My "Update on Pertussis" presentation - Chandigarh - May 2014

Update on Pertussis - Special reference to Quinvaxem - Chandigarh May 2014 from Gaurav Gupta

Chicken Pox vaccine not available in India - May 2014

Chicken Pox vaccine is not available in India at the present point of time. We are getting a lot of anxious calls from parents due to increased number of Chicken Pox cases. This is due to nonseasonal rains in North India. The good news are 
1. Chicken pox vaccine is likely to become available by first week of June - Varilrix by GSK 
2. Chicken pox disease in children is generally a mild disease. So while I would suggest that you consider taking the vaccine when it is available, there is certainly no need to panic at the present point of time.

An attempt to reduce antibiotic resistance & drug abuse in India - Schedule H1 drugs

Under the Drugs & Cosmetics Rules, drugs specified under Schedule H and Schedule X are required to be sold by retail on the prescription of a Registered Medical Practitioner only.  At present Schedule H & Schedule X contains 510 & 15 drugs, respectively.  Recently, a new Schedule H1 has been introduced through Gazette notification GSR 588 (E) dated 30-08-2013, which contain certain 3rd and 4^th generation antibiotics, certain habit forming drugs and anti-TB drugs. These drugs are required to be sold in the country with the following conditions:

(1)              The supply of a drug specified in Schedule H1 shall be recorded in a separate register at the time of the supply giving the name and address of theprescriber, the name of the patient, the name of the drug and the quantity supplied and such records shall be maintained for three years and be open for inspection.

(2)     The drug specified in Schedule H1 shall be labelled with the symbol Rx which shall be in red and conspicuously displayed on the left top corner of the label, and shall also be labelled with the following words in a box with a red border:

“Schedule H1 Drug-Warning: -It is dangerous to take this preparation except in accordance with the medical advice. -Not to be sold by retail without the prescription of a Registered Medical Practitioner.”

Source

Ministry of Health and Family Welfare, New Delhi on 30 Aug, 2013 vide GSR 588 (E) has notified Schedule H1 after consultation with DTAB. These Rules will come in force after six months of publication in official Gazette.

In Rule 65, in condition (3), (9), (11) (11A) wherever Schedule H is their “Schedule H and Schedule H1” shall be substituted.
In Rule 97 in sub rule (1) a provision is made that the formulation containing substance specified in Schedule H1, the drug formulation shall be labelled with symbol Rx which shall be in red and conspicuously displayed in the left top corner of the label and shall also be labelled with following Box warning:

“Schedule H1 Drug-Warning -It is dangerous to take this preparation except in accordance with the medical advice. -Not to be sold by retail without the prescription of a Registered Medical Practitioner,”

In Schedule H, Alprazolam, Cefdinir, Cefepime HCl, Cefetamet Pivoxil, Cefpirome, Cefpodoxime Poxetil, Ceftazidime Pentahydrate, Ceftizoxime Sodium, Chlordiazepoxide, Clofazimine, Codeine, Diazepam, Diphenoxylate and its salts, Ethambutol HCl, Ethionamide, Levofloxacin, Meropenam, Midazolam, Moxifloxacin, Nitrazepam, Pentazocine, Pyrazinamide, Sparfloxacin, Thiacetazone, Tramadol HCl, Zolpidem entries are omitted.

In Schedule H1, following drug substances and their salts excluding those intended for topical or external use (Except ophthalmic and ear or nose preparations) Alprazolam, Balofloxacin, Buprenorphine, Capreomycin, Cefdinir, Cefditoren, Cefepime, Cefetamet, Cefexime, Cefoperazone, Cefotaxime, Cefpirome, Cefpodoxime, Ceftazidime, Ceftibuten, Ceftizoxime, Ceftriaxone, Chlordiazepoxide, Clofazimine, Codeine, Cycloserine, Diazepam, Diphenoxylate, Doripenem, Ertapenem, Etambutol HCl, Ethinamide, Feropenem, Gemifloxacin, Imipenem, Isoniazid, Levofloxacin, Meropenem, Midazolam, Moxifloxacin, Nitrazepam, Pentazocine, Prulifloxacin, Pyrazinamide, Ribabutin, Rafampicin, Sodium Para-aminosalicylate, Sparfloxacin, Thiacetazone, Tramadol and Zolpidem are covered.

