Wednesday, July 24, 2013

What is the dose of Nexpro Junior (Esomeprazole) for infants with Reflux ?

For infants (less than 1 year old) with repeated vomiting & lack of weigth gain due to reflux (GERD), there are very limited medicines that are available for effective treatment in India.
A relatively new molecule is Esomeprazole marketed in the form of Nexpro Junior Satchets. I was trying to search for the effective dose in a 3 month old in my care who has significant reflux (vomiting, decresed weight gain, opisthotonic posturing etc.)
Here is what I found

Usual Pediatric Dose for Erosive Esophagitis

12 to 17 year olds: 20 or 40 mg once daily
Duration of therapy: 4 to 8 weeks
1 to 11 year olds:
-weight less than 20 kg: 10 mg once daily
-weight greater than or equal to 20 kg: 10 or 20 mg once daily
Duration of therapy: 8 weeks
Comments: Doses over 1 mg/kg/day have not been studied.

Due to acid-mediated GERD:
1 month to less than 1 year old:
-weight 3 kg to 5 kg: 2.5 mg once daily-weight greater than 5 kg to 7.5 kg: 5 mg once daily
-weight greater than 7.5 kg to 12 kg: 10 mg once daily
Duration of therapy: For up to 6 weeks
Comments: Doses over 1.33 mg/kg/day have not been studied.

Read more at 

Each satchet contains 10 mg of Esomeprazole and hence I have started the baby on 5 mg (1/2 satchets) once a day for the same.
Previously I have been using Junior Lanzol (Lansaprazole) tablets by Cipla, but they are a little difficult to dissolve in water to feed an infant. Hopefully this would be a more acceptable solution for an infant.

Thursday, July 18, 2013

What may trigger a sickle cell crisis?

I have a 5 year old girl in my follow up who has sickle cell disease. We were trying to look at precautions to reduce the risk of sickling in this situation. Here is what I found...
"What causes a sickle cell crisis for you may be different than what causes it for someone else. You may not know what causes a sickle cell crisis to happen for you. The following are triggers that may make a sickle cell crisis happen:
·         Dehydration:
o    This is when your body has lost too much fluid. Losing body water makes it more likely that red blood cells will block your blood vessels. With sickle cell disease, your kidneys are not able to save as much body fluid as people who do not have the disease. This makes you more likely to get dehydrated.
o    This can happen when it is hot outside. It can also happen if you do not drink as much liquid as your body needs. You are more likely to get dehydrated if you are at high altitude (such as in the mountains). Dehydration is also more likely if you exercise without drinking enough liquid.

·         Infections: Getting an infection in your lungs can cause a sickle cell crisis.
·         Hypoxia: Hypoxia happens when your body does not get enough oxygen. Hard exercise such as running can cause hypoxia. Being at high altitude and flying in an airplane can also cause lack of oxygen.
·         Cold temperature: Being in a cold place may trigger a sickle cell crisis for some people. A crisis may also be started if you quickly go from a warm to a cold place.
·         Surgery: Having surgery or a medical procedure puts a strain on your body. Having a baby causes a woman's body to work very hard, and can trigger a sickle cell crisis.
·         Emotional stress: Strong feelings, such as anger, frustration and depression may trigger a sickle cell crisis."

Wednesday, July 10, 2013

my eight year old child's ears stick out, and i was just wondering if cosmetic surgery (otoplasty) can be performed on her at his age?

I had this 8 year old girl with prominent ears whose parents wanted her to operated for cosmetic reasons, and wanted to know if this was the right age for cosmetic surgery of the ear.

Otoplasty to pin back, or reshape the ear (pinna) is most commonly done in children beginning from 4 years of age. Performing otoplasty in an old child is appropriate and offers the advantage that a child of that age can cooperate and cope well with his post operative care.


Read more about otoplasty here
(Apparently Indian Surgeon Sushruta was doing Oculoplasty in the year 5th century BC !)

Saturday, July 06, 2013

Using Pneumococcal Vaccine in Adults - How to use both PCV 13 & PPV 23?

There is a 'Pediatric' Pneumonia Conjugate Vaccine (PCV) & an 'Adult' Pneumococcal Polysaccharide vaccine (PPV). Previously we were using PCV in children below 5 years, and the "Adult vaccine' in older kids / adults as needed. 
However, since 2011 PCV is also being recommended (in the US) for adults above 65 years, and in people who are immunocompromised even between 19-65 years.
Now the same recommendations have happened in India for older adults too.
Hence we need to know how to use the pediatric vaccine & the adult vaccine in older adults & high risk patients.
Here is what the ACIP says
ACIP Recommendations for PCV13 and PPSV23 Use
Adults with specified immunocompromising conditions who are eligible for pneumococcal vaccine should be vaccinated with PCV13 during their next pneumococcal vaccination opportunity.
Pneumococcal vaccine-na├»ve persons. ACIP recommends that adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, and who have not previously received PCV13 or PPSV23, should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later (Table). Subsequent doses of PPSV23 should follow current PPSV23 recommendations for adults at high risk. Specifically, a second PPSV23 dose is recommended 5 years after the first PPSV23 dose for persons aged 19–64 years with functional or anatomic asplenia and for persons with immunocompromising conditions. Additionally, those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years, or later if at least 5 years have elapsed since their previous PPSV23 dose.
Previous vaccination with PPSV23. Adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants, who previously have received ≥1 doses of PPSV23 should be given a PCV13 dose ≥1 year after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.