address their own emotions and better support the affected child.

Section 6: Tip 4: Regular Follow-Ups and Monitoring

Importance of Consistent Medical Follow-Ups

Tracking Disease Progression and Adjusting Treatments

Regular medical follow-ups are essential for children with chronic pancreatitis, as they allow healthcare providers to:

• Assess Disease Progression: Frequent evaluations help track the severity of the disease and detect any new complications, such as diabetes or significant structural changes in the pancreas.
• Customize Treatment Plans: Follow-ups allow adjustments to medications, dietary plans, and supplements to meet the child’s changing needs. For example, increasing or modifying pancreatic enzyme replacement therapy (PERT) as symptoms evolve.
• Prevent Complications: Timely monitoring can help identify and mitigate risks before they escalate, such as malnutrition, infections, or significant growth delays.
• Collaborate with Specialists: Regular check-ins offer the opportunity to involve multiple specialists, such as endocrinologists or dietitians, to address specific challenges comprehensively.

By making follow-ups a priority, caregivers ensure that the child’s condition is managed proactively, reducing the likelihood of flare-ups and long-term health issues.

Key Health Indicators to Monitor

Growth and Weight

Children with chronic pancreatitis are at risk of growth delays and weight loss due to malabsorption of nutrients. Caregivers and medical professionals should:

• Track Weight Consistently: Regular weigh-ins can highlight issues related to insufficient calorie intake or digestive inefficiencies.
• Monitor Height: Any deviation from expected growth curves may indicate the need for dietary adjustments or additional supplementation.
• Assess nutritional markers: Blood tests can measure levels of essential vitamins, minerals, and proteins to detect deficiencies.

Digestive Health

Monitoring digestive function is crucial in identifying issues early and preventing complications.

• Frequency and Nature of Stools: Persistent diarrhea, greasy stools (steatorrhea), or other abnormalities may indicate poor fat absorption.
• Appetite Changes: A noticeable decrease in appetite or reluctance to eat could signal worsening digestive health.
• Pain Levels: Documenting the frequency and severity of abdominal pain provides valuable information for treatment adjustments.

Emerging Symptoms

Caregivers should remain vigilant for any new symptoms that could signal complications.

• Blood Sugar Fluctuations: Regular blood glucose monitoring can help detect early signs of diabetes.
• Signs of Fatigue or Weakness: These may indicate worsening malnutrition or an increase in disease activity.

Building a Support System

Role of Caregivers

Caregivers play a vital role in the effective management of chronic pancreatitis. They can:

• Coordinate Medical Appointments: ensuring regular follow-ups and maintaining detailed records of symptoms and treatments.
• Encourage Compliance: Helping children stick to prescribed diets, medications, and hydration routines.
• Provide emotional support: creating a nurturing environment where the child feels understood and supported.

Support Groups and Health Communities

Engaging with support networks can provide both practical advice and emotional reassurance.

• Pediatric Support Groups: Local or online groups connect families going through similar experiences, offering a sense of community and shared understanding.
• Health Forums: Evidence-based health communities allow caregivers to stay informed about the latest treatment options and best practices.
• Professional Counseling Services: Family or individual counseling can help address the emotional challenges of managing a chronic condition.

By fostering a network of support, families can better manage the physical, emotional, and logistical demands of chronic pancreatitis, ensuring the child thrives despite their condition.

Section 7: Tip 5: Encouraging an Active but Balanced Lifestyle

Benefits of Physical Activity

Suitable Low-Impact Exercises for Children

Physical activity is vital for children with chronic pancreatitis, but the type and intensity of exercise need to be carefully considered to avoid overexertion. Low-impact exercises provide numerous benefits, including improved circulation, enhanced mood, and better overall health, without straining the pancreas. Suitable options include:

• Walking: A simple yet effective way to keep children active. Daily walks in a park or safe environment can boost energy levels and improve digestion.
• Swimming: Gentle on the joints and engaging for children, the water provides a full-body workout while being low-impact.
• Cycling: Riding a bicycle at a comfortable pace is an enjoyable exercise that supports cardiovascular health.
• Yoga: A great option for promoting flexibility, balance, and relaxation (detailed further below).

By engaging in these activities, children can enjoy the physical and emotional benefits of exercise while avoiding strain on their bodies.

Preventing Overexertion

Tailoring Activities to the Child’s Energy Levels and Symptoms

Overexertion can exacerbate symptoms of chronic pancreatitis, such as fatigue and abdominal pain. It’s essential to tailor activities based on the child’s condition:

1. Listen to Their Body: Teach children to recognize warning signs like pain, dizziness, or extreme fatigue and stop the activity immediately.
2. Short, Frequent Sessions: Instead of long exercise durations, opt for shorter sessions (15–30 minutes) spread throughout the day.
3. Rest and Recovery: Encourage adequate rest after physical activity, ensuring children balance movement with sufficient downtime.
4. Modify Intensity: Start with gentle activities and gradually increase intensity as the child’s stamina improves, under medical guidance.