Source

Comment: This is indeed a laudable attempt to reduce drug misuse in our country, where routinely 'any' medicine can be purchased without prescription with your local 'helpful' pharmacy.

While there may be some logic in allowing medicines without prescription in a poor country, to reduce health costs, this has lead to a large number of people doing self - diagnosis & self - treatment, or asking the local pharmacist (who is many a times an underpaid school dropout himself!) for medicines.

Putting a lot of these medicines under schdule H1 will hopefully reduce antibiotic misuse and reduce the development of antibiotic resistance in India.

FAQs of Dengue

1. If the dengue mosquito is a day biter, why should we use mosquito net in the night?

The Dengue mosquito or Aedes aegypti prefers to bite during the day but this does not mean that it does not bite in the night also. A mosquito net prevents other bites from other mosquitoes including the Culex mosquito.

2. Up to what distance can a mosquito fly?

A mosquito can fly up to a distance of 100 to 200 meters.

3. How high can mosquitoes fly?

A mosquito can fly as high as 20th floor of a building step by step from one floor to another.

4. Which mosquito produces noise?

The Culex mosquito produces a buzzing noise by the beating of its wings.

5. Why does dengue usually begin in the doctors’ hostel at AIIMS?

The students go on leave/holiday leaving their hostel rooms closed. Water remains collected, where the dengue mosquito can breed.

6. Should an electronic repellant be used to kill the dengue mosquitoes?

Electronic repellants are effective for big sized mosquitoes and flies and may not be effective for malaria and dengue mosquitoes.

7. Should a repellant spray be used in the house?

A repellant spray can be used in the house if the mosquito density is high.

8. How long can the mosquito egg remain alive?

The mosquito egg remains alive for up to a year.

9. Should children wear full sleeve shirt and full length trousers?

Yes, children wear full sleeve shirts and full length trousers. This should be followed through the year.

10. Can the infection be transmitted through mosquito eggs?

Yes, the infection can be transmitted through mosquito eggs.

11. How should water storage vessels be covered?

Water that has been stored for use should be kept covered. You can use a clean old dhoti or any other cloth to cover the water storage vessels.

12. How many meals does a dengue mosquito take in a day?

A dengue mosquito takes 3–4 meals in a day.

13. How many meals does a malaria mosquito take?

A malaria mosquito takes a meal once in three days.

14. How big a feed is taken by a dengue mosquito?

A dengue mosquito takes small frequent meals.

15. What are the similarities between dengue mosquitoes and human beings?

Both dengue mosquitoes and human beings prefer fresh water; they both like decoration, both like AC atmosphere, both like to sleep in the night and remain active in the day time and both like to use coolers and both like to take 3–4 meals in a day.

-- 

Dr.Uday Ananth Pai
M.D.,D.C.H.

PRESIDENT  IAP MUMBAI 2014

Normal DPT (wP) versus "Painless DPT (aP)" - what does the science say?

SAGE-WHO recommendations vindicated IAP ACVIP stand on Pertussis vaccination:

wP Versus aP vaccines:

Acellular vaccines
o Lower initial efficacy
o Faster waning of immunity
o Possible reduced impact on transmission
o Likely to result in resurgence
o Magnitude and timing of resurgence difficult to predict
o Potential increased risk of death in those too young to be vaccinated

Must consider overall goal of national immunization program
1. Protection of infants ? No benefit of aP over wP vaccines
o disease-related mortality significantly reduced with either wP or aP vaccination
2. Protection of older children or adults ? Multiple doses of aP required
o Only possible with aP vaccines (less reactogenic)
o Requires repeat boosting (limited duration of efficacy) to limit/prevent resurgence and increased risks to infants
o Increased program cost
wP vaccines preferred when:
o Program target is prevention of infant disease
o Limited number of pertussis doses delivered / affordable

 aP vaccines should only be considered when:
o Program objectives include older children and adults
o Large numbers of doses may be included in a national immunization schedule
o Cost implications (higher unit cost & number of required doses)

CONCLUSIONS:
SAGE concluded that the licensed acellular pertussis vaccines (aP) lower initial efficacy, have faster waning of immunity, and possibly a reduced impact on disease transmission relative to currently internationally available whole-cell vaccines (wP). The risk of resurgence of pertussis associated with the use of aP vaccines including increased infant disease, indicates that countries currently using wP should continue using wP vaccines for early infant vaccination.

