Thursday, August 28, 2014

Parent Question: My 3 year old daughter has just been diagnosed with Bicuspid Aortic Valve - what should I do?

Parent Question: 
My 3 year old daughter has just been diagnosed with Bicuspid Aortic Valve - what should I do?

Ans: I have reviewed the ECHO, and the diagnosis is Bicuspid Aortic Valve with mild Aortic Stenosis, with normal size of all heart chambers & no other abnormality.
All that is needed in this case is a follow up ECHO as per the cardiologist opinion, generally after 6 months to 1 year. There is no other precaution to be followed in this condition at the present point of time.

Serial ECHO would be needed to make sure that there is no / minimal progression of the Aortic stenosis in this situation.
Here is some more information about this condition.

Bicuspid Aortic Valve

Bicuspid Aortic Valve

A bicuspid aortic valve is a fairly common congenital heart defect found in children. Fortunately many children with bicuspid aortic valves are completely asymptomatic. Those who require surgical intervention usually do well.

What is a bicuspid aortic valve?

A bicuspid aortic valve is a type of congenital heart defect found in children. The aortic valve connects the left ventricle and the aorta. When the heart squeezes, the valve opens, allowing blood to pass from the left ventricle into the aorta. When the heart relaxes, the valve closes, preventing backflow of blood into the heart. A normal aortic valve has three separate leaflets. A bicuspid aortic valve has only two as opposed to the normal three leaflets. In many cases, two of the three leaflets are “stuck” together resulting in the bicuspid valve. A bicuspid aortic valve is a congenital heart defect, in other words, a birth defect of the heart. Congenital heart defects are the most common form of birth defects, occurring in approximately 1 in 150 individuals.


A bicuspid aortic valve is one of the more common congenital heart defects.  The exact incidence is not entirely clear, but some experts feel it may be one of the most common congenital heart defects overall. Experts have estimated its incidence as anywhere from 1 in 200 to 1 in 1000 individuals.


The cause of a bicuspid aortic valve is not known. Clearly a portion of cases are genetic in nature. In fact, bicuspid aortic valves are known to run in families. Some experts have recommended screening family members if member of a family is diagnosed with a bicuspid aortic valve.

Signs and symptoms

The significance of a bicuspid aortic valve is based on its functional status. Bicuspid valves have a tendency to develop either narrowing (aortic stenosis) or leakiness (aortic regurgitation). Physiologically, aortic valve stenosis creates a situation in which the left ventricle must squeeze more forcefully to pump blood past the narrowed valve. Aortic valve regurgitation creates a situation in which the left ventricle must pump a greater volume of blood with each heartbeat.
A bicuspid aortic valve in and of itself does not cause any symptoms. Symptoms are based on the functional status of the valve, in other words, the degree of aortic valve stenosis or regurgitation. The majority of patients with aortic valve stenosis or regurgitation rarely have any noticeable symptoms during infancy or childhood. Infants with severe aortic valve stenosis may develop rapid breathingsweating, or signs of impaired blood flow to the body. Occasionally older children with long standing, significant aortic valve stenosis or regurgitation may develop symptoms with exercise such as fatigue or even fainting (syncope).
Most patients with bicuspid aortic valves gradually develop some degree of aortic stenosis or regurgitation over time. Usually this is a slow process that may even take decades to develop. A certain percentage of patients with bicuspid aortic valves never develop any functional abnormalities with the valve whatsoever.


Diagnosis of a bicuspid aortic valve can be made in a number of different ways. A patient with a bicuspid aortic valve usually comes to attention due to the presence of a heart murmur or an abnormal heart sound. There are many other different causes of heart murmurs, including normal causes. An echocardiogram uses sound waves to visualize the intracardiac structures and is the easiest way to diagnose a bicuspid aortic valve.


