Bypass Surgery Might Be History Soon...

In a ground breaking discovery that may eventually render bypass surgery history, researchers at TelAviv University have shown that an injected protein can regrow blood vessels in the human heart.

In heart disease, blood vessels are either clogged or die off,
starving the heart of oxygen and leaving it highly susceptible to a cardiac attack.

Dr. Britta Hardy of TAU's Sackler School of Medicine and her team of researchers have developed a protein-based injection that when delivered straight to muscles in the body, sparks the regrowth of tiny blood vessels.
The new vessels in the heart could give millions of people around the world a new lease on life.

"The biotechnology behind our human-based protein therapy is very complicated, but the goal is simple and the solution is
straightforward. We intend to inject our drug locally to heal any oxygen-starved tissue.

So far in animal models, we''ve seen no side effects and no
inflammation following our injection of the drug into the legs. The growth of new blood vessels happens within a few weeks, showing improved blood circulation," said Hardy.

The protein solution can also be added as a coating to a stent.

Usually, the implantation of a stent is accompanied by a high risk for blood clots, which necessitates the use of blood thinners.

"We could coat a stent with our peptide, attracting endothelial stem cells to form a film on the surface of the stent. These endothelial cells on the stent would eliminate the need for taking the blood thinners that prevent blood clots from forming," said Hardy.

If investment goals are met, the researchers are hoping that toxicity studies and Phase I trials could be complete within two years.

The researchers began the study for preventing leg amputations, positing that proteins from the human body could be used to trigger the growth of new blood vessels.

Hardy started by studying a library of peptides and testing them in the laboratory and later confirmed initial results. She then took some of the isolated and synthesized peptides and tested them in diabetic mice whose legs were in the process of dying.

Although diabetes is known to decrease blood circulation, Hardy found that her therapy reversed the decrease. "Within a short time we saw the formation of capillaries and tiny blood vessels.

After three weeks, they had grown and merged together with the rest of the circulatory system," she said. In mice with limited blood circulation, she was able to completely restore blood vessels and save their legs.

It was then a short step to studying the applicability of the research to cardiac patients. "It''s pretty obvious if there is regrowth or not.

Our technology promises to regrow blood vessels like a net, and a heart that grows more blood vessels becomes stronger. It's now imaginable that, in the distant future, peptide injections may be able to replace bypass surgeries," concluded Hardy. The study has been published in Biochemical Pharmacology.

Comments: While this is a fascinating proof of concept study, the human trial are years away. We must remember that actual availability of the drug may be at least a decade down the line. At any point of time, there may be unforeseen side-effects that may make it impossible to use the drug in any patients, just like many other promising investigational products in the past. 

Creative expressions competition at our Clinic - winners!

Charak Clinics recently conducted a creative expressions craft & drawing competition at Mohali. More than 30 children participated and the winners received gifts from Dr Gaurav Gupta himself.

The drawings & craftwork was exemplary with children between the age of 4 to 10 years showing their skills by making very imaginative & attractive displays. Some of the artwork has been displayed in the clinic at phase 7 mohali for the next few days.

 Prizes were sponsored by a local pharmaceutical company and consisted of School bags, watches and water color sets. All participants received participation gifts including a stationery set as well.
The Winners were
1. Abhmanyu - 10 years
2. Rashika - 5 years
3. Khushdeep - 4 years

Solid foods started earlier than 17 weeks may increase foo

Infants who are introduced to their first solid foods before 17 weeks of age have a higher likelihood of developing food allergies by 2 years, a U.K. team of researchers found.

Additionally, the researchers discovered that infants who receive their first cow’s milk products while still being breastfed were less likely to develop allergies than were those introduced to cow’s milk after breastfeeding had stopped.

The research, led by Kate E.C. Grimshaw, Ph.D., of the University of Southampton, England, and published online Nov. 18 in Pediatrics (2013 [doi:10.1542/peds.2012-3692]), supports currentrecommendations by the American Academy of Pediatrics that solid food be introduced at between 4 and 6 months, concurrent with breastfeeding, to prevent allergies (Pediatrics 2008;121:183-91;Pediatrics 2012;129:e827-41).

