Wednesday, April 05, 2006

Leg Cramps- Nocturnal

Leg cramps- Nocturnal

This is strictly not a pediatric topic. I will be discussing pediatric leg cramps in a different post. A close relative suddenly started waking up with calf pain and tightness that soon became disabling. She had ‘taut’ calf muscles that used to cause an inability to walk in the morning/ walk with great difficulty, over the day this gradually reduced and she was almost well by the evening. This would return the next morning with a vengeance. There was no set pattern and she had good days and bad. None of the usual stuff like massage, oral pain-killers and hot fomentation were very effective. Consulting a physician lead to a possibility of hypocalcemia, thyroid abnormalities etc. the calcium reprts were borderline whle the thyroid reports were fine. A reputed endocrinologist suggested the possibility of Nocturnal leg cramps.

However on reading a lot of information (& I will provide the links below) on the net, I could not find any specific reference to what she was having. Nocturnal leg cramps are supposed to affect people in the sleep, they are supposed to wake up in the night with severe cramping pains, she had none of these symptoms.

Starting her on calcium, Vit D and vitamin E was suggested. Initially there was little improvement. On further online research we found that it was recommended that the supplements (calcium, magnesium, Vit E, Vitamin C etc.) should be taken in the night, and that a higher dose (1200 mg of calcium) should be consumed. On starting this she had a very rapid recovery and is now feeling much better! Of course she is also doing a few calf stretching exercises that are prescribed along with supplements for this condition.

A couple of interesting things, the patient is a young lady of around 30 years, and she consumes a lot of dairy products, both of these should not predispose her to nocturnal cramps and hypocalcemia.

More tips

  • Eliminate as much sugar and caffeine as possible from the diet.

Supplement doses

  • Calcium: 1,200 mg. at bedtime,
  • Vitamin E: 400 I.U. twice a day after meals for two weeks. If symptoms are relieved, cut down to 400 I.U. once a day, If symptoms recur, up the dosage until symptoms are relieved but never take more than 1,200 I.U. daily,

If neither calcium nor vitamin E gives you relief, you may benefit from magnesium, potassium, or vitamin A.

  • Magnesium: 400 mg. daily. (many a times found with calcium)
  • Vitamin A: 10,000 I.U. daily.
  • Potassium: 100 mg./daily, Make sure you eat plenty of potassium rich foods - (bananas, tomatoes, potatoes, broccoli, cantaloupe, oranges, grapefruit)



To stave off future episodes of nocturnal leg cramps, consider the following tips:

  • Drink six to eight glasses of water daily. Doing so will help prevent dehydration, which may play a role in the cramping.
  • Stretch calves regularly throughout the day and at night. (See box below for more information.)
  • Ride a stationary bicycle for a few minutes before bedtime. This activity can help prevent cramps from developing during the night, especially if you do not get a lot of exercise during the day.
  • Keep blankets loose at the foot of the bed to prevent your toes and feet from pointing downward while you sleep.
  • Do aquatic exercises regularly during the week to help stretch and condition your muscles.
  • Wear proper foot gear.


Leg Exercise tips:

Nocturnal muscle cramps can often be prevented by doing leg-stretching exercises, such as the one outlined below.

1. Stand 30 inches from the wall.

2. While keeping your heels on the floor, lean forward, put your hands on the wall, and slowly move your hands up the wall as far as you can reach comfortably.

3. Hold the stretched position for 30 seconds. Release.

4. Repeat steps 1 through 3 two more times.

5. For best results, practice this exercise in the morning, before your evening meal, and before going to bed each night.


It is important to differentiate leg pain from cramps. Neuropathy (nerve damage), sciatica, as well as clogged arteries in the leg (vascular disease) can cause leg pain. These types of pain, tend to occur throughout the day and not just at night. Vascular disease also causes cramping with walking.


This information is not a substitute for medical diagnosis and treatment and is meant for patient education only.

Sunday, March 26, 2006

Risk factors in Autism?