Treatment of a bicuspid aortic valve in children is based entirely on the functional status of the valve. Children with a bicuspid aortic valve and mild stenosis or regurgitation require no specific therapy whatsoever. Children that remain in this category have a normal life-span and are free to participate in most activities without restriction. Children with severe or moderate to severe impairment of valve function require intervention to prevent long term damage to the heart. There are a number of different options, including both cardiac catheterization (valvuloplasty procedures) and surgery (valve replacement).
Up until recently, children with any form of heart defect, including a bicuspid aortic valve, were recommended to use antibiotics prior to dental work or surgery to minimize the risk of heart-related infection (SBE prophylaxis).  However, in May 2007 the American Heart Association changed this recommendation such that now most children with congenital heart disease, including those with a bicuspid aortic valve, no longer require this precaution.
In summary, a bicuspid aortic valve is one of the more common congenital heart defects. Fortunately the prognosis for most children diagnosed with a bicuspid aortic valve is good.
Other references

Thursday, August 21, 2014

Children Face the Highest Health Risk From Cell Phones - Medscape News

The potential harm from microwave radiation (MWR) emitted by wireless devices, particularly for children and unborn babies, is the highlight of a new review.
Although the data are conflicting, associations between MWR and cancer have been observed.
The review, by L. Lloyd Morgan, senior science fellow at Environmental Health Trust, and colleagues, was published online July 15 in the Journal of Microscopy and Ultrastructure.
The authors reviewed the current literature showing that children face a higher health risk than adults. They evaluated peer-reviewed cell phone exposure epidemiology from 2009 to 2014, along with cell phone dosimetry data, government documents, manufacturers' manuals, and similar publications.
Children and unborn babies face the highest risk for neurologic and biologic damage that results from MWR emitted by wireless devices, according to Morgan and colleagues.
The rate of absorption is higher in children than adults because their brain tissues are more absorbent, their skulls are thinner, and their relative size is smaller. The fetus is particularly vulnerable because MWR exposure can result in degeneration of the protective myelin sheath that surrounds brain neurons, they report.
Multiple studies have shown that children absorb more MWR than adults. One found that that the brain tissue of children absorbed about 2 times more MWR than that of adults (Phys Med Biol2008;53:3681-3695), and other studies have reported that the bone marrow of children absorbs 10 times more MWR than that of adults.
"Belgium, France, India, and other technologically sophisticated governments are passing laws and/or issuing warnings about children's use of wireless device," they write.
They note that MWR exposure limits have remained unchanged for 19 years, and that smartphone manufacturers specify the minimum distance from the body that their products must be kept so that legal limits for exposure to MWR are not exceeded. For laptop computers and tablets, the minimum distance from the body is 20 cm.
The authors explain that current exposure limits were established based on the erroneous assumption that tissue damage from overheating is the only potential danger of wireless devices.
However, extensive scientific reports have documented nonthermal biologic effects from chronic (long-term) exposure. Although government warnings have been issued worldwide, most of the public is unaware of such warnings, they write.
Raising "Appropriate Concerns"
The review authors "continue to raise appropriate concerns related to the ever-increasing role of technologies that emit nonionizing radiation, including cell phones and certain toys," said L. Dade Lunsford, MD, Lars Leksell Professor of Neurological Surgery at the University of Pittsburgh, who was not involved in the study.
"They indicate that certain types of tumors, at least as reported, may have increased in incidence, including the most malignant brain tumors and perhaps hearing nerve tumors," he told Medscape Medical News. However, he pointed out that there are issues with some of the data, and that many of the reports are anecdotal."Among the concerns with such public health data are the inability to determine if there is one or many environmental factors — cell phones are not the only concerns — that are related, or whether the perceived increase is simply better recognition at earlier stages based on the availability of MRI, as well as better reporting," Dr. Lunsford explained.
"Perhaps it is enough to simply raise the alarm in the hope of liberating either government or industry-sponsored appropriately designed investigational research," he noted.
"Regardless, it seems unlikely that the use of cell phones will diminish; cell phones have saved more lives than will ever be lost," Dr. Lunsford said. However, "concerns related to the greatly expanded use of digital toys in childhood clearly warrant better science and, for the time being, appropriate vigilance."
"Digital Dementia" Reported in Schoolchildren
The review points out the danger of childhood and fetal exposure to MWR, and the reasons the exposure is more pronounced in children than in adults, Morgan told Medscape Medical News.
"There are toys being sold to infants and toddlers that are dangerous," Morgan said. "The risk from exposure to any carcinogen is higher in children, and the younger the child, the higher the risk. The risk to adults from exposure to any carcinogen, to a first approximation, does not vary with age."
He explained that a problem known as "digital dementia" has been reported in school-aged children. The term was coined by German neuroscientist Manfred Spitzer in his 2012 book of the same name, and is used to describe how the overuse of digital technology is leading to a breakdown in cognitive abilities. It is sometimes also referred to as FOMO — fear of missing out — which is considered a form of social anxiety and is a compulsive concern about missing an opportunity for social interaction.
