Thursday, July 29, 2004

Question and Answers on Jaundice and Your Newborn

For all the 'new' parents, the american academy of pediatrics has come up with some new guidelines for jaundice in the newborns, and given below is the common frequently asked questions for the same.
The following Frequently Asked Questions" (FAQs) are from the American Academy of Pediatrics (AAP).
Published on 25th June 2004

Congratulations on the birth of your new baby!
To make sure your baby’s first week is safe and healthy, it is important that:

Your baby is checked for jaundice in the hospital.
If you are breastfeeding, you get the help you need to make sure it is going well.
Your baby is seen by a doctor or nurse at 3 to 5 days of age.
Here is some information about jaundice. (Please note: A Spanish version will be available late July 2004.)

Q: What is jaundice?
A: Jaundice is the yellow color seen in the skin of many newborns. It happens when a chemical called bilirubin builds up in the baby’s blood. Jaundice can occur in babies of any race or color.

Q: Why is jaundice common in newborns?
A: Everyone’s blood contains bilirubin, which is removed by the liver. Before birth, the mother’s liver does this for the baby. Most babies develop jaundice in the first few days after birth because it takes a few days for the baby’s liver to get better at removing bilirubin.

Q: How can I tell if my baby is jaundiced?
A: The skin of a baby with jaundice usually appears yellow. The best way to see jaundice is in good light, such as daylight or under fluorescent lights. Jaundice usually appears first in the face and then moves to the chest, abdomen, arms, and legs as the bilirubin level increases. The whites of the eyes may also be yellow. Jaundice may be harder to see in babies with darker skin color.

Q: Can jaundice hurt my baby?
A: Most infants have mild jaundice that is harmless, but in unusual situations the bilirubin level can get very high and might cause brain damage. This is why newborns should be checked carefully for jaundice and treated to prevent a high bilirubin level.

Q: How should my baby be checked for jaundice?
A: If your baby looks jaundiced in the first few days after birth, your baby’s doctor or nurse may use a skin test or blood test to check your baby’s bilirubin level. A bilirubin level is always needed if jaundice develops before the baby is 24 hours old. Whether a test is needed after that depends on the baby’s age, the amount of jaundice, and whether the baby has other factors that make jaundice more likely or harder to see.

Q: Does breastfeeding affect jaundice?
A: Jaundice is more common in babies who are breastfed than babies who are formula-fed, but this occurs mainly in infants who are not nursing well. If you are breastfeeding, you should nurse your baby at least 8 to 12 times a day for the first few days. This will help you produce enough milk and will help to keep the baby’s bilirubin level down. If you are having trouble breastfeeding, ask your baby’s doctor or nurse or a lactation specialist for help. Breast milk is the ideal food for your baby.

Q: When should my newborn get checked after leaving the hospital?
A: It is important for your baby to be seen by a nurse or doctor when the baby is between 3 and 5 days old, because this is usually when a baby’s bilirubin level is highest. The timing of this visit may vary depending on your baby’s age when released from the hospital and other factors.

Q: Which babies require more attention for jaundice?
A: Some babies have a greater risk for high levels of bilirubin and may need to be seen sooner after discharge from the hospital. Ask your doctor about an early follow-up visit if your baby has any of the following:

A high bilirubin level before leaving the hospital
Early birth (more than 2 weeks before the due date)
Jaundice in the first 24 hours after birth
Breastfeeding that is not going well
A lot of bruising or bleeding under the scalp related to labor and delivery
A parent or brother or sister who had high bilirubin and received light therapy

Q: When should I call my baby’s doctor?
A: Call your baby’s doctor if:

Your baby’s skin turns more yellow.
Your baby’s abdomen, arms, or legs are yellow.
The whites of your baby’s eyes are yellow.
Your baby is jaundiced and is hard to wake, fussy, or not nursing or taking formula well.

Q: How is harmful jaundice prevented?>
A: Most jaundice requires no treatment. When treatment is necessary, placing your baby under special lights while he or she is undressed will lower the bilirubin level. Depending on your baby’s bilirubin level, this can be done in the hospital or at home. Jaundice is treated at levels that are much lower than those at which brain damage is a concern. Treatment can prevent the harmful effects of jaundice.

