Thursday, November 27, 2014

Measles vaccine - correct age of administration?

Query : 
Measles vaccine should be give at start of 9 months or at completion of 9 months?

A: At completion of 9 months.
Since October 2014, the Indian Academy of Pediatrics (IAP) is in fact recommending using MMR in place of measles at 9 months

To avoid any confusion, you can subscribe to a free service by IAP for SMS reminders for vaccination for all parents, 
just do the following

How to register for the service

Parents opt-in to the service by sending a text message by SMS to the national shortcode 566778 from any mobile phone in India, in the following format*** :

Immunize < Space>   
Example : Immunize Rekha 04-11-2013

The phone will immediately receive a confirmation message.
Text message reminders** will  be sent to the phone for 12 years, following the IAPCOI prescribed immunization schedule.  
3 reminders are sent, at 2 day intervals, for each vaccination that is due. An example of a reminder is - "Rekha is due for a vaccination this week, please do not forget to visit your doctor"**

Wednesday, November 19, 2014

Use of TdaP in pregnancy found to be safe - does not cause Preterm deliveries of smaller baby size

New Study Finds Tdap Vaccine During Pregnancy Not Associated With Increased Risk of Preterm Delivery or Small Birth Size
A study looking at safety of the Tdap vaccine during pregnancy was published in theJournal of the American Medical Association in Nov 2014.
Researchers used administrative and electronic health record data from two CaliforniaVaccine Safety Datalink sites to study whether maternal Tdap vaccination during pregnancy is associated with increased risks of health problems for the mother or baby.
The study found that Tdap vaccination during pregnancy was not associated with increased risk for hypertensive disorders of pregnancy, preterm birth, or having a baby who is small for his or her gestational age.
This study adds important information on the safety of Tdap vaccination during pregnancy, following continued widespread pertussis transmission and current recommendations to routinely vaccinate during pregnancy.
For more information on Tdap vaccination during pregnancy, see
For more information on Tdap vaccine safety, see:

Commmunicated in Adolescent India forum by Dr Alok Gupta MD FIAP, Jaipur - India

Chicken Pox vaccination - Can it be done in older children / adults?

Question : 
my daughter age is 12 years and son is 08 years. Please let me know if they can be vaccinated against chicken pox now? Can adult also get vaccinated against chicken pox?

Ans: Anyone who has NOT had a definitely diagnosed Chicken Pox disease can get vaccination against Chicken Pox, whether a child or an adult. The minimum age is 1 year, while there is no maximum age.
So all of you can get vaccinated against Chicken Pox.

Tuesday, November 18, 2014

Are Odomos mosquito repellant bands effective?

Q: I would like to know if the mosquito bands available are really effective?

A: They are probably using Citronella which is not very effective in preventing mosquito bites.
You can find user reviews here
I would recommend using additional protection like the cream as well, especially if the child is playing during the evening time in the park or in an area with a large number of mosquitoes,

Warm regards
Dr Gaurav Gupta

300 Doctors Summoned By MCI For Accepting Bribe From Pharma Company

The Medical Council of India has summoned about 300 doctors from across the country to Delhi to answer questions on an anonymous complaint that they had been bribed by a pharmaceutical firm. About 100 of these doctors appeared before MCI's ethics committee on Monday.

According to the complaint, the Ahmedabad-based pharma company has been paying doctors lakhs of rupees as well as gifting them cars and flats and sponsoring family foreign trips in return for prescribing its medicines even though cheaper alternatives from better known companies are available.

Of the 150 doctors summoned to appear at the last meeting of the ethics committee, 109 appeared. The rest were summoned on Monday. "About 135 are left and they have been asked to appear at the next meeting of the committee in December. According to the rules, they have to be given three chances," explained Dr KK Aggarwal, a member of the panel.
The letter asking doctors to appear before the committee on Monday said: "Please bring your ITR, bank statement for the last three years, passport in original, as well as a set of photocopies of the said documents." The letter also warned that "in case you fail to appear on the above said date and time, the ethics committee will proceed for ex parte decision against you on the basis of available records in the council office".

That had about 100 doctors thronging MCI's office. They were asked to give a response in writing. While many submitted their responses and documents immediately, others chose to wait and talk to their lawyers. "The letter sent to us with a copy of the complaint did not include the details of the charges against us though the complaint did mention that it included details of charges against each doctor. Without knowing the exact allegation against us, how can we be expected to respond?" said a doctor.

Dr Ajay Kumar, who chaired Monday's meeting, said, "They have a week to respond. We did not want to reveal the exact allegations against them in the letters. But when they appeared today, the complaint against them was read out. Now they know the content of the complaint and they have been given a proforma to fill as response."

