Saturday, July 28, 2012

Children's Toe Walking Not a Sign of Bigger Problems

This is a common question in OPD Pediatric practice - parents worried about their preschooler walking on tip toes. It is reassuring to note that this latest study supports a policy of allowing the children to 'grow' out of this problem.
Here is the Medscape article on the same ....
"More than half of young children who toe walk will stop doing so on their own by about age 5. And most children who are toe walkers will not have any developmental or neuropsychiatric problems, a new study finds.
"Walking is such a notable milestone, and if it is not typical, it is often a concern for parents and physicians," says pediatrician Lee Beers, MD, who practices at Children's National Medical Center in Washington, D.C., and who reviewed the study for WebMD. It appears in the journalPediatrics. "This study certainly makes me feel more comfortable when I see toe walking in children who are otherwise developing well."
Toe walking can accompany disorders such as cerebral palsy and muscular dystrophy, but it also occurs among children who have no such underlying conditions. In such cases, children are said to be idiopathic toe walkers.
The cause is unknown, lead author Pahr Engstrom, MD, of the Karolinska Institutet in Stockholm, says in an email.
It could be related to nerves, muscles, a mixture of both, or another unknown factor, he says.
Prior to this study, the number of children who were idiopathic toe walkers was also unknown.
The Study
The parents of more than 1,400 children participated in the study, which was conducted in Blekinge County in southeast Sweden. At their child's routine 5.5-year checkup, parents were asked questions about their child and toe walking. Here's what the researchers found:
  • Nearly 5% of all young children had toe walked at some time. However, by age 5 1/2, fewer than half of them were still doing so.
  • Toe walkers typically begin doing so when they first walk independently, though some walk normally during the first year and beyond.
  • Former toe walkers did so for one to two years before walking normally.
  • Children still toe walking at age 5 1/2 do so about 25% of the time.
  • Children with a diagnosed cognitive or neuropsychiatric disorder such as autism were more likely to toe walk; in the study, 41% of such children were current or past toe walkers.
What Parents Should Know
For parents, it is important to understand that toe walking does not indicate an underlying problem for most children, says Jonathan Strober, MD, a pediatric neurologist at UCSF Benioff Children's Hospital in San Francisco. He was not involved in the research.
Nevertheless, he says, many parents become understandably alarmed when their child starts to toe walk. He was no exception. His 3-year-old daughter is a toe walker.
"I freaked out," he says. "As a neurologist, the worst possibilities went through my head."
Fortunately, Strober's daughter is just fine. And what he likes most about this study is that it offers reassuring evidence that the same can be said for most toe walkers.
"The fact that your kid toe walks is not a sign that they have autism," he says.
Beers agrees.
"A lot of kids who toe walk are developing normally," she says, "If it's an isolated finding, it is not something to be too worried about. If there are no underlying concerns, it's just something to keep an eye on."
However, Beers does say that kids who spend a lot of time on their toes can develop stiffness, tightening, and pain in their Achilles tendon, which can be eased with stretching exercises.
"Parents can help their kids to stretch while reading or watching TV," says Beers. "That helps keep the Achilles tendon supple and stretched out."
Treatment for toe walking is seldom necessary for children ages 6 and under, unless the condition has caused a shortening of the Achilles tendon or calf muscles. If that has happened, surgery may be required, Engstrom says.
Although different treatments have been suggested, Engstrom says more studies are needed to determine the best one.
Engstrom, P. Pediatrics, July 2012.
Pahr Engstrom, MD, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
Lee Beers, MD, pediatrician, Children's National Medical Center, Washington, D.C.
Jonathan Strober, MD, pediatric neurologist, UCSF Benioff Children's Hospital, San Francisco."

Friday, July 27, 2012

Which vaccines can I receive while I am pregnant?

Are some vaccines recommended while a women is pregnant?
The following vaccines are considered safe to give to women who might be at risk of infection:

Hepatitis B — Pregnant women who are at high risk for this disease and have tested negative for the virus can receive this vaccine. It is used to protect the mother and baby against infection both before and after delivery.
Influenza — This vaccine can prevent serious illness in the mother during pregnancy. You can receive the vaccine at any stage of your pregnancy.
Tetanus/Diphtheria — This combination of vaccines is routinely recommended for pregnant women, both those who have never been immunized and those who have not received a booster in 10 years. We usually only give this in pregnancy when there has been trauma. If it has been more than 2 years since the last dT, you will be offered dTaP after pregnancy.

My comments: These vaccines are not only safe, but are being recommended more & more in the West due to the protection they offer to mother & the baby. Recent studies have shown that even in developing countires (like Bangladesh) use of vaccines (like the Influenza vaccine) have lead to an increased birth weight for the babies, probably due to decreased infections in mothers. I would encourage obstetricians to change their attitude and use more of these vaccinations to improve maternal and infant health. Nowadays, more International societies are recommending TdaP vaccination (in place of the standard TT or Td) during pregnancy to reduce the risk of babies catching pertussis (kaali khaansi) before they get the first dose of DPT vaccination at 1.5 months.

Tuesday, July 24, 2012

Approach to the management of an incidentally detected HBsAg carrier

I had a mother who was incidentally detected to be Hbsag +ve during pregnancy. She has been asymptomatic even after two kids and apparently suffers from no ill-efefcts, the question waws, how to monitor such a person. Here is what I found ....

  1. No treatment is required
  2. Reassurance should be given to patients
  3. Family members should be screened with HBsAg and anti-HBs; if negative they should be vaccinated and success of vaccination should be tested by anti-HBs assay
  4. Protected intercourse should be practised until partner has developed protective antibodies. Eventual offspring needs active and passive vaccination
  5. Avoid alcohol
  6. Patients should be made aware of possibility of reactivation or superinfection by other viruses and advised to consult their physician if there is jaundice, malaise or increased fatigue
  7. They should regularly be followed up at every 6-12 months' intervals with transaminases, as fluctuations in ALT and HBV DNA levels are common during the course of chronic HBV infection
  8. If person is more than 50 years of age or there is positive family history of HCC, AFP estimation and USG should be performed every 6-12 months.
  9. They should not be denied employment or hospital treatment. Universal precautions should be taken while treating such patients in the hospital
  10. In the case of health care workers, they should be allowed to do routine designated duties and there is no need for changing the duty. They must follow universal precautions.
  11. They should not be allowed to donate blood, organ or semen
  12. Close monitoring is required and prophylactic lamivudine therapy should be given if undergoing chemotherapy or receiving immunosuppressive medications
  13. For pregnant women vaccinate the newborn at birth with acute and passive immunization within 12 hours of birth.