Dr. Grimshaw and her colleagues’ study identified the 17-week mark as the "crucial time point," with solid food introduced before this time appearing to promote food allergies, while solid food introduced after this time apparently not doing so.

For their research, Dr. Grimshaw and her colleagues used a large prospective cohort study (n = 1,140) to identify mothers of 41 infants diagnosed with food allergies by age 2 years. These infants were matched with 82 controls born on close to the same date. All mothers of infants in the cohort study kept detailed daily food diaries describing their feeding practices through the first year after birth.

Dr. Grimshaw and her colleagues found that solid foods were introduced significantly earlier among the infants with allergies, with 35% of the former receiving their first solids before and including 16 weeks, compared with 14% of control infants (P = .011).

Of the infants who received cow’s milk concurrently with breast milk, the duration of concurrent feeding was longer – 9 weeks – in the control group, compared with 5.5 weeks in the allergy group (P = 0.47), suggesting that the duration of overlap was important and that longer overlap was helpful. However, there was no significant difference between the two groups in terms of the age at when the cow’s milk was introduced into the diet, they said.

Dr. Grimshaw and her colleagues listed as strengths of their study its prospective design that allowed for data collection from birth onward, and before any signs of allergy could become evident; only three infants in the study had evidence of allergy before 24 months. Also, they noted, a thorough diagnostic standard was used to identify allergies.

Although the optimum duration of exclusive breastfeeding has yet to be established, "Health professionals can provide advice that is consistent by encouraging exclusive breastfeeding for as long as possible followed by continued breastfeeding alongside the introduction of complementary foods to maximize the duration of concurrent breastfeeding and solid food introduction," Dr. Grimshaw and her colleagues wrote in their analysis.

The study was funded by the U.K. Food Standards Agency. Dr. Grimshaw declared an advisory relationship with Nutricia, while her coauthor Dr. Graham Roberts disclosed a relationship with Danone Baby Nutrition. Another coauthor on the study, Clare Mills, Ph.D., disclosed associations with Novartis, PepsiCo International, and DBV Technologies.

Source

Comment: The recommendation for exclusive Breast feeding for the first 6 months continues to gain credence with increasing scientific evidence in its favor.

Use a smartphone to diagnose ear infections in kids !

ORLANDO – A novel smartphone otoscope attachment provides clear, transmittable images of the ear drum or tympanic membrane, and could revolutionize the approach to diagnosing and managing ear infections, according to Dr. Kathryn Rappaport.

In a prospective study involving 63 children who presented to an emergency department between May and December 2012 with upper respiratory tract symptoms, the technology was as effective as a conventional otoscope, and was widely accepted by parents, Dr. Rappaport of Baylor College of Medicine, Houston, reported at the annual meeting of the American Academy of Pediatrics.After receiving clinical care, each child in the study underwent bilateral otic videoscopy using both the smartphone otoscope (CellScope Oto) and a camera-fitted conventional otoscope. The procedures were performed in random order, said Dr. Rappaport, who was at Emory University in Atlanta when the study was conducted.

Of the children, who had a mean age of 2.9 years, 49 received a clinical diagnosis of acute otitis media by an ED practitioner. Based on independent scoring by four physicians who evaluated 31 CellScope Oto videos and 31 conventional otoscope videos from 26 subjects, there was no difference between the two technologies in either the diagnostic quality of the images or diagnosis confidence ratings.

Diagnosis and treatment decision making were similar with each device. Overall, the physician raters were in fair agreement regarding the clinical ED diagnosis of acute otitis media, while two of the raters had moderate to substantial agreement with the ED diagnosis and two had poor agreement with the ED diagnosis from images obtained via conventional otoscope, Dr. Rappaport said, noting that there was a significant correlation between antimicrobial use and image quality.

This indicated that higher-quality images were more likely to be associated with a definitive diagnosis, she said.