Take-Home Messages About Safe Use
As a take-home message for physicians and other healthcare practitioners, Morgan emphasized that wireless telecommunication devices need to be used in a safe manner. These devices are now part of everyday life, "but they can be used in a manner that is safe enough," he said. "Cars are not safe, for example, but they are safe enough. The essential problem is the vast majority of the public has no knowledge of their hazards."
Morgan and his colleagues have made some recommendations.
The first is that "distance is your friend." The intensity of radiation decreases as the square of the distance from the source increases (the inverse-square law). He explained that holding a cell phone 15 cm from your ear "provides a 10,000-fold reduction in risk."
Unless a cell phone is turned off, it is always radiating. When not in use, it should not be kept on the body. The best place for a cell phone is somewhere like a purse, bag, or backpack.
Devices should be kept away from a pregnant woman's abdomen, and a mother should not use a cell phone while nursing, Morgan noted. "And baby monitors should not be placed in an infant's crib."
Children and adolescents need to know how to use these devices safely. Cell phones should not be allowed in a child's bedroom at night, he continued. "The Pew Research Center has reported that 75% of preteens and early teens sleep all night with their cell phone under their pillow."
Because the risk is cumulative, and more radiation is absorbed with more hours of use, children should be taught to minimize their wireless phone use, Morgan explained. Landlines, Skype, and computer phone services (when connected to the Internet with a cable) do not emit radiation and their use should be encouraged.
Finally, Wi-Fi routers in the home should be placed away from where people, particularly children, spend the most time. "Boys should not keep a cell phone in their front pants pockets," he said. There is a potential harm to sperm, although no prepuberty studies of young boys have assessed whether early exposure to MWR has any effect on sperm after puberty, he acknowledged.
"And girls should not place their cell phone in their bras," he added. This recommendation was based on a case study of 4 young women with a history of putting cell phones in their bras and who developed breast cancer — 2 at the age of 21 years (Case Rep Med2013;2013:354682).The authors note that some studies have shown an increased risk for brain cancer with cell phone use, although some of these data have been disputed. In recent years, glioblastoma rates have increased in Denmark and the United States, and brain cancer incidence has increased in Australia, according to data drawn from cancer registries. The average time between exposure to a carcinogen and the diagnosis of a resultant solid tumor is 3 or more decades, so it will likely be several decades before tumors induced by childhood MWR exposure are diagnosed, they note.
Commenting to Medscape Medical News, Dr. Lunsford pointed out that much of the data are anecdotal and do not fit the hypothesis of a long latency interval between exposure and tumor development. For one of the 21-year-old women who developed breast cancer, cell phone exposure was only 6 years. "Unfortunately, we know neither the denominator nor the numerator of these index cases. Usage data are a closely guarded secret of phone service providers and a patient's own recall of exposure may or may not be correct due to recall bias," he noted.
In addition, the mechanism of oncogenesis is poorly understood and seems to conflict with the understanding that rapidly dividing cell lines, such as those in the skin, are the most susceptible to neoplastic transformation. However, there appear to be no reports of increased risk for local melanomas, basal cell cancers, or squamous cell cancers, which are the ones that would be expected to develop, Dr. Lunsford said.
Conflicting Data From Previous Studies
The potential health risks related to cell phone use, especially brain tumors, have remained a hot-button issue. Studies have been inconsistent and results have been conflicting. Currently, there is no consensus about the degree of cancer risk posed by cell phone use, if any at all.
A recent French study, for example, found that the heaviest users face a higher-than-average risk for gliomas and meningiomas (Occup Environ Med2014;71:514-522). There was no association between brain tumors and regular cell phone use, but the association was significant for those with heavy life-long cumulative use.
The first study to specifically assess the health impact of cell phone use on children and adolescents, conducted in Europe, found no association with risk for brain cancer, as reported by Medscape Medical News in 2011.
However, the debate was reignited the same year when the World Health Organization classified radiofrequency electromagnetic fields as possibly carcinogenic to humans (group 2B) on the basis of the increased risk for glioma that some studies have associated with the use of cell phones.
Also in 2011, a nationwide Danish extension study found no evidence of an overall increase in brain tumors or any cancers over an 18-year period. The original Danish study compared cancer risk for all 420,095 Danish cell phone subscribers with that for nonusers from 1982 to 1995, with follow-up to 1996. The update extended follow-up to 2007.
When analyzed by morphologic subtype of intracranial central nervous system tumor, there was a slight but nonsignificant increase in the incidence rate ratio for glioma in men (1.08; 95% confidence interval, 0.96 to 1.22). The ratio was highest in the shortest-term users (1 to 4 years).
However, the results of extension study were met with a fierce rebuttal from group of international experts, who joined together and posted their response on, a health education and advocacy group based in the United States.
J Microsc Ultrastruct. Published online July 15, 2014. Abstract
While the jury is still out on this one, I would certainly recommend keeping cell phones as far as possible from the developing brains of our children, especially less than 2 years age, till we have more data on their safety. Pregnant women are another group that need to remember to use these devices carefully. 

