Friday, December 16, 2011

Top 10 Pediatric stories of 2011

Here are the highlights from the Medscape Top 10 for Pediatrics in 2011:
10. How Should We Sedate Children for CT Scans?
What sedative agent is best for sedating children who need head CT scans?
9. Infants Should Sleep on Their Backs: AAP
Recommendations for safe sleep for infants are released.
8. Immunization Resource Center 
In aggregate, articles about ACIP and AAP immunization recommendations produce the highest interest among our pediatrician members. Rather than single out just one of the many popular articles on this subject, you can find them all in our convenient resource center.
7. Is Acetaminophen Harmful in Children?
Just how safe is acetaminophen for kids?
6. Clinical Practice Guideline: Tonsillectomy in Children 
Is your care of children consistent with best practice?
5. AAP Issues New Guidelines for Management of Iron Deficiency
First published a full year ago, the continuing interest in this article speaks to the importance of the topic.
4. AAP Issues Guidelines for UTI Management in Children
The intense interest in these new guidelines is reflected in another top read article in 2011-- an expert interviewwith Maria Finnell, MD, lead author of the accompanying clinical report.
3. New Children's Hospital Rankings Hinge More on Outcomes 
US News & World Report's annual list of the best children's hospitals.
2. I'm Struggling to Live on $160,000 a Year: MD Lament
In a world where rising costs collide with stagnant reimbursements, what was once a fortune may no longer be enough to support your family.
1. Starting Solid Foods: Are We Doing It Right?
Is the decades old practice of starting infants on white rice cereal the best practice?

Saturday, November 12, 2011

Parents questions regarding new vaccines:

When is the earliest that you can give a Prevenar 13 booster if you have given the first dose after 1 year age?
Answer: The recommended primary series is three doses given at 2, 4, and 6 months of age with 2 months between doses. A fourth (booster) dose is recommended at 12 to 15 months of age. If the first dose is given after the age of 1 year however, then at gap of at least 60 days should be kept before giving the booster dose. 

Friday, September 16, 2011

How technology is changing doctor-patient relationship in Chandigarh, India!

Today, there was a first in my decade long practice in Chandigarh. I am aware that Chandigarh has a large proportion of tech savvy educated parents. I received a call regarding some readability issues with one of my prescriptions. This is uncommon, not because my hand writing is good. It is terrible, like many male colleagues of mine! But I still get less than my fair share of the stick in this situation because I provide computerized prescriptions. However, occasionally when I write an additional drug with my hand, the chemists/ parents have some difficulty in going through it.

When I asked the parents to come to me (since I could not remember the drug whose name was illegible), the mother instead suggested sending me a scanned copy of the prescription on email!

She actually sent it across, and I am attaching the same here. For those who are interested, the word they could not get was “nostrils” where I had advised the application of Mupirocin (T Bact cream) so as to decrease chances of recurrent skin infection.

It just got me thinking about the increasing time-saving use of technology in the present day and age. I believe that the role of email will slowly increase as a communication tool, and hence doctors need to be up to date with this important means of instant communication. Things like medico-legal implications, charging for these online consultations, medical insurance issues, email storage for long term etc. are all issues that will challenge the physicians of the future in India, especially the metros, over the foreseeable future. In the meanwhile, I will enjoy my first scanned & emailed prescription, sent back to me, containing an illegible entry!

Wednesday, September 14, 2011

Vaccine Myths shattered !

In this modern era of Internet and net savvy parents, many of these concerned parents have some queries / objections regarding vaccines.
These are increasing on a daily basis due to many factors, including increasing number of newer vaccines, newspaper / media reports (generally factually incorrect, I may say) regarding potential side-effects, and genuine concerns regarding the effect of so many vaccines on the child's immune system.
I would like to shatter a few of the common misconceptions regarding vaccinations using this forum.

Myth: it’s better to develop natural immunity then get vaccinated.

Fact: the difference between vaccination and natural infection is the price paid for immunity. The price paid for natural immunity (infection) is the physical economical & mental agony the entire family goes through after one suffers from a disease. In comparison price paid for vaccination is negligible. Also it is important to remember that many of the diseases that we getting protected against can actually cause a large number of complications including death of a child. In fact thousands of children die in India every year due to vaccine preventable diseases, hence getting a vaccination done is preferable to allowing 'natural immunity' for most diseases.

Myth: by relying on vaccines, my child’s immune system becomes weak or does not develop at all.

Fact: No, vaccine do not weaken immune system. People generally believe that vaccines offer ready made protection. This is NOT the case. In fact the vaccines work like a 'mini-disease'. The body acts on vaccine germs and produces antibodies, which fight against disease germs when the child comes in contact with disease any time in future.

Myth; vaccines are known to cause serious side effects.

Fact: In most cases, vaccines cause no side effects or only mild reactions such as fever or soreness at the injection site. Very rarely, people experience more serious side effects like allergic reactions. Be sure to tell your doctor if your child has had any severe reaction to previous vaccine, or has health problems or known allergies to medications or food.