The anonymous complaint was received by the department of pharmaceuticals in August. "The vigilance division of the department was of the view that since it involved such a large number of doctors, it ought to be examined in detail. So, they sent it to MCI in the first week of September, though anonymous complaints are usually disregarded," said Dr Aggarwal.
According to the complaint, one of the ways in which the firm would bribe doctors would be by paying lakhs of rupees for running advertisements on a TV installed in their clinics. The letter gave the name of each doctor with his or her address and the bribe given to him or her.

It alleged that the doctors were violating basic norms and claimed that the turnover of the company had grown from zero to Rs 400 crore in just five years. The letter alleged that company's brands were priced 15% to 30% higher than those of well-established companies like Cipla, Ranbaxy, Sun, Aristo, Alkem, Zydus and Cadila but still doctors were prescribing its products as the company "was buying doctors by way of offering various means of bribes".

The complainant claimed that the firm was adding the cost of bribes to its products, forcing the patient to pay up. The complainant sought an I-T probe since doctors who allegedly accepted these bribes were evading income tax.
Comment: I believe that this and cash backs from labs are two endemic problems that should be tackled by MCI.
There is certainly a case for small tokens (like pens, stationery items etc.) that can remind the doctor to prescribe a certain brand - without a significant financial value attached. This has been suggested by the American Medical Association as well. However, scientific studies have shown that when large gifts are given by pharma companies, including travel grants, this does influence doctor dispensing, even if the doctors feel that they are being neutral. Of course, cars, houses and similar extremely high cash value items are completely wrong, as is being suggested in the present case.

Friday, November 14, 2014

Punjab to start providing 5 in 1 vaccine free through government dispensaries from December 2014

Yesterday, the Hindustan times paper reported that Punjab government will provide 5 in 1 vaccine containing DPT, Hep B & Hib (brain fever vaccine) free of charge at government facilities in the state. 
This is good news especially for the lower to middle class which were primarily taking the government vaccines, It will not only provide protection against a dreaded disease - hib, that can cause meningitis, ear infections and blood infections, BUT it will also lead to a lesser number of injections being given to the child (3 instead of 6 in the govt at present).
For the government as well, it will lead to less wastage and less time needed per child, since the number of injections, needles and syringes are reduced.
The 5 in 1 vaccine has been proven to be safe in large scale government programs across the country and internationally.
How would this impact private practitioners? 
Doctors in practice have a weird problem, the 'healthy season' when kids are well, is actually bad for the business :)
Plus one of our target customer base was the people whose children had taken the govt vaccines only, and not taken Hib yet. 
However, given that Hib can lead to very serious diseases, it is good step in the right direction, and while there is controversy regarding the burden of hib disease in our country I believe that this vaccine would be a success in our country, and help achieve better health for our children.
As far as practising pediatricians are concerned, this may help increase our vaccination rates too, since Hib vaccine will become de facto standard rather than being an additional vaccine, and we do claim to have better storage & vaccination techniques than most government centers. Over a period of time, since Modi government has already announced that they would be rolling out Rotavirus & MMR (or MR) vaccines too, we private practising pediatricians would probably need to focus more on the special situation vaccines like Influenza, the 'luxury/ lifestyle vaccines' like CP & Hep A, & Typhoid which for some strange reason is still not in the government of India's horizon.
Also, our practice in the coming generations would move more towards preventive pediatrics, and non infectious diseases in children.

Punjab government introduces 5 in 1 vaccine shortly - HT

Indian government to introduce 4 new vaccines - BBC

Thursday, November 13, 2014

Clinical pearls learnt in the tricity Chandigarh's Pediatric meeting - newborn Inborn error of metabolism screening in India

While many accuse doctors of spending most of their time wining & dining in meetings, there is always opportunity to pick up some very useful tidbits that can impact our day to day OPD practice as well.
In our recent meeting of the pediatricians of Chandigarh, Panchkula & Mohali this is what I learnt regarding screening our newly born babies in India for certain serious & life threatening diseases.
The talk was by an eminent neonatologist from a leading corporate hospital, and was simple and quite useful.
While in the west, neonatal screening is taken as a given, and routinely done, in India this is an emerging concept, and many big hospitals, and most small hospitals and clinics do not do this routinely. 
Here is what I remember .... 
There is a lot of data that has emerged from India in the last 10 years regarding the utility of newborn screening, including from Goa - the first state to start newborn screening, and even our own city of Chandigarh where GMCH 32 is doing a pilot project for the last many years now.
Every child should be screened for the commonest three disorders ...