As for parent reactions to the use of the device, most (95%) responded favorably, stating that the CellScope Oto images improved their understanding of their child’s management. Also, 90% said they thought the technology would be easy to use, and they would feel comfortable using it remotely to transmit images to a provider.

The CellScope Oto has the potential to improve diagnosis and management, and to reduce costs associated with acute otitis media in children, Dr. Rappaport said.

The video images can provide a baseline, as well as ongoing documentation of a child’s condition. The video documentation could allow a child to be followed over a period of time – without the need for regular office visits – to help monitor for progression or resolution of middle ear effusion and to guide diagnosis and treatment decision making, she explained.

"Acute otitis media is the most common reason for antimicrobial prescriptions in children. In the future, we would like to study whether the ability to monitor for resolution of a patient’s middle ear effusion using digital imaging with the smartphone otoscope will lead to decreased antimicrobial prescriptions for acute otitis media in children," she said in an interview.

Dr. Rappaport reported having no relevant financial disclosures.

Source

Comments: While many Indian doctors have been shy in adding emails / internet to their forte, almost everyone possesses a smartphone. Hence these technological innovations, once popularized can certainly impact the practice of the Indian pediatrician too !

How long after reconstitution (mixing) can I use a vaccine?

Q: I have accidentally reconstituted a Chicken Pox & MMR vaccine (mixed the powder & the diluent) for a child who did not need the vaccine. For how long can I store this vaccine after this?
A. Vaccines should be used immediately after reconstitution if possible. The life of each reconstituted vaccine varies from product to product. Consult the product package insert for the most up-to-date information about expiration dates and times following reconstitution. Unused reconstituted vaccines kept beyond these limits should not be administered. The best way to avoid such waste is to reconstitute and draw up vaccines
immediately before administration.

Shelf Lives of Reconstituted Vaccines

Vaccine	Expiration after Reconstitution
Varicella (Chicken Pox)	30 minutes (protect from light)
DTaP/Hib	30 minutes
MMR vaccine	8 hours (protect from light)
ActHIB®  vaccine (Hib)	24 hours

--> Mark each opened multidose vial with the date it was first opened. Mark reconstituted vaccine with the date and time it was reconstituted. Dating these vials is important for two reasons. First, some vaccines expire within a certain time after opening or after reconstitution. This may not correspond to the expiration date printed on the vial by the manufacturer. For example, multidose vials of meningococcal vaccine should be discarded if not used within 35 days after reconstitution, even if the expiration date printed on the vial by the manufacturer has not passed. Second, dating opened or reconstituted vials helps manage vaccine inventory by identifying vials that should be used first.
Source


On a slightly different note, Multi-dose vials used for mass immunizations are to be best used as per the following WHO policy

Multi dose vials of OPV, DTP, TT, DT, Td, hepatitis B, and liquid formulations of Hib vaccines from which one or more doses of vaccine have been removed during an immunization session may be used in subsequent immunization sessions for up to a maximum of four weeks provided that all of the following conditions are met:

• The expiry date has not passed;
• The vaccines are stored under appropriate cold chain conditions;
• The vaccine vial septum has not been submerged in water;
• Aseptic technique has been used to withdraw all doses;
• The VVM, if attached, has not reached its discard point.

The revised policy does not change recommended procedures for handling vaccines that must be reconstituted, that is, BCG, measles, yellow fever, and some formulations of Hib vaccines. Once they are reconstituted, vials of these vaccines must be discarded at the end of each immunization session or at the end of six hours, whichever comes first.

The rationale for these differing recommendations is as follows. Most freeze-dried (lyophilized vaccines) do not contain preservatives and consequently must not be kept more than the manufacturer's recommended limit and never longer than six hours after they are reconstituted. Liquid injectable vaccines such as DTP, TT, DT and hepatitis B contain preservatives that prevent growth of bacterial contamination. Should contamination take place within the vial, the action of these preservatives prevents any increase in bacterial growth over time and actually decreases the level of contamination.
Source

AAP Releases New Principles for rational use of antibiotics in URI

Effective use of antibiotics to treat pediatric upper respiratory tract infections (URIs) rests on 3 basic principles: accurate diagnosis, consideration of risks vs benefits, and recognizing when antibiotics may be contraindicated, according to a clinical report by the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP).