“Vaccines”- Yes But how many ?

As you know, prevention is always better than cure. Fortunately, due to progress in vaccine science & technology, it is possible to protect children against several serious diseases through vaccination; normally a baby is exposed to millions of germs daily. It is much better to protect them against diseases through vaccination then let them be at risk & suffer.

Myth: My child does not require vaccines, as he/ she is healthy, active & eats well.

Facts: vaccination is intended to help keep kids healthy, because vaccines work by protecting the body before disease strikes. If you wait until your child gets sick, it will be too late for the vaccine to work. The best time to immunize kids is when they’re healthy.

Myth: Combination vaccines cause more side effects.

Fact: Combination vaccines are as safe & effective as individual vaccines there are two practical factor in favor of giving a child several vaccines during the same visit. First, to immunize children as early as possible to give protection during the vulnerable early months of their lives.

Second, giving several vaccines at the same time will mean fever clinic visits & fewer injections, which saves parents both time and money and may be less traumatic for the child. There are studies done that show that the discomfort caused is less with combination vaccines as compared to individual shots.

Just think - what would you want for yourself - 3 injections separately or a single injection containing all 3 vaccines ?

Myth: It’s OK to skip certain vaccine.

Fact: In general skipping vaccines is not a good idea. This can leave your child vulnerable to potentially serious disease that could otherwise be avoided. If you have reservations about any particular vaccine, discuss your concerns with your child’s doctor, if your child falls behind the standard vaccination schedule, catch-up vaccination is also available.

Myth: If I have missed a dose of any vaccine, it is no longer needed later

Fact: For most vaccines, if the dose is missed on the due date, you still need to take it at any later date (catch - up vaccination). Talk to your doctor regarding when these doses should be completed.

Myth: Vaccine may not be 100% effective; so why vaccinate?

Fact: Vaccines indeed are the most effective weapons we have against diseases. They work in 85% to 99% of cases. Smallpox has been eradicated from the face of earth & a dramatic reduction in the incidence of diseases like Polio, Diphtheria, Pertussis, Measles & Mumps are evidence of power of vaccines. Vaccine failure is rare & in such a case the disease is usually milder.

Myth: vaccines are for babies only. There is no need to vaccinate after 2 to 4 years of the age.

Fact; Diseases continue to affects school going children, adolescents & adults. It is always better to keep your child protected. Few vaccines (like DPT) do not provide life long protection. Protective efficacy of these vaccines wanes off over a period of time so regular boosters are required.

There are some new vaccines (like HPV) for adolescent girls to prevent Cervical Cancer. Some vaccines (like Flu) need regular vaccination as the virus keeps changing. For most of the vaccines age is not a barrier. Ask your doctor if you have missed any vaccine as you can always catch-up.

A friendly reminder for parents:

Adults need vaccination too! Check with your doctor to know what vaccines you might need. Your baby is counting on you.


Vaccination Information Pamphlet by GSK

Monday, September 12, 2011

Frequently asked questions regarding vaccines

What is vaccination?

Vaccination protects children against serious diseases by stimulating the immune system against disease germs.

How does vaccine immunity differ from natural immunity?

Normally in most diseases the disease-germ enters the body, produces the disease & the body mounts fighting power against the germ and lastly one recovers from the disease. Here immunity against disease is produced after one has suffered from the disease.

A vaccine is nothing but whole or part of the disease germ, which has been processed or modified in such a way that it loses its capacity to produce disease but it can still induce fighting power in the body when administered. Hence by vaccination one develops immunity without suffering from the disease.

Rather than reinvent the wheel, I have decided to post a list of excellent detailed FAQs that interested parents can go to and read.

I would recommend the following links

1. CDC

2. Web MD

3. Medicine Net

Wednesday, August 24, 2011

Can I take antibiotics while I am breastfeeding my baby?

Most antibiotics are quite safe during breastfeeding, even though small amounts may be secreted in the Breast Milk.
The only potential side effect in infants whose mothers are breast-feeding and taking antibiotics such as penicillins, cephalosporins, macrolides, and aminoglycosides are changes in their intestinal flora (bacteria that are normally present in the intestines). This may lead to loose stool and diarrhea in the infant, but these side effects are temporary.
You have to be careful only for a couple of antibiotics (which your doctor is anyways unlikely to prescribe) during breastfeeding.
Flagyl / Metronidazole is excreted in large quantities in breast milk and may lead to loose stools/ fungal infection in infants and is hence better avoided, or the milk discarded for 24 hours after a course of this medicine.
Chloramphenicol is a rarely prescribed antibiotic that CANNOT be taken during breast feeding, since it can lead to bone marrow suppression & serious liver damage. The good news is that this antibiotic is in any case very rarely prescribed nowadays.
For more information about antibiotic and other medicine safety during breast feeding read here

Monday, August 15, 2011

When can I fly with my newborn baby ?