Putting your baby in sunlight is not recommended as a safe way of treating jaundice. Exposing your baby to sunlight might help lower the bilirubin level, but this will only work if the baby is completely undressed. This cannot be done safely inside your home because your baby will get cold, and newborns should never be put in direct sunlight outside because they might get sunburned.

Q: When does jaundice go away?
A: In breastfed infants, jaundice often lasts for more than 2 to 3 weeks. In formula-fed infants, most jaundice goes away by 2 weeks. If your baby is jaundiced for more than 3 weeks, see your baby’s doctor.

Find more information on neonatal jaundice from Charak Clinics

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Saturday, July 24, 2004

Does your child R.A.P. ?

This article does NOT refer to the musical preferences of today's kids. Rather it deals with another common problem that almost 10-20% of school-going children have.. RAP or Recurrent Abdominal Pain.
Does my child have it?
Almost all kids have abdominal pain at some point of time, however RAP is defined as 3 episodes of abdominal pain over 3 months or more, interfering with daily activities like going to school etc.
What causes RAP?
Only around 10 % of RAP are caused by organic (physical) causes, the rest 90% are functional. This means that once the physical examination & basic lab tests are normal, you can be pretty confident that there is nothing wrong in the child's abdomen.
It is interesting to note that an Indian study has shown that children with functional RAP are likely to belong to a nuclear family, have history of marital fights between parents, irritable bowel syndrome and chronic painful disorders and maternal dysmneorrhoea in the family. School tantrums (before going to school) , absenteeism and punishments in shchool were more common among these children too. Generally sleep was not afffected in these kids. There was however no difference in school performance from their peers. All this indicates that family and school stressors may play a significant role in causing RAP.
What tests are needed to confirm the diagnosis?
In most cases only complete blood count, Stool & urine examination (three times each), and maybe an X ray/ Ultrasound abdomen will suffice to confirm the diagnosis. More expensive & invasive tests are not indicated routinely.
What is the treatment?
Reassurance is the KEY for the parents (and the child). Telling them that there is nothing wrong physically with the child is very important. Of course this does not mean that the child is lying, the pain is real, but the cause is not in the abdomen. Sometimes, simple distraction by telling the child that the parent has been 'taught' how to take care of the problem (like blowing on the abdomen) can bring about wonderful results. A psychological evaluation for stressors maybe useful. Medicine use should be avoided as far as possible.

Tuesday, July 20, 2004

Welcome to India, traveler: Vaccination & health tips

Are you an NRI visiting India after a long time?
Or are you a tourist wanting to see the some of the most beautiful history in the world?
Please come to see the Taj Mahal, Forts of Rajasthan, Ajanta & Ellora caves, beaches of Goa & Kerala & so much more!
But before you reach here please remember to check with your pediatrician as to the status of the following vaccines for your kids.
Hepatitis A vaccination (Avaxim, Havrix, Travel shot) is recommended for both adults as well as kids traveling to India. The first dose of hepatitis A vaccine should be administered at least 2 (and preferably 4) weeks prior to departure. The first dose of the hepatitis A vaccine series provides rapid protection against hepatitis A. Travelers should complete the vaccine series as recommended to ensure long-term protection, using an accelerated schedule if necessary. 
Typhoid vaccination is also a good idea since it is transmitted by contaminated food & water.
Both typhoid & hepatitis A vaccines are NOT routinely given in the US and other developed countries but these diseases are very common in India and other developing countries.
It is assumed here that your child is already on a regular vaccination schedule featuring DPT, Hib, Hepatitis B, MMR vaccines and may even have received optional vaccines like Chicken Pox etc. 
Yellow fever vaccine is NOT required unless you are coming from a yellow fever endemic countrylike the Sub-sahara africa or Central America. India does not have yellow fever.
Cholera vaccine may be needed if there is an ongoing cholera epidemic in the area you wish to travel (generally cholera occurs in the monsoons months of June to September in epidemic form, transmitted by unclean water). Japanese Encephalitis maybe indicated only in special situations like epidemics, while Rabies vaccine maybe taken if likely exposure to animals. 
Remember that all vaccines should be ideally taken at least 4-6 weeks before travelling for maximum effect