Of the nearly 50 million pediatric antibiotic prescriptions written annually, as many as 10 million of those "are directed toward respiratory conditions for which they are unlikely to provide benefit," lead author Adam L. Hersh, MD, PhD, and fellow committee members write in an article published in the December issue of Pediatrics. Often this occurs because it is hard to distinguish bacterial infections, which respond to antibiotics, from viral infections, which do not.

The report emphasizes "the importance of using stringent and validated clinical criteria when diagnosing acute otitis media (AOM), acute bacterial sinusitis, and pharyngitis caused by group A Streptococcus(GAS), as established through clinical guidelines," the authors write.

The first principle of judicious antibiotic prescribing is to determine the presence of a bacterial infection. For example, with AOM, this requires an otoscopic examination to observe characteristic inflammatory changes in the tympanic membrane plus bulging of the membrane or new-onset otorrhea not attributable to otitis externa, or mild bulging of the tympanic membrane accompanied by intense erythema or pain of recent onset. Acute bacterial sinusitis is diagnosed from persistent, worsening, or severe symptoms. Pharyngitis resulting from GAS can be diagnosed by taking a throat culture to identify the organism.

Following these diagnostic guidelines can help clinicians rule out the common cold, nonspecific URI, and bronchitis, which are viral in origin and will not respond to antibiotics, the authors write.

The second principle is to weigh the benefits against the harms of antibiotics. In the case of AOM, the evidence suggests that although at least 50% of patients may get well without antibiotics, antibiotics hasten recovery and are especially helpful for patients who are younger or have bilateral or severe disease. The evidence for using antibiotics to treat acute bacterial sinusitis is limited and mixed, and the role of the drugs in preventing complications such as orbital cellulitis or intracranial abscess also is unproven. Nevertheless, the AAP recommends antibiotics for children with clinical features of acute bacterial sinusitis, especially when the symptoms are worsening or severe. As for GAS pharyngitis, good evidence suggests that antibiotics can shorten symptom duration, although their effect on limiting fever is less clear, and they may reduce horizontal transmission. Antibiotics also may prevent suppurative complications of GAS pharyngitis such as peritonsillar abscess.

The harms of antibiotics can potentially outweigh these benefits, the authors warn. Most of the clinical trials reviewed have used amoxicillin or amoxicillin-clavulanate, which have been associated with adverse events ranging from mild (eg, diarrhea and rash), to severe (eg, Stevens-Johnson syndrome), to life-threatening cardiac and anaphylactic reactions. What is more, a growing body of evidence suggests that antibiotic use early in life may upset the normal microbial balance in the intestine and other organs, possibly setting the child up for lifelong health problems, including inflammatory bowel disease, obesity, eczema, and asthma. "Application of stringent diagnostic criteria and use of therapy only when the diagnosis and potential benefits are well established is essential to minimizing the impact of antibiotic overuse on resistance in individuals and within communities," the authors write.

Principle 3 is implementation of judicious prescribing strategies, including selection of the antibiotic most likely to eliminate the infecting organism, using an appropriate dose, and treating for the shortest duration possible. The committee suggests that physicians consider a "wait-and-see" approach before prescribing antibiotics, especially for older patients with mild to moderate AOM or sinusitis. They also recommend an assessment of the child's overall antibiotic exposure.

These principles "can be used to amplify messages from recent clinical guidelines for local guideline development and for patient communication; they are broadly applicable to antibiotic prescribing in general," the authors conclude.

The authors have disclosed no relevant financial relationships.

Pediatrics. 2013;132:1146-1154.