Monday, August 18, 2014

Parent vaccine FAQs: Delay in vaccine - can it cause a problem

Question : 
The vaccination for my son, in India, due in the 9th month has not yet been taken. Now he is 10 months old. We are planning to give the vaccination this month itself. Will the delay cause any problems?

A: There is NO problem in giving the vaccine at the age of 10 months. 
The delay will not cause any problems in the future. However, please remember that any delay in the vaccines can cause your child to have an increased risk of suffering from the disease against which the vaccine is supposed to give protection,

Friday, August 08, 2014

Parent FAQs: When should I change my baby's feeding bottle?

Q: When should I change my baby's feeding bottle?
A: As per this babycenter article

Signs a nipple should be tossed

Check your nipples often (at least every two to three months) for these signs of wear and tear:
  • Breast milk or formula pours out in a stream. Liquid should drip steadily out of the nipple — if it comes rushing out, the hole is too big and the nipple should be replaced.
  • Discoloration — this could be a sign that the nipple is deteriorating.
  • Thinning — this an early sign that the nipple is weakening. To test a nipple's strength, pull hard on the bulb. The nipple should rebound into its original shape. If it doesn't, throw away the nipple.
  • Stickiness or swelling — this could be a sign that the nipple is deteriorating.
  • Cracks, tears, or breaks — pieces of the nipple could break off and become a choking hazard.

Signs a bottle should be tossed

You should replace your baby's bottle if you notice:

  • Cracks, chips, or breaks — Your child could cut, pinch, or otherwise injure himself. This is especially dangerous if you use glass bottles.
  • And remember, if you use bottles with disposable liners, you should throw away the liner after each use.

Tuesday, August 05, 2014

Can I breastfeed my baby during / after I have dengue fever?

Q: I had high fever, and I continued to breastfeed my 9 month baby, as my medical doctor told me to. Later I was diagnosed as Dengue, and my pediatrician is not happy with the fact that I breastfed the baby. Now my baby has some cold, and I am worried that he may get dengue from me/ the breast feed?

A: Your pediatrician is probably wrong on this one. this article says that "Anti-dengue activity was found in the lipid component of human milk and colostrum. This suggests that breast feeding will protect the infant from the dengue virus in the endemic area of dengue infection." The study found that breastmilk can contain anti-dengue antibodies. This can help to protect your baby from the infections. 

How to treat a pulled elbow in Pediatic OPD practice ? Youtube to the rescue !

I reach the clinic at 9 AM in the morning, and I see this cute 3 year old girl whose parents complain that she has been not moving her left arm since last evening, when her grandfather accidentally picked her up by one arm. 
Clinical Diagnosis : Pulled Elbow
Problem: I do approximately 1 reduction every few months, so I need to review the technique before I do it again. During our student days, we used to send these kids routinely to the orthopedician, however, in practice I found that I could do the closed reduction successfully in about 75 % of the cases.
So I sent the kid outside with a couple of candies to keep her busy, and immediately googled the video from youtube !
2 minutes later, VOILA ... I have a set of happy baby, satisfied parents & a really happy & relieved pediatrician :)
Here is the video 
with detailed tips on how to do this reduction at your pediatric office practice.
Of course, if you are in doubt, not comfortable, I would suggest that you visit your orthopedician colleague once with the patient, and see how simple the procedure really is.
I just found an excellent parent focused study done in the US, published in April 2014, that talks about nurses doing the reduction in pediatric emergency departments as well.
You can read the article in Medscape here (requires free registration)