Malaria prophylaxis should be started before arriving in India and continued after reaching back. Use personal mosquito repellants creams (containing DEET), mosquito nets, insect sprays and electronic repellants in malaria endemic region. Not only will these protect you from Malaria but also Dengue, Filaria and Japanese encephalitis as well.
Common tips for the visitor:
  • Drink bottled water of reputed brands like Bisleri, Aquafina, etc.
  • Packaged fruit juices & cold drinks maybe consumed.
  • Avoid cut fruits, tap water, spicy food, roadside vendors, ice cubes, fountain drinks even with all the temptation to just ‘taste’ the local delicacy.
  • In case bottled water is unavailable carry 1 micron filter, and iodine tablets for purifying the water.
  • Carry vomiting medications like Metaclopramide (Perinorm)/ Ondansetron (Emeset); ORS solutions; Abdominal pain medications like Meftal spas, and antibiotics for traveller’s diarrhea ‘delhi belly’ like Ciprofloxacin while traveling to remote tourist spots. In bigger towns almost all these medicinces are easily available over the counter.
  • While in hot tropical areas consume lot of fluids to avoid heat stroke, stay in the shade, use sunscreens and hats and sunglasses.
  • Wear long sleeved shirts, long pants to prevent insect bites
  • Eat only thoroughly cooked food or fruits and vegetables you have peeled yourself. Remember: boil it, cook it, peel it, or forget it.
  • Carry all your prescription medicines, and the prescription too

Once again all travelers coming to our beautiful India Namaste, Dhanyavad plus have a safe and enjoyable trip!  

See latest CDC information on travel to india

Friday, July 16, 2004

Chicken Pox vaccine: To give or not to give

About the CHICKEN POX Vaccine:

Varicella vaccine has been available since in Japan since 1985, and in the US since 1995, and is approved for use in healthy children 12 months of age or older, and susceptible (i.e., no evidence of having had chickenpox in the past) adolescents and adults.
Varicella vaccine is highly effective in protecting against severe chickenpox.
More than 6 million doses of varicella vaccine have been given since it was licensed in March 1995.
It is recommended by the American Academy of Pediatrics  that all children be routinely vaccinated at 12-­18 months of age and that all susceptible children receive the vaccine before their 13th birthday.
The Indian Academy of Pediatrics has the following statement on its website for both Chicken pox & Hepatitis A vaccines;
At present IAP committee on Immunization consider these vaccine as additional vaccines. However, both are excellent vaccines- highly efficacious and very safe.
A history of chickenpox is considered adequate evidence of immunity, with no vaccination needed.

Isn't my child better off getting chicken pox and having permanent natural immunity than risking side effects and getting only partial immunity from the vaccine?
Answer: Probably not. Some doctors may still advise you to wait and see whether your child gets chicken pox by age 10 before having her vaccinated, but there's not much logic behind this advice any longer. The idea was that the vaccine was still pretty new (it came out in 1995 in the US, 1985 in Japan) and we didn't know much about its effectiveness or side effects, whereas chicken pox itself was generally thought to be a mild disease that most kids got through with only a little itching.It's true that the vaccine won't guarantee that your child will never get chicken pox — about 10-15 percent of those vaccinated may still get a very mild case, with no fever and fewer than 10 blisters. And experts can't be sure that the immunity it offers is permanent. But we do know that the chicken pox vaccine has been used in Japan for about 25 years with no evidence of fading immunity. We also know that shingles (a painful and disfiguring rash caused by the same virus) is less common and less severe in people who have been vaccinated than in those who actually had chicken pox as kids.
And as with all vaccines, a certain number of children will experience mild side effects. Up to 20 percent of children will have pain where they received the shot, about 10 percent will have a low fever, and about 4 percent will have a mild rash. But there has never been a serious adverse reaction linked to this vaccine.
On the other hand, chicken pox is not always a mild illness. Of the 3 to 4 million U.S. children each year who come down with it, one in 1,000 will develop complications such as severe pneumonia or a brain infection called encephalitis, and about 50 will die. Children with chicken pox are also more susceptible to "flesh-eating" streptococcus infections, although those infections are quite rare.
This information came to you courtesy the babycenter!
As of now 2 brands of Chickenpox vaccines are available in India, Varilrix by GSK & Okavax by Aventis. The basic difference according to manufacturer’s literature is that while Varilrix requires 2 doses after 13 years age, Okavax can be given in a single dose for all ages.