Source (requires free medscape account)

Comments: I am a firm believer in reducing antibiotic use in children, and it pains me to see most prescriptions by private pediatricians in India featuring antibiotics almost by default. I think that over the next few decades, we will reduce the use of antibiotics since the long term problems related to their overuse will become even more evident.

My child has been diagnosed with a hole in the heart - ASD, what should I do?

Q: I have a 1 year old daughter who was diagnosed with an 4.3 mm "Ostium Secoundum ASD" on the 15th day of life. Now she is 1 year old and without any symptoms, what should I do? 
A: Ostium Secondum ASD is a relatively common birth defect. For a small size ASD like in your child, it does not require any specific treatment unless there are symptoms. I would suggest repeat ECHO at 1 year age (now) and then yearly ECHO till 4-5 years age. There is around 70 % chance that this will close or become less than 3 mm with no flow through the ASD. In this situation, the child is normal and does not require any further treatment / evaluation. If the ASD remains large or the child has symptoms (like irritability, increased sweating, difficulty feeding, weight loss etc.) then you need to get in touch with a pediatric cardiologist for further evaluation and specific treatment like a catheter device or surgery.
More reading
http://pediatrics.aappublications.org/content/118/4/1560.full
http://emedicine.medscape.com/article/889394-treatment
http://emedicine.medscape.com/article/890991-treatment

What is the normal reaction after getting the BCG vaccination?

Question: What is the normal reaction after getting the BCG vaccination?
Answer: Children in India are routinely given BCG at birth. 
In the individuals previously uninfected by M.tuberculosis, about 2 to 4 weeks after the 
vaccination, erythema around an area of induration appears. Approximately at the site of prick 
of injection a nodule shows up. Within 3 to 10 days time, it softens giving rise to a pustule. 
Bursting of the pustule in about 2 to 5 days after its appearance results in an ulcer 4 to 8 mm 
in size. This painless depressed ulcer with undermined edges is soon covered by a thin crust 
or scab, which tends to peel off at the slightest provocation. The healing of ulcer in to a 
depressed, thin, shining scar with undermined edges in 4 to 6 weeks of its formation, marks 
the uneventful termination of sequence of occurrences at the site of BCG vaccination. 
In an individual previously infected with Mycobacteria, exaggerated and accelerated reaction of 
similar nature as described above, is seen. The reaction in this case starts within hours after 
vaccination and ulcer, 6 to 12 mm in size, occurs within a week. Ulcer also heals into the scar 
earlier. Size of the erythema, induration, nodule, pustule, ulcer and scar all are bigger than 
those in the uninfected. 
Similarly a repeat BCG vaccination also results in bigger local reactions. They are, however, 
smaller than those in the infected individuals. Onset of reaction in them, is almost similar to the 
infected. 
http://openmed.nic.in/526/01/NLNOKU78.PDF

Question - Reaction after BCG vaccine

Question: My baby girl is 1 month old. she had her bcg vaccine in 1 week after birth, and after 3 weeks it started swelling, is that a sign of tb or is it normal?
Answer. This is absolutely normal. The vaccine site is supposed to swell and then drain with a white pus like painless discharges. After a few weeks there would be a small white scar remaining at the site,
In fact if no reaction happens, you are supposed to repeat the vaccination for BCG !
Hope this helps
Regards
Dr Gupta, 

Parent Question : Baby, Child care, Mother Care & Parenting Magazines in India

Question: I have been blessed with a newborn baby, & I want to know which child care magazines to subscribe to?
Answer: I have limited personal experience with magazines for mother & child care in India. However, I have found 'Parenting' to be a good magazine, and had subscribed to it for the clinic for an year too.
Many of the child rearing tips have been very helpful & not known to me too.
Here is a list of some other magazines that are not available in India

1. Parenting
2. Mother & Baby
3. Child
4. Parent Edge
5. Parents India
6. Responsible Parenting - A new magazine focusing more on the mental & emotional aspect of Parenting

You can get details of subscription here
http://www.indiamags.com/indian-edition/parenting
http://www.bookstok.com/magazines/details/parenting

While there are many foreign child care magazines available in India, these magazines mentioned above tend to maintain an Indian focus, and have tips that are generally more useful to Indian parents,
I would welcome any additions and suggestions and reviews by the parents themselves

Help - My baby has been bitten by a Rat - Does he need Rabies Vaccine ?