I had a well-educated family whose kid was diagnozed with autistic spectrum disorder in my clinic yesterday. They were obviously devastated by the diagnosis and had a lot of questions. One of the questions that I felt unable to answer at that point was about whether they should try to have another baby, meaning thereby as to what were the chances of the second baby having the same disease.
Autism is a lifelong neurological syndrome that affects a childs ability to interact with the other people. It is characterized by the abnormal development of communication skills, social skills, and reasoning. Males are affected four times as often as females. Children may appear normal until around the age of 30 months.It limits their ability to interact with others socially, in fact many autism suffers avoid human contact.
Autism Symptoms vary widely in severity, include impairment in social interaction, fixation on inanimate objects, inability to communicate normally, and resistance to changes in daily routine. Characteristic traits include lack of eye contact, repetition of words or phrases, unmotivated tantrums, inability to express needs verbally, and insensitivity to pain.
There is a GENETIC component to autism, however since multiple genes are involved, the actual transmission in quite complex and difficult to predict in a particular family.
However a simplified answer to the question (chances of second baby having the disease) is as follows:
  • Overall incidence of Autism 1: 500 ( and possibly increasing!)
  • Chances of autism in identical twins 60-90 %
  • Chances of autism in fraternal twin 2-4 %
  • Chances of autism in a sibling 1: 20 (5%)
  • Chacnes of autism in the third child if two kids are autistic 1: 3 (35 %)
  • Chances in second degree relatives (aunts , uncles, grandparents, grandchildren) 0.18 %
  • Chances in third degree relatives (cousins) 0.12 %
Early intervention is the key to success in treating this condition and limiting the problems faced by these kids.


Social/Communication Red Flags:

If your baby shows any of these signs, please ask your pediatrician or family practitioner for an immediate evaluation:

  • No big smiles or other warm, joyful expressions by six months or thereafter
  • No back-and-forth sharing of sounds, smiles, or other facial expressions by nine months or thereafter
  • No babbling by 12 months
  • No back-and-forth gestures, such as pointing, showing, reaching, or waving by 12 months
  • No words by 16 months
  • No two-word meaningful phrases (without imitating or repeating) by 24 months
  • Any loss of speech or babbling or social skills at any age

Saturday, March 25, 2006

ELIDEL (Pimecrolimus) - Misleading claims for marketing in India

Elidel (PIMECROLIMUS) hs been launched in India for the first time by Novartis for treating Atopic Dermatitis.
I would like to highlight my concern about the marketing for this. The Medical reps and the product monograph state that this is 'safe' for children from 3 months onwards, and tout this as a major advantage over Tacrolimus.
However the international novartis website for ELIDEL clearly states that Elidel should not be used in children below 2 years of age.
Also FDA has recently (march 2005) instructed novartis to put warning labels on this drug in the US which clearly states that this drug is not to be used in children less than 2 years. Also more disturbingly this goes on to state that the long term safety of this drug has not been established and there maybe a small chance of skin and lymphoreticular malignancies in people using this drug, though a causal relationship has not been established. It also advises that this medicine should be used for short term only
This is in complete contrast to the product monographs (in india) which states (on page 53)that "Elidel has an excellent safety profile and induces no clinically significant adverse effects".
On page 54 the monograph further goes on to state that this drug is indicated for long term management of atopic eczema in infants above 3 months of age.
I think that at the very least these issues should be communicated to the pediatricians and the dermatologists who are going to prescribe the medicine to thier patients in good faith. There is no reason for the medicine to be available for infants in India till the time its safety is not proven, and definitely not if their are any concerns about its long term safety.

Thursday, March 23, 2006

Preventing asthma in your child - Precautions before and after birth

All of us who have strong family history of allergies, be it nasal allergy (allergic rhinitis), skin allergy or asthma have a higher than average risk of having kids with allergies. This is more so if both parents (& their immediate family) are sufferring from multple allergies.
In my practice I often find such parents worrying about how to prevent asthma in their newborn child, especially if they already have a child with asthma.
The truth is that we really do not know of any sure shot way to prevent this from happening, but here are a few things that can help;
  • breast-feeding- exclusively for 6 months
  • maternal dietary restriction during breastfeeding - avoiding foods with potential for allergy like milk, nuts, wheat, egg etc. (these maybe avoided during pregnancy also in certain cases with the doctor's consent)
  • late introduction of solids and allergenic foods (milk, nuts, wheat, egg) - again indtroduction of solids after 6 months and allergenic foods probably after 1 year
  • and the use of hypoallergenic infant formulas (this is a new concept, and is still not FDA approved)
As I said before, there is no guarantee that this will work, but it may improve the chances of your kid not getting any major allergies as they grow

Wednesday, March 22, 2006

Antibiotics in babies may cause asthma!

Antibiotics are the wonder drugs from the 20th century. However their success has also been their downfall.
Antibiotic misuse has lead to increasing drug resistance, and nowadays this has lead to a decrease in their prescription by many physicians. Now there is another reason to ask your pediatrician to think again before giving an antibiotic prescription.
A recent canadian study in Chest Medical journal has suggested that those children treated with even a single course of antibiotics under the age of one are twice as likely to develop asthma in childhood as kids who are not given any antibiotics!
It found that for each extra course of antibiotics during the first year of life a child was 1.16 times more likely to develop asthma. What pediatricians and parents need to remember is that most respiratory infections in this age are viral and do not require antibiotics. It is believed that this effect may be as a result of anitbiotics killing the beneficial bacteria in the intestine, leading to alteration of immunity, which perhaps leads to asthma.