As communicated by Dr Naveen Thacker 

Soda consumption is associated with negative behavior in young children

J Pediatr. 2013;163:1323-8.

Question: Among young children, what is the association of soda consumption with negative behavior?

Design Prospective birth cohort from the Fragile Families and Child Wellbeing Study.

Setting 20 large US cities.

Participants Children age 60 months.

Intervention Daily soda consumption vs. none.

Conclusions Soda consumption is associated with negative behavior among very young children.

Commentary During the past two decades, there have been substantial studies on the adverse effects of soft drinks on human health, especially chronic disease among adults. Find-
ings from these studies have led to changes in policies (eg, taxing soft drinks) in some countries. The study by Suglia et al focuses on soft drinks and behavior among children.
Consistent with findings among adolescents in Norway and US, high soft drink consumption is positively related to behavior problems in children age 5 years. The study is important because of its large sample size and ability to adjust for a range of confounding factors. The study’s findings are supported by existing evidence. In addition to the chemicals in soft drinks mentioned by the authors, phthalates from plastic packaging may also explain the link. A high maternal prenatal urinary phthalates level is associated with child behavior problems at age 3 years. Data from the National Health and Nutrition Examination Survey suggest that there is an association between phthalates and attention deficit disorder in children. High consumption of soft drinks among young children is of great concern and supports focusing attention towards reducing consumption. 
Zumin Shi, PhD
University of Adelaide
Adelaide, South Australia

Fake medical certificates demanded by school teachers for students attending family function. what is the solution?

Many pediatricians have faced this problem.This question has been asked in a forum of pediatricians and has given me food for thought as well.
What is happening is that Teachers are not only forcing the parents for a medical certificate after a short illness but even if the family is going out of town for a family function they ask the parents to get a medical certificate !!
Now this becomes very embarrassing for a doctor who does not like to issue fake certificates and the family is a regular? from decades! ! How to say No!! 

I have issued medical certificates once in a while on demand of 'strict' schools where every leave has to be condoned with a medical certificate, even if it is for a family function. How do we proceed since otherwise the child/ parents may be harassed?
I remember what my father did when I was 10 years, and we wanted to see the 1982 Asian Games in Delhi. He was a pediatrician in the Army, and he could obviously have generated a medical certificate from one of his colleagues. However, he chose to go to Principal of the school and told her the truth. The principal appreciated this fact, and was quite impressed to day the least.
I am not saying that this will work for everyone, but stating the truth may be an alternative to consider, rather than asking your pediatrician for a false certificate.

Being born 4-6 weeks premature can affect brain structure, function

• Copyright © 2014, The American Academy of Pediatrics

VANCOUVER, BRITISH COLUMBIA – The brains of children who were born just a few weeks early differ from those born on time, and these differences may affect learning and behavior, according to a study to be presented Monday, May 5, at the Pediatric Academic Societies (PAS) annual meeting in Vancouver, British Columbia, Canada.

Studies have shown that children who were born between 34 and 36 weeks’ gestation (late preterm) have more social, behavioral and academic problems than children born at full term (37-41 weeks). However, few studies have looked at the brain structure of late preterm children.

Researchers from the University of Iowa conducted magnetic resonance imaging (MRI) scans on 32 children ages 7-13 years old who were born at 34-36 weeks’ gestation. In addition, they administered cognitive tests to the children, including the Wechsler Intelligence Scale for Children, Benton Judgment of Line Orientation (which assesses visual perception), Grooved Pegboard (which assesses fine motor skills and coordination) and Children’s Memory Scale. Parents also completed a behavioral assessment.

Results were compared to 64 children born at full term who were recruited for another study in which they completed the same cognitive and behavioral assessments, neurological exam, and MRI sequences as the late preterm group.

Preliminary analysis showed differences in both cognitive function and brain structure in the late preterm children compared to full term children. Functionally, late preterm children had more difficulties with visuospatial reasoning and visual memory. They also had slower processing speed. Processing speed refers to the ability to perform automatically a simple task in an efficient manner. Children with slower processing speed may require more time in the classroom setting to accomplish a task.

Structurally, the brains of late preterm children had less total cerebral white matter, which is critical to communication between nerve cells, and smaller thalami, a brain region involved in sensory and motor signaling.