Question: Help - My 3 year old boy baby has been bitten by a Rat - Does he need Rabies Vaccine ?
Answer: Rabies is transmitted through the bites, scratches, abrasions, or contact with animal saliva via mucous membranes or a break in the skin. 

Dog, cat and bats can transmit rabies. Raccoons, skunks, foxes and coyotes can also transmit rabies. Rabies has been reported in large rodents (woodchucks and beavers) but small rodents, such as squirrels, chipmunks, rats, hamsters, gerbils, guinea pigs, mice, and lagomorphs (rabbits and hares) are almost never identified as infected with rabies virus; there has never been a case of transmission to a human from one of these animals.

Source

Hence, your child is NOT going to get Rabies from this rat bite. However, I do suggest that All children are at a risk for dog bites (& monkey bites in certain regions of India) and hence I personally recommend that every parent should consider Rabies vaccine for their child routinely to prevent this fatal disease. I have given the Rabies vaccine to my daughter :-)

Why HPV (Cervical Cancer ) vaccination can’t wait ?

• Commentary
• Copyright © 2013 by the American Academy of Pediatrics
Why HPV vaccination can’t wait
1. Larry K. Pickering, M.D., FAAP
A vaccine is available that prevents cancer, but only 50% of eligible adolescent girls and far fewer adolescent boys have been provided this protection. Rates of human papillomavirus (HPV) vaccine uptake for adolescent females during 2012 have not changed from rates in 2011.

Dr. Pickering
Research indicates that pediatricians anticipate a “difficult” conversation when talking with parents of an 11- or 12-year-old about the HPV vaccine because it may involve a discussion of sexual issues.
However, this does not need to be the case. Research shows that HPV vaccine acceptance, like any childhood or adolescent vaccine, is influenced predominantly by your strong recommendation. This means not just suggesting that parents consider HPV vaccine, or mentioning casually that it’s available, but presenting the vaccine with the conviction and urgency that it deserves — that HPV vaccine will prevent several types of cancer, and this prevention should begin today.



Photo courtesy of the National Cancer Institute
Vaccine preventable cervical cancer.
“A conversation about HPV vaccination isn’t difficult. A difficult conversation is one I have nearly every week — when I have to look a young woman in the eye and tell her she may no longer be able to have children — or even worse, that she may die from cervical cancer. That’s a difficult conversation,” said Daron Ferris, M.D., professor in the Department of Obstetrics and Gynecology at Georgia Regents University Cancer Center.
HPV vaccine is cancer prevention — and it can’t wait. Not only does the immune system respond better at the recommended 11- to 12-year-old range when initiating the HPV vaccine series, but protection begins immediately after the recommended doses are given.
For each year HPV vaccine rates stay at 30% coverage instead of achieving 80%, 4,400 future cervical cancer cases and 1,400 cervical cancer deaths will occur. Let’s remove HPV vaccination from the realm of sexuality and place this childhood vaccine where it belongs — as cancer prevention. Just like any other vaccine, HPV vaccine needs to be given well before exposure occurs.
Don’t let your patients become an oncologist’s patients in 20 years. We have a powerful tool to prevent cancer now, and we must not fail to protect the children in our care.
FOOTNOTES
• Dr. Pickering is editor of the 2012 AAP Red Book.
  
  
  Source
  
  
  Comments:
  India has a far higher number of Cervical Cancer cases than any other country in the world (including China!) We are the Cervical Cancer capital of the world, and unfortunately there is a very high level of resistance against Cervical Cancer vaccine. Neither the ob/gyn nor many pediatricians are convinced about the need for the vaccination. This along with parental & adolescent hesitation  regarding any vaccination leads to abysmal rates of HPV (& other adolescent) vaccination. More than a lakh women (hundred thousand) are going to die every year due to this disease in India, and many of these deaths can be easily prevented by this vaccine. It is my humble submission to advise & use it freely in practice.