Ideally your healthy newborn should be around 2-3 months old before being exposed to the recycled air, germs and the large number of people on flight.
However for most healthy babies, 2-3 weeks is a reasonable time frame in case you cannot wait.
Get her examined by your pediatrician, including the ears, and carry medicines like Crocin (Acetaminophen) for any fever/ pain/ irritability, and you should be good to go !
Many parents worry that the changes in air pressure that happen when you fly can harm their baby's ears. It's true that "popping ears" during takeoff and landing can be a bit painful for some infants, but it won't cause any lasting damage. Your baby will feel more comfortable if he has something to suck on during takeoff and landing, so you may want to breastfeed or give him a bottle or pacifier. You can give him some infant pain reliever (such as acetaminophen) if his ears really seem to bother him.
Get more tips for traveling with babies here

Saturday, August 06, 2011

Vaccination health news from India - Depressing Statistics, Innovative solutions

That India ranks low globally in its rate of vaccinating its population probably comes as no surprise. In 2010, only 72% of Indian babies received the three doses of the DPT vaccine against diphtheria, tetanus and whooping cough. This was quite poor when compared to 95% for Bangladesh and 83% for Indonesia. The reason for this dismal statistic has been attributed to weak, decentralized public health infrastructure and inadequate monitoring. And so, in a bid to make sure that there is extensive coverage of babies that would require vaccination, India's health minister has come out with a new initiative. This would involve collecting mobile phone numbers of all pregnant mothers to monitor their babies' vaccinations. While this project has already begun, the quantum of funds invested for this project is not known. That said, one wonders whether this plan will really solve the problem that confronts India. For starters, there could be discrepancies in the mobile numbers themselve s, a problem that the health ministry is also facing. What India could probably do is make healthcare a priority at the Centre rather than relegating it to states.

Saturday, June 04, 2011

Should my child take sports drinks/ energy drinks after exercise?

The short answer is NO. Plain water is the BEST rehydrating solution for most children doing routine exercises / activities.
For a longer version, read on ...
In India, the fad of sports drinks and energy drinks is fast catching on. For starters, is there any difference between the two?
Yes, Sports drinks contain carbohydrates, minerals, electrolytes, and flavoring, and are intended to replace water and electrolytes lost through sweating during exercise. Although they may be useful for young athletes participating in prolonged, vigorous physical exercise, they tend to be overused and are usually unnecessary. Some brands available in India include Gatorade, Stamina (Amul) and Sofit (Godrej).
Unlike sports drinks, energy drinks contain stimulants including caffeine, guarana, and/or taurine. Rigorous review and analysis of the literature suggest that energy drinks are never appropriate for children or adolescents. Because caffeine has been associated with harmful neurologic (brain) and cardiovascular (heart) effects in children, caffeine-containing beverages, including soda, should be avoided. Energy drinks can make a normal child restless and anxious.The excessive sugar present in these drinks not only adds to the calorie counts, but also acts as a laxative. Energy drink brands available and aggressively marketed in India include Red Bull, XXX & Cloud 9.
For most children engaging in routine physical activity, plain water is the best form of rehydration. Use of sports drinks can increase the risk of obesity and tooth decay, and is not required for routine activity.

Specific AAP (American Academy of Pediatrics) recommendations regarding use of sports drinks and energy drinks in children and adolescents include the following:

  • Pediatricians should educate patients and their parents regarding the potential health risks of energy drinks and sports drinks and explain the significant differences between these types of drinks. The terms should not be used interchangeably.
  • Energy drinks should never be consumed by children or adolescents, because the stimulants they contain pose potential health risks.
  • Children and adolescents should avoid and restrict routine consumption of carbohydrate-containing sports drinks, which can increase the risk for overweight, obesity, and dental erosion.
  • For pediatric athletes, sports drinks should be consumed in combination with water during prolonged, vigorous physical activity, when rapid replenishment of carbohydrates and/or electrolytes is needed.
  • For children and adolescents, water, not sports drinks, should be the principal source of hydration.
Given the increased awareness and easy availability of these drinks in the Indian Market, pediatricians and parents need to be aware of the potential risks of these drinks.

So what should an active child take if he indulges in vigorous activity?

It's better for children to drink water during and after exercise, and to have the recommended intake of juice and low-fat milk with meals. The recommended intake of juice is 6 oz (~ 180 ml/ 1 small glass) for children 1-2 years, and up to 2 glasses (6-12 oz/ 2 glasses) for older children only.

Suggested reading

Saturday, May 28, 2011

An uncommonly diagnosed common problem in kids - Helping children with voiding dysfunction!

