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."

http://www.medscape.com/viewarticle/507163

http://emedicine.medscape.com/article/1016198-overview

(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.

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.

Source

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.

Source

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.

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

IAP 2011 Immunization Boooklet

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:

Cancer

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

Gastroenterology

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

Kidney

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

Neonatology

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

Orthopaedics

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

Pulmonology

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

Urology

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

http://www.medscape.com/viewarticle/742874?src=mpnews&spon=9 (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.

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

IAP Guide book on Immunization 2011 (Page 161)

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:

http://www.whattoexpect.com/toddler/ask-heidi/left-handed.aspx

http://www.babycenter.com/404_when-will-i-know-whether-my-baby-is-a-righty-or-a-lefty_6716.bc

http://en.wikipedia.org/wiki/Left-handedness

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

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.

TIP:

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

http://pediatrics.about.com/od/diarrhea/a/06_brat_diet.htm

http://www.uptodate.com/contents/patient-information-acute-diarrhea-in-children

http://www.nlm.nih.gov/medlineplus/ency/article/002466.htm

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:

1. http://pediatrics.about.com/od/weeklyquestion/a/04_baby_tremors.htm

2. http://www.epilepsy.com/info/family_parents_newborn

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.

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

1. http://www.babiestoday.com/articles/basic-care/picking-your-pediatrician-50/3/

2. http://pediatrics.about.com/od/choosingapediatrician/Choosing_a_Pediatrician.htm

3. http://www.parents.com/baby/care/pediatricians-medicine/checklist-choose-the-right-pediatrician/

4. http://kidshealth.org/parent/system/doctor/find_ped.html

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 !