So what is my Opinion regarding the vaccination?
Answer: If you can afford it, take it! Recent data suggests that Chicken Pox vaccine may be more effective if taken at 15-18 months rather than 1 year, so ask your pediatrician to give it at 15 months.   
More india specific vaccine information at Charak Clinics

Thursday, July 15, 2004

Chicken Pox facts

So you wanted to know about chickenpox!
Here are a few facts on this common comunicable disease
• Chickenpox is caused by a virus called the varicella zoster virus.
• Chickenpox is usually mild but it may be severe in infants, adults and persons with an impaired immune system.
• Almost 100 children die every year in the US, whle more than 10,000 are hopsitalized due to severe chicken pox.
• Chickenpox is highly contagious, approximately 90% of persons in a household who have not had chickenpox will get it if exposed to an infected family member.
• The virus spread from person to person by direct contact, or through the air.
• Chickenpox develops within 10-¬21 days after contact with an infected person.
• Chickenpox has a characteristic itchy rash which forms blisters that dry and become scabs in 4¬5 days. An infected person may have anywhere from only a few lesions to more than 500 blisters on their body during an attack (average 200-400).
• Chickenpox is contagious 1¬2 days before the rash appears and until all blisters have formed scabs.
Effective medications (e.g., acyclovir) are now available to treat chickenpox in healthy and immunocompromised persons.
Facts on chicken pox courtesy CDC via medicinenet
Next time: chickenpox vaccine to be or not to be!

Tuesday, July 13, 2004

Fever is a friend for my baby: Fever facts & myths

What is fever?
Any temperature above the maximum normal value is called fever. The human body temperature varies from 98 to 99 F, average 98.6 F (37 C). Practically any temperature measured above 99 F may be considered to be fever.
How is fever measured?
Mercury thermometers are still one of the best ways to measure temperature. Not only are they inexpensive, but also reliable. Newer techniques include digital thermometers (good), ear thermometers (good, but need practice, also expensive) & skin thermometers (not recommended).
What are the areas used for placing the thermometer?
Armpits, groin in small babies, & below the tongue in older children (5-7 years onwards). Special rectal thermometers give the most accurate readings. You should inform the doctor as to the site from where you have checked the temperature. As a rule of thumb you may add 1 degree to the temperature measured at the armpits for detecting fever.
My child has fever. When do I need to show a doctor?
The smaller the baby, the more is the likelihood of serious problems. In any child below 3 months, definitely consult a doctor. In case the baby is unduly lethargic, refusing to feed, vomiting or has a high grade fever, any child of 1 to 2 year needs to be shown to a child specialist. In an older child or adult any fever lasting more than a week definitely merits a medical consultation.
What are the causes of fever?
It may be a common cold, or even cancer! This means that a lot of conditions including infections, inflammations (swellings) & other rare diseases like cancers etc. may cause fever. Only a detailed history, examination & relevant investigations if needed may point to the exact cause.
What are the investigations needed?
These will depend on the exact cause suspected. Remember in young children more tests may be needed because we need to rule out serious illnesses more aggressively. A general set of tests may include Blood counts (TLC, DLC), ESR, Widal (typhoid), Malarial parasite, urine routine & culture (especially in girls), and many others like chest x ray, abdominal USG, Blood culture, ECHO as per the history & examination findings.
What is the treatment?
Recent studies indicate that both Ibuprofen (Brufen, Ibugesic) & are equally safe & effective in treating high fever. Nimesulide is not recommended for children less than 1 year.
The safest & probably most effective treatment would be sponging with tepid water (not too hot & definitely not cold).
Fever Facts & Myths
All fever need treatment. FALSE
Most fever are viral in origin and will get better with time, do not use medicines to treat temperature if it is below 101 F (~ 38 C), especially if the child is active and playful.
Untreated fever will keep on getting higher. FALSE
In fever the body’s thermostat has changed & set to higher level. In a vast majority of cases the fever will settle at a slightly higher level even without treatment. The primary purpose of fever medicines is to make the child (& parent) more comfortable.
We should try to bring the temperature back to normal with treatment. FALSE
FEVER IS A FRIEND. There is no need to bring the temperature to normal as fever helps the body fight infections better. It helps in increasing the body’s defense mechanisms like hormones, infection controlling cells, enzymes, chemical reactions within the body to counter inflammation effectively.
Certainly no bodily harm is likely to come to a child by a fever of even 103-105 F!
High fever in children leads to seizures. PARTLY TRUE
Actually it is not the height of fever but the rapidity of fever rise that determines whether a child prone to febrile seizures will actually have a fit or not. In a child with definite febrile seizures nothing bad is likely to happen even if he has recurrent seizures, he will likely outgrow them by the time he is 5-6 years old.
For more information of febrile seizures click here