My child wants to go the toilet repeatedly!
She rushes to the toilet, and sometimes passes urine in her underwear!
This is a fairly common complaint in Pediatric Office Practice.
It is the tendency of the Pediatrician & the parent to blame this on a lazy, inattentive child who is simply too busy to stop whatever they are doing. However this can very easily be a sign of voiding dysfunction. Repeated wetting can lead to lower self esteem in a child, so this condition should not be left undiagnosed and untreated.
I am going to use this forum to provide links to some important and helpful articles that are great learning resources for parents & pediatricians.
This is an excellent primer for pediatricians regarding a common problem that we encounter in our practice, voiding dysfunction. Unfortunately we rarely investigate this thoroughly, beyond the usual urine examination, and do not seek specialist consultation, especially in India. This is due to two reasons, first a lack of awareness of the problem of voiding dysfunction, and secondly, since we lack qualified/ interested Pediatric urologist in our country.
Hopefully these articles will educate us regarding this relatively common condition.
"In a study of 7-year-old Swedish schoolchildren, 20% reported needing to get to a bathroom quickly. Additionally, it was reported that 6% of girls and 3.8% of boys continued to have problems with daytime wetting at this age. Upadhyay et al. (2003) found that half of children with dysfunctional voiding symptoms had a history of urinary tract infections."
(Please note: Both these articles require free registration)
Dysfunctional voiding refers to an abnormality in either the storage or emptying phase of micturition and is associated with urgency, frequency, incontinence, and UTIs. It is important to distinguish dysfunctional voiding from enuresis. With enuresis, there is normal voiding with complete expulsion of urine at a socially less acceptable time or place. Enuresis occurs more frequently at night (nocturnal), can occur during the day (diurnal), and is usually self-limiting.
Recommended Audience - Pediatrician, Pediatric Urologist, and Family Physicians. While parents can read the article, they may find it technically demanding.

Friday, May 27, 2011

My child is swimming - how do I prevent Swimmer's Ear?

It's summertime, and everyone seems to be hitting the pool.
While swimming is not as prevalent in India, as some of the western countries, it is fast catching up, with the mushrooming societies, wherein a swimming pool is a must. While swimming is a great low impact exercise, it can lead to a few minor medical problems.
Swimmer's ear (also known as otitis externa) is an infection of the outer ear canal that can cause pain and discomfort for swimmers of all ages, more so in children. Symptoms of swimmer’s ear usually appear within a few days of swimming and include Itchiness inside the ear, Redness and swelling of the ear, Pain when the infected ear is tugged or when pressure is placed on the ear, and in advanced cases pus draining from the infected ear. This is not the same thing as a middle ear infection (fluid in the ear).
If you can wiggle/ move the outer ear without pain or discomfort then your ear condition is probably not swimmer's ear.

Swimmer’s ear can occur when water stays in the ear canal for long periods of time, providing the perfect environment for germs to grow and infect the skin. Germs found in pools and at other recreational water venues are one of the most common causes of swimmer’s ear. Swimmer’s ear cannot be spread from one person to another. Swimmer's ear can often be treated with antibiotic ear drops, after consulting your doctor.
Now coming to its prevention,

DO keep your ears as dry as possible.

  • Use a bathing cap, ear plugs, or custom-fitted swim molds when swimming to keep water out of your ears.

DO dry your ears thoroughly after swimming or showering.

  • Use a towel to dry your ears well.
  • Tilt your head to hold each ear facing down to allow water to escape the ear canal.
  • Pull your earlobe in different directions while your ear is faced down to help water drain out.
  • If you still have water in your ears, consider using a hair dryer to move air within the ear canal.
    • Be sure the hair dryer is on the lowest heat and speed/fan setting.
    • Hold the hair dryer several inches from your ear.

DON’T put objects in your ear canal (including cotton-tip swabs, pencils, paperclips, or fingers).

DON’T try to remove ear wax. Ear wax helps protect your ear canal from infection.

  • If you think your ear canal is blocked by ear wax, consult your health care provider rather than trying to remove it yourself.

Suggested reading - Tips for healthy swimming

So have a great time swimming, but follow the above tips for a safe summers!

Top 5 things NOT to do for a Pediatrician - to save money and health !

Research among pediatricians has outlined "Top 5" practices to avoid in order to deliver better quality, more cost-effective medical care.

For pediatricians, the top 5 quality-improving activities include:

• Don’t prescribe antibiotics for pharyngitis unless the patient tests positive for streptococcus.

• Don’t obtain diagnostic images for minor head injuries without loss of consciousness or other risk factors.

• Don’t refer otitis media with effusion early in the course of the problem.

• Advise patients not to use cough and cold medications.

• Use inhaled corticosteroids to control asthma appropriately.


I believe that these are excellent tips.
All of us should follow these as far as possible, diligently and conscientiously, not only for a more scientific practice, but also as the Hippocratic Principle goes "First, do no harm".
Avoiding unnecessary CT scans would reduce the radiation exposure to the developing brain of the children, while avoiding antibiotics would reduce chances of side-effects, antibiotic resistance, and even possibly allergies and reduced immunity in children (studies have correlated multiple antibiotic use with increased risk of allergies, and increased risk of recurrent infections).
Finally, it is amazing to note the stigma attached to the diagnosis of asthma in our country. Not only are parents / pediatricians unaware of the diagnosis, convincing them regarding the use of inhalation therapy is a uphill task. Inhalation is the BEST treatment for asthma, as millions of children and hundreds of studies have clearly demonstrated. It is safe, effective and does not lead to significant side-effects. Its use MUST be encouraged amongst doctors and parents alike.