1. Congenital Hypothyroidism
2. Congenital Adrenal Hyperplasia
3. G6PD deficiency (especially common in North India)

As the incidence of these diseases in India is very common and approaches 1:1000 in most studies, & these conditions can be treated if detected on time, it makes a lot of sense to screen for these 3 conditions in India

Ideal time for heel prick screen - 2 days to 7 days age
If screening done before 2 days - repeat around 2 weeks age.
Cost of screening - in most private labs between 900 to 1700 rupees.
For affording parents, a much more detailed TMS screen can be done that costs upwards of 4,000 rupees and screens for 40 diseases, most of them rare and not easily treatable.
Turn around time - 4-7 days.
Screening to be done by simple drops of blood to be taken on filter paper, and then dried and put in an envelope and sent to the lab, mentioning details of anything special including the day of life of the baby when the screening sample was taken.
I have done the TMS (40 disease) screen for my daughter when she was born, and got back normal results

Tuesday, November 11, 2014

What I learnt in the last Pediatric Meeting - using Rifaximin in Indian Children - clinical pearl by Dr B R Thapa

I am just going to discuss a clinical pearl of wisdom that I learnt from Dr B R Thapa regarding using a relatively new antibiotic Rifaximin  (available in India as SIBOFIX - Dr Reddy's) during his talk in August 2014 at our Chandigarh quarterly meeting of Pediatricians from the tricity of Chandigarh Panchkula & Mohali.
When I asked him about when to use this particular antibiotic in children with diarrhea, here is what he said - as I understood it...

"In the monsoon months, there is a higher incidence of bacterial diarrhea due to water and food contamination, in India. hence if my clinical judgement I feel that the child is having a bacterial diarrhea - high fever, significant stomach pain, unwell look, then it may be possible to use Rifaximin. The benefits of using Rifaximin are that it is completely non-absorbable, hence the chances of side-effects are less, and it is very safe for kids (licensed above 2 years age at present in India). Also, there is little chance of antibiotic resistance developing given that there is no absorption in the body. Finally, since it stays in the body for a long time, ONLY three days of medicine is good enough to treat most infections"

I have been using this medicine in my practice after this discussion, and have found good results in diarrhea with possible bacterial infection.
I would be happy to know the experience of other pediatricians who have used this drug, especially in Indian children.
Just as an aside, Rifaximin is also recommended for use in cases of traveler's diarrhea, for people traveling across the world.
Please remember that this is just my opinion, and how I remember the conversation. Any errors are mine.

Monday, November 10, 2014

Vaccination FAQs - Reaction to Pentaxim and mixing different vaccines, what to do?

Query : 
My baby D.O.B is 26th October 2014.

He got Pentaxim{DTaP},Rotavirus,Heb B2 ,prevenar 13 {PCV13} and Polio drop on 8th Oct 2014. But he was crying so much and there was so much swelling in his leg where injection has been injected.

My current paed has given Hept B2 plus DTap plus prevenar in a single shot by mixing all the vaccine in single syringe.

Did this practice is approved or not because this time i went to another doctor on 9th Nov 2014 for vaccine and he said it is not good to mix all the vaccine in one shot. Kindly guide me what is correct way to inject vaccine.

Ans :
It is NOT correct to give different vaccines like Dtap & Prevenar mixed in a single syringe.
This may lead to problems in the efficacy of the vaccines (they may not work well) and may lead to more side-effects too,
The vaccines should be injected separately. If there was a significant reaction to Pentaxim, you could try taking QUINVAXEM - a DTwP brand that may have possibly lower or similar reaction, or you may try taking Pentaxim again.

Dr Gupta, MD

Friday, November 07, 2014

New guidelines for managing bronchiolitis (Double Pneumonia in common Indian Parlance) issued by AAP, Oct 2014

A new clinical practice guideline that offers physicians guidance for the diagnosis and management of infants with bronchiolitis was published online Oct. 27 in Pediatrics.
Shawn L. Ralston, M.D., from the American Academy of Pediatrics Subcommittee on Bronchiolitis, and colleagues evaluated published evidence to revise the 2006  relating to diagnosis and management of .
The researchers note that bronchiolitis should be diagnosed based on history and physical examination; risk factors for severe disease should be assessed when physicians are making decisions about evaluation and management of children with bronchiolitis. Radiographic and laboratory studies should not be obtained routinely. For and children with a diagnosis of bronchiolitis, albuterol (or salbutamol) and epinephrine should not be administered; nebulized hypertonic saline should not be administered to infants in the emergency department but may be administered to infants and children who are hospitalized. Systemic corticosteroids should not be administered to infants in any setting. For prevention of bronchiolitis, palivizumab should not be administered to otherwise healthy infants with a gestational age of 29 weeks or older and should be administered to infants with hemodynamically significant heart disease or  of prematurity during the first year of life.
"The goal of this guideline is to provide an evidence-based approach to the diagnosis, management, and prevention of bronchiolitis in children from 1 month through 23 months of age," the authors write.
More information: Abstract
Full Text
Journal reference: Pediatrics  
Comment: After reading these guidelines, I am actually confused as to what will work in bronchiolitis. Everything that we use, from Adrenaline, to Salbutamol & steroids have been shown to be not effective! I guess moving forward we need to look at more options to manage this vexing condition.