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

Healing:
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 http://www.drugs.com/dosage/esomeprazole.html#iukblX6mMgSAPTLx.99 

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.

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."

http://www.drugs.com/cg/sickle-cell-crisis.html

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.

Source

Read more about otoplasty here

http://en.wikipedia.org/wiki/Otoplasty
(Apparently Indian Surgeon Sushruta was doing Oculoplasty in the year 5th century BC !)

http://drderoberts.com/cosmetic-surgery-in-syracuse/syracuse-otoplasty/

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-naïve 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.

Source

How to tell the difference between sinus infections and colds in children?

Parent Plus Copyright © 2013 by the American Academy of Pediatrics

When your child has a runny nose, cough and fever, it can be hard to tell whether it’s just a common cold or a more severe illness like a sinus infection. Here are some tips to help you handle your child’s illness and know when your child should visit the pediatrician.

Know the odds. While colds are common, fewer than one in 15 children gets a bacterial sinus infection during or after a cold.

Differentiate the symptoms. Children with a cold have a runny nose with mucus that starts clear and then becomes cloudy or colored. Colds may include a fever that lasts one to two days, but symptoms improve on their own in 10 days. There are three types of sinusitis:

• Persistent: Runny nose, daytime cough (can worsen at night) or both last for 10 days and do not improve.
• Severe: Fever over 102.2 degrees Fahrenheit lasts for at least three days in a row. Mucus is thick and cloudy or colored.
• Worsening: A cold starts to improve, but fever returns or daytime cough or runny nose gets worse.

Talk with your pediatrician about whether to medicate. Kids with persistent sinusitis can either be observed to see if they improve on their own, or they can take antibiotics if they are particularly uncomfortable. All kids with severe or worsening sinusitis should take antibiotics to help them recover faster.

Consider the drawbacks of antibiotics. Side effects of antibiotics can include vomiting, diarrhea, upset stomach, skin rash, allergic reactions or yeast infections.

And remember, whenever you have a question about your child’s illness, talk with your pediatrician.

© 2013 American Academy of Pediatrics. This Parent Plus may be freely copied and distributed with proper attribution.

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Upcoming illnesses - have you heard of NOMOPHOBIA, RINGXITY ??

New Mobile Illnesses

Up till now the debate has been whether mobile radiations can cause brain cancer or not. But of late a new spectrum of diseases related to mobile use has come to the notice of medical profession and it is anticipated that ten years from now they will take an epidemic shape.

1.      Computer vision syndrome – it happens in 90% of the cases who use computer for more than three hours at a stretch. It leads to drying of eyes and headache. Prevention is to take a 20 seconds break after every 20 minutes and look by a distance of 10 feet for these 20 seconds.

2.      Blackberry thumb –This is a pharyngitis inflammation of the thumb leading to pain. This can be prevented by alternatively using fingers while texting using Blackberry phone.

3.      Stiffneck occurs due to constant use of mobile in one hand with neck flexed. The prevention lies in alternative shift of phone from one hand to another.

4.      Cellphone elbow is a pain in the elbow because of the stretching of ulnar nerve  because of use of mobile phone in a flexed position. The prevention lies in using hands free set.

5.      Nomophobia – It is present in 50% of the mobile users and is a type of mobile addiction. In literal meaning it means ‘no mobile phobia’ which means that all the time one is having a fear of losing the phone.

6.      Ringxity – It is a resultant anxiety of not getting a phone in the last 30 minutes. It is present in the 30% of the mobile users.

7.      Phantom ringing – It is present in 20-30% of mobile users and presents as someone feels that mobile is ringing when actually it is not.

8.      Social site addiction – With the use of smart phone, one is addicted to facebook, internet, Twitter and other applications. They can end up in insomnia, fragmented sleep, etc.