Thursday, May 26, 2011

What's new in the latest 2011 Immunization Schedule for Indian Children by the Indian Academy of Pediatrics?

The Indian Academy of Pediatrics (IAP) is the parent body of more than 16,500 pediatricians (as of 2007) in India, and is responsible for establishing standardized guidelines for various childcare issues. The latest guide-lines provide some important changes that child specialists and parents need to be aware about, regarding vaccination of their children.
Here is a list of altered recommendations in the 2011 guidelines
  1. Hepatitis A has been rightfully preponed to age 1 year (from 1.5 years previously) for the first dose. The second dose is 6 months after the first dose.
  2. An additional dose of Chicken Pox vaccine (Booster) is recommended at 5 years age. This is probably as per the US guidelines, and due to the fact that lots of breakthrough cases were being witnessed after CP vaccination. For children who have not taken CP vaccination, two doses can be given at three months interval. Adults above the age of 13 years can take two doses at a month gap.
  3. MMR booster is now clearly recommended at 5 years. While this is the same recommendation as before, the fact that soon a combination vaccination of CP & MMR is likely to be made available in India, would make this a more convenient option.
  4. The confusing recommendation of some (newer, more expensive) vaccinations to be given after"one to one" discussion with parents has been removed. This makes it easier for pediatricians to recommend the vaccines, and the parents to decide as per their paying capacity (since we do not have Insurance cover for vaccines in India yet), about the decision to take the vaccine or not.
This appears to be a well thought out, comprehensive and scientific set of recommendations that have simplified the Immunization guidelines for Indian Children. Parents should take printouts of this guideline and encourage their pediatricians to follow the same, since vaccination schedules tend to vary across India.
The guidelines are not only less confusing, but also have moved towards International standards now, making it easier to vaccinate children in this era of global movement.

Suggested Reading

Monday, May 23, 2011

List of Top Pediatric Hospitals in the USA - 2011

Published below is a list of the top Pediatric hospitals in the USA published by US News & World report. All the hospitals were scored in 3 areas: reputation among pediatric specialists, clinical outcomes, and care-related indicators of quality such as nurse–patient ratios, surgical volume, and the availability of specialized programs. For this publication, US News & World Report solicited data from 177 hospitals and received responses from 100. The magazine also asked some 1500 pediatric specialists to name the 5 best hospitals where they would send children with serious or difficult problems without regard to cost or geography.

Here are the top 3 in each category:


  1. Children's Hospital Boston and Dana-Farber Cancer Institute
  2. Children's Hospital of Philadelphia
  3. St. Jude Children's Research Hospital, Memphis, Tennessee

Diabetes and Endocrinology

  1. Children's Hospital of Philadelphia
  2. Children's Hospital Boston
  3. Children's Hospital of Pittsburgh of UPMC


  1. Cincinnati Children's Hospital Medical Center
  2. Children's Hospital Boston
  3. Children's Hospital of Philadelphia

Heart and Heart Surgery

  1. Children's Hospital Boston
  2. Children's Hospital of Philadelphia
  3. University of Michigan C.S. Mott Children's Hospital


  1. Children's Hospital Boston
  2. Seattle Children's Hospital
  3. Cincinnati Children's Hospital Medical Center


  1. Children's Hospital of Philadelphia
  2. Children's Hospital Boston
  3. Cincinnati Children's Hospital Medical Center

Neurology and Neurosurgery

  1. Children's Hospital Boston
  2. Children's Hospital of Philadelphia
  3. Johns Hopkins Children's Center, Baltimore


  1. Children's Hospital Boston
  2. Children's Hospital of Philadelphia
  3. Children's Medical Center–Texas Scottish Rite Hospital for Children, Dallas


  1. Children's Hospital of Philadelphia
  2. Cincinnati Children's Hospital Medical Center
  3. Children's Hospital Boston


  1. Children's Hospital Boston
  2. Children's Hospital of Philadelphia
  3. Riley Hospital for Children at Indiana University Health, Indianapolis

Hospitals appearing on the 2011 to 2012 honor roll are as follows (repeated numbers indicate a tie):

1. Children's Hospital Boston

1. Children's Hospital of Philadelphia

3. Cincinnati Children's Hospital Medical Center

4. Texas Children's Hospital, Houston

5. Children's Hospital Colorado, Denver

5. Johns Hopkins Children's Center, Baltimore

7. Seattle Children's Hospital

8. Children's Hospital Los Angeles

8. Children's Hospital of Pittsburgh of UPMC

8. New York–Presbyterian Morgan Stanley-Komansky Children's Hospital

8. St. Louis Children's Hospital–Washington University

Read more here (requires free registration)

While we do have list of medical colleges ranked (a bit arbitrarily in my opinion) that is published annually by an Indian Periodical India Today, a similar study in India would be very informative and illuminating.