Saturday, July 10, 2004

Monsoon Hungama: My child & the rain

Monsoon is the time of getting drenched in puddles & rivulets of water, tea , pakoras, and maybe a few holidays from school!
What fun, but it is also a time when a few common diseases strike children.
Dirty water can be a big risk for children, leading to diarrhoea, vomiting & dehydration. Treatment would involve adequate fluids like ORS, neembu paani, salty Lassi (Buttermilk), light juices, curd, bananas etc. Antibiotics should not be taken without a doctor's consent.
Poor quality of water can also lead to Typhoid & hepatitis A, prevention lies in using a filter or boiling the water. Please ensure that your child has taken vaccination for both these vaccine preventable diseases. Remember Typhoid vaccine is needed every 3 years. Hepatitis A vaccine is not the same as Hepatitis B vaccine and needs to be given separately. Avoid eating cut fruits, chaat or drinking juice from roadside vendors.
Foods To Eat: The monsoon brings with it the magnificence of mangoes, the aroma of roasted corn and the sweet tasting jamuns, enjoy them.
Small boils & pustules are very common in rainy seasons, prevent them by regular baths especially after playing in th rains. Treatment with antiseptic creams usually suffices, though a doctor's opinion should be taken in case of no improvement.
Malaria is another side-effect of the abundance of stagnant water during the monsoons. Avoid having stagnant water in your house. Empty the water coolers, the unused flower pots etc. Use a mosquito repellant & a Mosquito net if possible. Some of the other diseases you will prevent by these measures include brain fever (viral encepahlitis like JE), and Dengue fever.Any high grade fever should prompt a visit to your Pediatrician.
So enjoy this season with tea, bhuttas, hot snacks & by following some of these common precautions.

Tuesday, July 06, 2004

Cough Syrups: The PLACEBO effect

In case you are wondering about the title; a Placebo is a medicine that has no active ingredient, but is prescribed by doctors to encourage the patient's expectation to get well.
Also it also plays an important role in drug trials to find out if a particular medicine is more effective/ has more side-effects than if no medicine was given.
As pediatricians most of us are aware that the innumerable cough syrups available in the market are not very effective in reducing children's cough. In the July issue of 'Pediatrics' Medical Journal, an interesting study has shown that two of the most commonly used medicines in cough mixtures, namely dextromethorphan & diphenhydramine, are no better than sugar syrups (placebo, right!) in treating cough caused by common cold.
So what should a parent do?
Confirm with a child specialist that your child has an upper respiratory infection; try using home made "daadi maa ke nuskhe" (grandmother's recipes) like Ginger & honey (adrak, shahad) based concoctions, or try hareera (traditional cough mixture).
Common Cough tips:
Avoid ice, extremely cold drinks;
Try to rest the throat by not shouting;
Warm saline gargles if possible,
Saline nasal drops;
Plenty of fluids to maintain hydration
Humidification of air;
Avoid dust & smoke,
No antibiotics without the pediatricians consent, and try not to 'pressurize' him into writing an antibiotic prescription ! :-)
What is the best way to heal a cough?
Give it TIME to heal. In case it does not go within a week reconsult the doctor.