9.      After TV facebook is the number two cause of relational disharmony within the family and is present in 20% of the houses.

10.     Smart phone is a cause for parent-child conflict in 30% of the cases. Often children get up late and end up going to school unprepared. On an average, people spend 30-60 minutes in the bed playing with the smart phone before sleep.

Here are a few steps that may help to reduce these upcoming dreaded diseases !

1.     Electronic curfew means not using any electronic gadgets 30 minutes before sleep.

2.     Facebook holiday – One should go for a facebook holiday for 7 days every three months.

3.     Social media fast – Once in a week, one should avoid use of social media.

4.     One should use mobile phone only when mobile. One should not use computer for more than three hours in a day.
5.     Mobile talktime of not more than two house a day.
6.     One should not recharge mobile battery more than once in a day.
7.     Mobile can also be a source of infection in the hospital setup, therefore, it is disinfected everyday.

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Full Disclosure : I suffer from Phantom Ringing Syndrome on a regular basis, and sometimes from CVS - Computer Vision Syndrome too :)

Fish Medicine for asthma

SOURCE

The fish cure for asthma is back in the news. The Bathini Goud family, living in Hyderabad, claim that they can cure asthma by making people swallow a 2-inch live fish filled with medicine. They claim that

they have been using this treatment for over 160 years.

As per their claim the medicine is stuffed inside the mouth of a live murrel fish, 5-6 cm in size. This fish with medicine is slipped into the mouth of the asthmatic patient, which can easily be swallowed as the fish is slippery. This needs to be taken for three consecutive years.

The medicine is administered on a specific day Mrigashira Kanthi Nakshatra, which normally coincides with arrival of monsoon rains in the first or second week of June. Three doses are given to the patients after every 15 days.

The Goud family never discloses ingredients of their drug. They provide the medicine free of cost. Some people went to the Court of the Andhra Pradesh on 27.01.2013 but the court declined to interfere
and pass any orders regarding the administration of substances popularly known as Fish Medicine. They reasoned that although the treatment had no medicinal value, analysis had shown the samples to
not be harmful. They said that “if people flock to have a substance out of faith the courts cannot interfere”.

My opinion (Dr KK Agarwal)

Asthma is classified as mild intermittent asthma, moderate persistent asthma and severe persistent asthma. The distinction between intermittent and mild persistent asthma is important because current guidelines for moderate persistent asthma call for initiation of daily control medicine. For moderate persistent asthma, the preferred long-term controller is low-dose inhaled steroid.

Mild intermittent asthma is the largest segment of asthmatic patients and they do not require long term treatment. These are the people who may never require steroid inhalers. Over a period of time, these
asthmatics may show improvement. Many mild intermittent asthmatics who are allergic to a particular
protein may improve over a period of time.

Homeopaths, Ayurveda physicians, naturopaths and others who claim that they can cure asthma, they work only on patients with mild intermittent asthma. If they can demonstrate their results in severe asthma, then their methods can be believed to be of use.

The very fact that anybody has claimed does not mean that it is not scientific or scientifically validated. If they can prove their claim, there is no reason why they should not get Noble Prize. We have seen a similar claim by a person who gives a medicine for jaundice in Chandni Chowk and another person in Agra who claims that the can cure any type of cancer with a herb mixed with Bakri ka doodh (goat milk).

- See more at: http://blogs.kkaggarwal.com/2013/06/fish-medicine-for-asthma/#sthash.Rbg66u8w.dpuf

Comment: Being a child specialist with specific interest in Asthma & childhood allergies, I am frustrated many times with the Indian mentality to deride the use of Inhalers & any long term allopathic medicines in the treatment of asthma. The 'lack of faith' in inhalers & the increasing incidence of the disease, has lead to the increasing popularity of these unconventional & unscientific cures.
I would be extremely happy if a local medical college would try to conduct some sort of a trial on the use of this medication in asthma patients. I have had a few patients who have tried this in my practice, and have not found anything that could be explained solely by magical remedies.