Sunday, May 22, 2011

What are some good Internet Resources for Information about Newer Vaccines?

I understand the need for getting the latest unbiased information about the newer vaccines, since many mass media (like newspapers, TV channels etc.) are filled with horror stories regarding drugs and vaccines. Most of these reports, at least in the Indian media, are sensationalized, over simplified and have inaccurate conclusions with the intention of boosting sales. These lead to avoidable panic, and sometimes serious delays in providing appropriate vaccinations to children.
However since the internet is a very democratic medium, and virtually anyone can (& does) provide their opinion online, it can be tough for a parent to search for accurate information online. Here are a few websites that provide excellent, well researched and peer -reviewed information (checked by experts) online.
  1. Indian Academy of Pediatrics - Committee on Immunization - provides latest recommendations for vaccinating children in India.
  2. WHO - Immunization - WHO Position papers on vaccines
  3. CDC - Vaccination
  4. Immunization Action Coalition - Educational material for parents
  5. Children's Hospital of Philadelphia - Information for parents, especially regarding vaccine safety
  6. PATH - Excellent updated information about vaccination from different resources
  7. National Network for Immunization Information
Suggested Reading

Wednesday, May 18, 2011

When will I know if baby is a righty or a lefty? He seems to use both hands equally now? Can I "make him" a righty?

As with many developmental milestones, there is no single age 'engraved in stone' by which time a child would be definitely righty or lefty. Generally speaking though, you would be able to figure out your baby's handedness at around 2 years age.
While your baby's preference for her right or left hand may start to appear as early as 6 to 9 months of age, this is unlikely to be consistent. Some children may be ambidextrous (using both hands equally) until they're 5 or 6, when they finally make a choice.
Do remember, hand dominance is greatly influenced by genetics. If both you and your partner are left-handed, your child has a 45 to 50 percent chance of being left-handed as well. (In the general population, around 10 percent of people are left-handed.) Statistically, the identical twin of a left-handed person has a 76% chance of being left-handed, identifying the cause(s) as partly genetic and partly environmental.
TIP: If your baby seems to be using one hand exclusively before he's 18 months old, however, talk to your pediatrician, as early hand dominance may be a sign of neurological problems.
The nature versus nurture debate ... While genetics alone don't entirely explain why someone ends up right or left-handed, hardwiring of your child's nervous system is at least part of the reason. Forcing him to use his right hand when he's really a lefty is unlikely to work in the long run and will only confuse or frustrate him.
Remember, while being lefthanded has been associated with social stigma, especially in India, studies have suggested that the proportion of left-handers is increasing and left-handed people as a group have historically produced an above-average quota of high achievers, and among college-educated people, left-handers earned 10 to 15 % more than their right-handed counterparts!

Suggested reading:

Tuesday, May 17, 2011

Latest Indian Academy of Pediatrics (IAP) recommendations 2011 for vaccinating children in India

Iap Guide Book on Immunization Iap Immunization Time Table 2011

Finally we have the latest guidelines from the Indian Academy of Pediatrics, the official & the largest body of Pediatricians in India.
Unfortunately, in India a lot of Pediatricians, especially from the smaller cities and towns seem to be following somewhat random schedules, that are not only outdated but may lead to decreased vaccine efficacy.
I would encourage parents to download this chart, and use this as a guide for getting their children vaccinated in India

Saturday, May 14, 2011

TIPs - The most common question asked by parents to pediatrician? Diet in Diarrhea !

This is probably the commonest query any pediatrician gets asked in their practice.
Surprisingly the answer to this question is very variable even amongst the pediatricians.

Here is what the present scientific evidence suggests
1. Do not starve your child. While this may reduce the immediate loose stools, it will make them weaker and more prone to recurrent diarrhea.In fact, the American Academy of Pediatrics states that 'most children should continue to eat a normal diet including formula or milk while they have mild diarrhea.'
2. For mild diarrhea, avoid any significant changes in diet.
3. Dehydrated children require rehydration (replacement of lost fluid). After being rehydrated, many children will be able to resume a normal diet.
4. Most children with diarrhea tolerate full-strength cow's milk products. It is not necessary to dilute or avoid milk products (except in children with known allergies to cow's milk).
5. Recommended foods include a combination of complex carbohydrates (rice, wheat, potatoes, bread), lean meats, yogurt, fruits, and vegetables.
6. Foods to avoid include fatty foods, very sweet juices & carbonated (fizzy) drinks as these are more difficult to digest.Do not start any new foods (that the child has not taken previously) during a diarrhea episode. During vomiting, avoid the temptation to feed large quantities of food/ drink. Give small frequent clear fluids/ soups/ ORS every few minutes to avoid dehydration.