“Late preterm birth accounts for 8% of all births each year in the United States, making it a public health issue,” said presenting author Jane E. Brumbaugh, M.D., FAAP, associate, University of Iowa Stead Family Department of Pediatrics. “The effects of late preterm birth on the brain have not yet been fully characterized, and it has been assumed that there are no significant consequences to being born a few weeks early. Our preliminary findings show that children born late preterm have differences in brain structure and deficits in specific cognitive skills compared to children born full term.”

Parents of late preterm children also reported more problems with hyperactivity, inattention, opposition and aggression than parents of full term children.

“The developing brain is vulnerable to what most might consider a minor ‘insult’ in being born late preterm. Moreover, these effects are enduring,” said senior author Peggy C. Nopoulos, M.D., professor of psychiatry, neurology and pediatrics with University of Iowa Health Care.

To view the study abstract, go to

http://www.abstracts2view.com/pas/view.php?nu=PAS14L1_3670.1.

Your 4 year-old: Dealing with a lisp - unclear speech in playschool child

Pronunciation difficulties are still common at four. For example, is your child is still saying "torry" instead of "sorry"? Many children don't master the initial s and z sounds until age 7 or 8. Other sounds that can cause a problem: f, v, l, r, and sh. Usually the culprit is immature control of the muscles used to form sounds.

While you may think his baby speech is cute, don't say so to your child or mimic his pronunciation. He may stick to it even after he doesn't need to. Don't correct his words, either. You don't want to make him any more self-conscious than he may already be. Simply model correct speech.

Lisping occurs when children push out their tongues when forming an s instead of letting their tongue rest behind their teeth. Most children outgrow lisping eventually. But if your child's speech makes him unintelligible or prompts teasing from other children, you may want to see a speech pathologist. In general, the younger a child starts speech therapy, the better the outcome.
Source

Changes in sexuality after birth of baby occur in both parents

Parents experience a change in sexuality following the birth of a child, with low sexual desire linked to factors related to the care of the baby like stress and fatigue, suggests new research in the US.

The retrospective online survey, involving 114 partners of postpartum women (95 men, 18 women, 1 unspecified), questioned new parents about their sexuality in the 3 months following the birth of their youngest child to determine changes in physical, social, psychological and relational experiences.

The results showed that in the first 3 months following birth, 81.7 percent of partners reported reengagement of sexual intercourse with the birth mother, 69.6 percent reported participating in oral sex and 72.7 percent reported masturbating. Masturbation occurred earlier in the postpartum period than did intercourse (p<0 .001="" all="" and="" between="" birth="" both="" but="" differences="" either="" enjoyed="" enjoyment="" equally="" groups="" higher="" in="" initiation="" intercourse="" it="" masturbation="" mother="" no="" of="" on="" or="" oral="" p="0.359).</p" parent.="" participated="" partner="" postpartum="" reengage="" reported="" s="" sex="" significant="" than="" the="" there="" time="" to="" took="" was="" were="" with="">

Participants ranked factors related to sexual and intimate feeling in participants and their partners as most frequently contributing to high desire and fatigue and stress as the top influences for low desire. Time constraints was selected as the third most common factor contributing to low postpartum sexuality. There were no significant differences between the genders in self-reported perceived stress, body image self-consciousness or average level of fatigue (all p>0.40). However, women partners of new mothers perceived more support from their significant others and friends and had significantly higher overall social support scores than their male counterparts (all p<0 .035="" p="">

“Results from this study and previous research suggest that postpartum sexuality can be conceptualized as an individualized experience within a partnership, as well as one that occurs in a larger social and relational context,” said study author Dr. Sari M. van Anders of the University of Michigan, Ann Arbor, Michigan, US, and colleagues.

“While most studies on postpartum sexuality focus on the birth mother, few if any have examined the role of sexuality in the mother’s partner and whether this in turn influences the birth mother’s perception of her own sexuality,” said Dr. Juan Dominguez, principal investigator of the Neuroendocrinology and Motivation Lab at the University of Texas at Austin’s Department of Psychology.

Dominguez warned that these gender-specific findings should be interpreted with caution due to the small sample size of women partners and time lapse between the postpartum period and the collection of data.

“This small caveat notwithstanding, the study provides a clearer window in which to view the postpartum sexuality of co-parents, how postpartum sexuality may vary between partner’s gender, and the idiosyncratic changes in sexual activity that follow parturition,” added Dominguez. “These findings will be a source of information for health professionals who counsel mothers after birth.”

Source (Free registration needed)