This approach allows children to stay active while avoiding unnecessary physical stress, keeping their pancreatitis symptoms in check.

Holistic Approaches

Incorporating Mindfulness and Yoga for Stress Management

Mindfulness and yoga are valuable tools for children managing chronic pancreatitis. These holistic approaches promote not only physical well-being but also emotional resilience. Here’s how:

1. Yoga:
   • Stress Relief: Yoga postures and breathing exercises can help alleviate tension and reduce abdominal discomfort. Poses like Child’s Pose (Balasana) and Cat-Cow (Marjaryasana-Bitilasana) are gentle and beneficial.
   • Improved Digestion: Certain poses, such as seated forward bend (Paschimottanasana), can support digestion and enhance pancreatic function.
   • Flexibility and Strength: Yoga encourages controlled movements, fostering physical stability without strain.
2. Mindfulness Practices:
   • Meditation: Short, guided meditations teach children to focus on the present moment, helping to manage anxiety related to their condition.
   • Deep Breathing: Practices like belly breathing or alternate nostril breathing (Nadi Shodhana) encourage relaxation, which can ease pain and improve overall health.
   • Body Scanning: A mindfulness technique that helps children identify areas of tension and consciously relax them.

Integrating these practices into daily routines not only helps manage the physical aspects of chronic pancreatitis but also promotes mental clarity and emotional balance.

Section 8: Case Studies or Real-Life Examples

Success Stories: Thriving Despite Chronic Pancreatitis

Case Study 1: Sarah’s Journey to Wellness

Sarah, a 10-year-old diagnosed with chronic pancreatitis due to a genetic mutation, struggled with severe abdominal pain and weight loss. After being placed on a structured, low-fat diet plan by a pediatric nutritionist and starting Pancreatic Enzyme Replacement Therapy (PERT), Sarah’s health improved significantly. Her caregivers encouraged her to participate in yoga sessions tailored for children, helping her manage pain and reduce stress. Quote: “The combination of the right diet and activities like yoga made such a difference for Sarah. Her energy is up, and she’s finally able to enjoy school again.” Sarah’sother.

Case Study 2: Liam’s Path to Pain Management

Liam, a 14-year-old athlete, was devastated when pancreatitis made him step back from sports. Through his doctor’s guidance, he adopted a fitness routine focusing on low-impact exercises like swimming and walking. Regular hydration and mindful meal planning helped him avoid flare-ups. He also found solace in joining an online peer support group for teens with chronic illnesses. Quote: “At first, I thought I’d never play again, but finding new ways to stay active kept my spirits up. Sharing stories with others who get it really helped.” — Liam.

Case Study 3: Building Resilience in Ananya

Ananya, a 7-year-old, faced anxiety due to frequent hospital visits for her pancreatitis treatment. Her parents introduced creative outlets like painting and storytelling to help her express emotions. Family counseling sessions guided them in maintaining a positive environment. Over time, Ananya grew more confident in discussing her condition with teachers and friends. Quote: “Helping Ananya understand her condition and express her feelings brought us closer as a family. She’s learning to handle challenges with grace.” — Ananya’s Father.

Conclusion

Key Takeaways from the Five Tips

• A pancreatitis-friendly diet tailored to individual needs can significantly reduce flareups and improve digestive health.
• Hydration and probiotics play an essential role in supporting overall pancreatic and digestive function.
• A combination of pain management techniques and emotional support can enhance a child’s quality of life.
• Consistent follow-ups with healthcare providers ensure timely adjustments to treatment plans and monitor health indicators.
• Encouraging an active but balanced lifestyle helps children stay physically and mentally healthy while navigating their condition.

Encouragement for Caregivers

Parents and caregivers play a vital role in empowering children to live fulfilling lives despite chronic pancreatitis. By fostering open communication, engaging with the right medical professionals, and implementing holistic management strategies, families can navigate the challenges together and provide children with the tools to thrive.

Call to Action

Explore these additional resources for more support and guidance:

• National Pancreas Foundation: pancreasfoundation.org
• Local or Online Pediatric Pancreatitis Support Groups
• Diet and Wellness Tips from Mindful Living Guide

Additional Content Suggestions (Optional Sections)

FAQs About Chronic Pancreatitis in Children

• What causes chronic pancreatitis in children?
• Is chronic pancreatitis curable or manageable?
• Can children lead normal lives with this condition?

Myths vs. Facts About Pediatric Pancreatitis

• Myth: Children can’t develop pancreatitis.
  • Fact: While less common, children are still susceptible, often due to genetic factors.
• Myth: There’s no effective treatment for pediatric pancreatitis.
  • Fact: With early diagnosis and comprehensive management, children can live healthy lives.

Infographic or Downloadable Checklist for Parents

Include a printable checklist with items such as:

• Approved foods and meals for a pancreatitis-friendly diet.
• Hydration tracking tools for children.
• Signs to monitor and report to the doctor.