Here is what you need to do
For mild diarrhea in children below 6 months, continue breast feeding/ formula feeding.
For older children, increased intake of clear fluids like coconut water, ORS, and a normal diet would help. Many children develop mild and temporary lactose intolerance. Continuing dairy foods may make the diarrhea last longer, but it can also allow a faster return to a regular diet. Hence milk intake may be temporarily restricted if there are explosive stools, lots of redness around the anus, and excessive gas, stomach pain etc. It would be appropriate to let your pediatrician suggest this rather than doing this routinely each time a child has diarrhea. You may add easily digestible foods like banana, apples (not juice), rice, khichdi, daal (Pulses), yogurt/ curd, potato (not fried), and toast.

Finally, remember that a full appetite is often the last behavior to return after any illness. Children should be allowed to take their time returning to their normal eating habits. No specific diet is recommended for diarrhea, but children usually tolerate bland foods better.

While lots of ready to drink ORS are available in the Western Countries (like Pedialyte), however the same is not easily available in India. Electral ready to drink ORS solution is now available in green apple and mango flavor at some of the larger cities.
Suggested reading

Thursday, May 12, 2011

The Internet Parent series - Help, is my baby having a seizure?

Here is the typical scene - you maybe feeding your infant and you suddenly notice that he has tremors in one leg. You have heard horror stories of infant seizures, and are hence obviously concerned. So is this really a seizure?
Seizures can be tough to diagnose in an infant. However here are some clues that would suggest if your child is having a seizure, or more likely a normal behaviour like tremulousness.
1. Can the movements be controlled by touching/ holding the arms /legs gently? If so, these are more likely to be normal tremors. Seizures cannot be reduced/ stopped this way.
2. Do these movements occur only at specific times, like changing diapers (or feeding as in this case)? This would be again more likely to a normal behaviour since seizures cannot be started this way).
3. Is the child developing normally? If your baby is otherwise behaving and developing normally even after repeated movements, this would make seizures less likely.
4. Are these episodes occurring both during sleep and while the infant is awake? If so this is more likely to be a seizure.
Finally, it is more likely that bilateral (both arms or leg together) movements that are symmetrical and persistent may be seizures.
While these are some useful pointers in trying to rule out seizures, given the fact that seizures can be very subtle in newborn and infants, anytime you have a doubt regarding an abnormal movement, it is a good idea to discuss this with your pediatrician.
It may be a good idea to videotape an abnormal episode (with your mobile/ camera) since this can provide invaluable information to your pediatrician too !
Suggested Reading:

Wednesday, May 11, 2011

TIP - When should I start plain cow's milk for my baby?

The short answer - The American Academy of Pediatrics clearly recommends NOT using cow's milk till the child is at least 1 year old. We can switch over to cow's milk between 1-2 years age slowly in most children.
The slightly longer version - Cow's milk is for the calves! While this may sound simple enough it hides quite a few important facts that would help us make the choice between cow's milk and formula.
In India, there is often an obsession for starting "fresh cow's milk" as a healthy & superior alternative to formula milk. However it must be remembered that cow's milk was created by mother nature for the calves. Thus it has far higher content of protein (since calves grow much faster than a human baby), higher phosphorus and lower sugar (lactose) than human milk.
In fact the formula milk is man's way of artificially trying to replicate mother's milk from the cow's milk. Thus we reduce the things that are in excess in cow's milk, add the things that are deficient in cow's milk, and try to make this as close as physically possible to mother's milk.
While this formula milk is still inferior to mother's milk, it is generally speaking a far better choice than cow's milk.
Of course since this is an expensive option, full fat cow's milk (& NOT toned/ slim milk) may be a reasonable alternative for these babies, where affordability may be an issue.

Monday, May 09, 2011

TIP - How do I choose "Dr Right" pediatrician for my precious baby?

If you already have a baby, the choice may be obvious for you and quite simple.
However for the first time parents, or when moving to a new location, this may be a cause of significant anxiety.
Here are some tips to help you begin your search for the "right" Pediatrician.
1. Start searching for a pediatrician preferably a couple of months before the delivery. Some babies have no respect for the 'due date' and you do not want to be caught off guard in this situation. Talk to your friends, relatives, ob/gyn & your family doctor.
2. It is very important that your pediatrician should be located close to you, at an easily accessible location, since you are likely to visit him quite often (usually more often than you think!) especially for the first born. Remember that even in the best case scenario, you would have close to 10 visits in the first year itself, so having a convenient location would make your life easier :)
3. Have a face to face meeting with your pediatrician if possible. Many pediatricians may charge for this, so ask in advance. Your level of comfort is important since they are going to be handling your most precious possession ! Try to find out their attitude regarding vaccinations, breast feeding, antibiotic use etc. if possible. You should know the working hours, emergency contact location, and appointment schedules of the clinic, since these vary considerably in practice. Which hospital does your pediatrician admit children too? Do they attend to the emergencies themselves? Try finding about the experience and qualifications of the Pediatrician too, either by asking politely, or by looking around in the clinic. Finally since in India, almost all consultations are self-paid, you would want to be comfortable with consultation charges.
4. Even though the pediatrician is the most important person in making your decision, you would want to see if the reception staff is polite, helpful and if the waiting area is child-friendly.
Remember that choosing a pediatrician is possibly the start of a relationship that could last 18 years or more! Give yourself enough time and data to make an informed choice.
More reading here