Monday, July 05, 2004

Pulse Polio: A few facts & myths

Another Sunday (July 4th); another Pulse Polio in many parts of India.
So what is this Pulse Polio & how does it differ from our routine vaccination?
Before we begin, a small story. North Nigeria decided last year to stop Polio vaccination because they felt that Polio drops were a western conspiracy to reduce fertility & spread HIV in Nigerian children! Sounds unbelievable right, but it is true! (Interestingly similar complaints have been heard in some parts of UP & Bihar-areas with the maximum cases of Polio in India at present). Stopping Polio vaccination has lead to a rapid rise in the number of polio cases in Nigeria & surrounding African countries!
What lessons does this hold for us? We need to aggressively give all the kids (less than 5 years) as many polio drops as suggested by the local health authorities to finish Polio once & for all. Just like finished off Small pox 30 years ago.
Pulse Polio Facts:
1. Every child (newborn to 5 years) needs pulse polio! Irrespective of whether they have been given routine polio drops or not.
2. Pulse polio protects the whole area from Polio, not just your child. This means that by giving it sincerely the whole country will become Polio free!
3. Mild cold, fever & loose motions should not be used as an excuse to avoid Polio drops
4. Pulse Polio is to be given according to your local schedule. This means that not all campaigns would involve your child, for example in the present round Punjab & Chandigarh were not involved in polio vaccination. Ask your pediatrician or contact us if you are living in Chandigarh or its surroundings.
Pulse Polio Myths
1. Pulse Polio does not cause any disease, neither HIV, nor serility, nor POLIO. It is the same polio drops that we give during routine immunization, but given to all children in an area on 1 specific date.
2. Pulse Polio cannot be given later if missed. This is because the logic behind Pulse Polio is to remove the Polio virus from circulation & this is only possible by giving the vaccine to the entire population on a single day. You may take the dose within the next 2-3 days but not later.
For more information on baby care issues, visit Charak clinics

Saturday, July 03, 2004

Obesity: Yeh dil maange more

Welcome to India; did you know that 1 in 5 children in our well- to-do schools are overweight?
We are soon going to top the world in diabetes & heart diseases. This is good news for a lot of people.... the drug companies, fast food makers, hotels & restaurants, but disconcerting news for us parents & peditricians.
So how do we prevent Obesity in our kids?
1. Lifestyle changes: No to DIETING; yes to NUTRITION; meaning more healthy foods like vegetables, fruits & whole grain cereals, avoid pre-packaged snacks, ice-creams & chocolates. Decrease eating out and fatty foods.
Think of a day's consumption like an Indian 'Thali' (plate of food) wherein a quarter is carbohydrate cereal (like rice & chappati), another quarter is protein like Milk, egg, dal, meat etc., while the other 50% should be salads, fruits & vegetables. Fried snacks & sweets should be reserved for a few special occasions.
2. Increase physical activity: Involve hildren by asking them to walk or cycle to school, engage in extracurricular play etc. If they do not like team sports, individual sports like dancing & martial arts can be encouraged.
3. Decrease sedentary behaviour: Most importantly TV viewing should be restricted to 1 hour on school days; 2 hours on the weekends. Computers & tuitions should be discouraged during evening play hours.
These are just the tip of the measures needed to conrol obesity. We as pediatricians & parents have a great role to play in keeping our children healthy.
Encourage your doctor to record children's weight & height on a chart during each visit & let you know if your kids are at risk for obesity.
Remember 'chubby' is not cute; & 'overweight' is not healthy!
For more baby problems log on to Charak clinics

Friday, July 02, 2004

Healthy criticism: Health care in the villages?

A study published in a renowned international journal (Lancet, May 2004) has shown that in rural Rajasthan 41% of 'doctors' do NOT have a medical degree.
Whats more, 68% of clinic visits lead to an injection being given, while only 4 % of cases are investigated.
Almost 45 % of Govt staff are absent from primary health centres, while the health centres themselves are closed for a whopping 56% of the time during regular hours! I knew that our halthcare in the villages was bad, but still this is a real eye opener.
The per capita spending on health of India ($ 4) is far less than even neighbouring countries like Sri Lanka ($ 15) & Bhutan ($ 8).
Thought for the day
Can we really hope to be a developed nation by neglecting our citizen's fundamental right to health?