Sunday, May 08, 2011

The Internet Parent (TIP) - Guide to common childcare & parenting questions

Today I am starting a new project that should (hopefully) consist of the common questions that I am asked in my Pediatric Practice.
I will try to post a question every day, and would love to have feedback / queries from parents (& would be parents) too !
While many such resources are available online, only a few are from pediatricians, and almost none from an Indian Pediatrician.
I hope to fill this gap, and try to not only educate parents, but myself in the process, and have fun.
While I would like to provide standard advise as far as possible, we all know that no two children are alike, and no single formula (one size fits all approach) exists for parenting.
As a parent and as a pediatrician, my brief would be to provide accurate information, clear common myths, and where ever possible share my experience, so that we are able to bring up healthy and happy children.
Remember, health is not defined as just the absence of disease, but a state of complete social, mental and physical well -being (by WHO).
I would love to be a part of making your children healthy !

Thursday, March 17, 2011

Latest American Academy of Pediatrics Recommendations (2011) for Limiting Sun Exposure in Children & its relevance to indian children

Specific recommendations for pediatricians for Limiting Sun Exposure in Children include the following:

  • Health-supervision practices should include advice about UVR exposure, such as avoiding sunburn and suntan, wearing clothing and hats with brims, using sunglasses, and applying sunscreen. If possible, outdoor activities should be scheduled to limit exposure to peak-intensity midday sun (10 AM to 4 PM).
  • When a child or adolescent might sunburn, he or she should use sunscreen to reduce the known risks for sun exposure and sunburn, including the increased risk for skin cancer. Sunscreen with a sun-protection factor (SPF) of at least 15 should be applied every 2 hours and after swimming, sweating, or drying off with a towel. People may prefer avoiding sunscreens containing oxybenzone, as these may have weak estrogenic effects when absorbed through the skin.
  • Although all children need counseling about UVR exposure, this is particularly true for children at high risk for the development of skin cancer, including those with light skin, nevi, and/or freckling; and/or a family history of melanoma.
  • Skin cancer prevention is a lifelong effort, and beginning in infancy, at least 1 health maintenance visit per year should include advice about UVR exposure. All children are at risk for adverse effects of UVR exposure on the eyes and immune system, although not all children sunburn. Especially appropriate times for counseling about UVR exposure include during the spring and summer in northern states, before anticipated sunny vacations, and during visits for sunburns.
  • Because outdoor physical activity should be strongly encouraged, this should be promoted in a sun-safe manner.
  • Sun-protection practices tend to wane in early childhood. Beginning at age 9 or 10 years, it may be helpful for pediatricians to discuss sun protection with children, together with parents, to encourage joint responsibility for the child's sun protection.
  • Infants younger than 6 months should be kept out of direct sunlight and covered with protective clothing and hats. When sun avoidance is impossible, parents may apply sunscreen only on exposed areas. Absorption of sunscreen ingredients may be higher in preterm infants.
  • Pediatricians should become familiar with chemical photosensitizing agents. People using these oral or topical agents should limit sun exposure and avoid all UVA from artificial sources. When sun exposure is inevitable, they should wear fully protective clothing and high SPF sunscreen that also blocks UVA wavelengths.
  • Breast-fed and formula-fed infants and other children should receive vitamin D supplementation in accordance with guidelines, for a total intake of at least 400 IU of vitamin D daily. Children at risk for hypovitaminosis D may need laboratory testing of 25-hydroxyvitamin D concentration.
  • Deliberate UVR exposure to artificial sources and overexposure to sun with the goal of increasing vitamin D concentrations or for other reasons should be avoided.
  • Pediatricians should advocate for adoption of sun-protective policies (eg, shaded playgrounds, outdoor time before 10 AM, and allowing hats at schools and child care facilities).
  • Pediatricians should support and advocate for legislation banning use of tanning parlors by children younger than 18 years.
Source (needs free registration)
These are impressively detailed and well thought out recommendations. Being a tropical country we have a very high rate of UV exposure via sunlight in our children in India. The good news is that being dark-skinned we are naturally protected against high rates of skin cancer by the high melanin content in our skin. However there are a few important points regarding sunscreen usage that should be of interest to everyone.
Sunscreens of around SPF 15 are generally as effective as the higher SPF (& more expensive) ones. However liberal use 15-30 minutes before and repeated use after every 2 hours, swimming, bathing, toweling etc is important.
Avoid Sunscreens below 6 months if possible (though they can be used in sun exposed areas if needed), and avoiding Sunscreens with oxybenzone if possible. The US FDA approves Zinc Oxide and Titanium Dioxide for usage in Sunscreens.
For more information about sunscreens and children safety & UV radiation hazard read theAAP policy statement here