How to care for cracked nipples ?

Is there any treatment or relief for cracked or bleeding nipples?

If your nipples bleed or crack, here's what you need to do: 

• Take a look at the pictures in our how to breastfeed article and read our advice on how to make sure that your baby is latched on well. Talk to your doctor, or ask her to put you in touch with a breastfeeding specialist if you need extra help.
• You may find certain feeding positions to be more comfortable than others. Some nursing mums find it easier to lie down sideways and feed their baby.
• Many mums find rubbing a little modified lanolin ointment or cream on their nipples helps them recover. This treatment, called moist wound healing, eases pain and allows wounds to heal faster without forming a scab. You won't need to wash the ointment off before feeds. Your local chemist should be able to help or you could ask your doctor to prescribe an appropriate ointment. You can also rub some of the fat-rich hindmilk onto your breasts after a feed.
• Don't put soap, lotions, or perfumes on your nipples. Washing or bathing with plain water is all it takes to keep your breasts and nipples clean.
• Take a painkiller. If the pain is severe, you can take a mild painkiller about 30 minutes before feeding. Check the most appropriate type with your doctor.
• If you choose to use something to help you like a nipple shield, only do so with the advice of a breastfeeding counsellor or your doctor. If you can, try to use them only as an emergency fix.

If a crack or wound shows no sign of healing, check with your doctor. 

Will my cracked or bleeding nipples affect my baby?

Babies generally ignore cracked or otherwise injured nipples. A little blood in your milk won't hurt them, and, as long as you can bear it, you can carry on breastfeeding. The important thing is to get your baby feeding efficiently so your nipples have a chance to heal. 

Sorting out the problem will help your baby, too. If your nipples are suffering because your baby is not latched on well, he probably isn't getting the best from your milk. Feeds may dragon without your baby sucking efficiently. He may not take in enough of the calorie-rich hindmilk that comes at the end of a feed. He'll need that rich milk to gain weight.

Can I still breastfeed even with cracked and bleeding nipples?

If you've got cracked nipples, feeding your baby can be unbearably painful. If it's impossible to feed, you can carefully express your milk and give it to your baby by bottle, cup or palladaiin the meantime. Find out how to safely store expressed breastmilk. 

You may be in a lot of pain from your cracked nipples, especially if your baby bites when breastfeeding. But try to remember it won't last forever. Following the tips in this article and getting help from your doctor will put you on the road to recovery. Then you and your baby will be able to enjoy breastfeeding once again. 
Source
There is a good quality OTC Mother care cream now available in India, you can buy it here
Finally you can find some additional home remedies for cracked nipple here

Newborn Parenting FAQs - Colic

Q:  In which month does colic start and how to cope with it?
A: Colic is actually something that we pediatricians do not know much about either :)
It is believed to be possibly due to spasms in the intestines, that occur without any apparent cause in a certain percentage of babies between the age of 1-6 months. 
If the baby is otherwise active, playful through the day and has crying episodes lasting for a few hours in the evening / night, without fever, diarrhea, vomiting etc. during this age group, please talk to your pediatrician regarding the possibility of colic.
Just like we are not sure about the cause of colic, the treatment of colic is also unsatisfactory. We commonly suggest simethicone drops (brands like Colic Aid, Spasease, Espumisan). Traditional home remedies like massage, relieving flatulence and other remedies like gripe water & even janam ghutti (traditional ayurvedic medicine) have been used in India to help the babies. It is important to try to stay relaxed and hand over the baby to a sympathetic ( & preferably calm disposition) if you are feeling too stressed out since anxiety in parents has been shown to worsen the colic in some babies. Driving around in the car has been shown to work in many kids as well ... though doing this in the middle of the night may lead to weird looks from the neighbors :)
The good news is that colic resolves by 6 months in most babies.

A fascinating animal study suggests that gut bacteria may influence vaccine response

By Sharon Nirenberg

NEW YORK (Reuters Health) - The composition of intestinal microbes may impact the efficacy of the seasonal influenza vaccine, a study in mice shows.

"Gut bacteria express a protein called flagellin, which triggers a receptor known as TLR5 (toll-like receptor 5) on immune cells, causing increased production of antibodies in response to flu vaccination," said co-author Dr. Bali Pulendran of Emory Vaccine Research Center in Atlanta, Georgia.

"Depletion of gut bacteria by antibiotic treatment may affect immunity to vaccination in humans," Dr. Pulendran told Reuters Health by email. "People in different communities, such as those in rural areas of developing countries versus those in developed countries, have very different types of gut bacteria, and it is conceivable that this difference influences immunity to vaccination."

In a report online September 18 in Immunity, Dr. Pulendran and colleagues describe how they administered the trivalent influenza vaccine to Tlr5-knock-out mice as well as wild-type mice.

The mice without Tlr5 demonstrated reduced antibody titers and decreased plasma cell frequency in response to vaccination, the researchers found.

They also compared vaccine-induced immune response between mice raised in a germ-free environment, mice treated with antibiotics, and germ-exposed mice.

Mice raised in a germ-free environment and those treated with antibiotics showed reduced antibody titers in response to vaccination. However, when the germ-free and antibiotic-treated mice orally received flagellated E. coli to reconstitute the gut microbiota, the antibody response to the vaccine was restored.

"The results of our experiment do raise the possibility that antibiotic treatment may impact immunity to vaccination in humans, but this can only be definitively tested in an experiment in humans," Dr. Pulendran concluded.

SOURCE: http://bit.ly/1r29g5d

Immunity 2014.

Comment: A wonderful concept that further illustrates the pitfalls of antibiotic misuse. There are many things about proliferating & rampant antibiotic use that we are yet to know, and I believe that in half century from now antibiotic use would be far more restricted as compared to what we have today due to various reasons, including the fact that we may come to know that they do end up causing long term problems to people taking them.

Vaccine FAQs: Which pneumonia vaccine is better in India?

Q: Pneumococcal vaccination is of two types 1. contain 10 virus 2. contain 13 virus and I am from India, so I want to know that whether first or second I have give to my child?

A: It is preferable to give the vaccine with the 13 strains since it covers the 10 bacterial strain + and additional 3 strains.
Of course the 13 strain vaccine (Prevenar) is almost twice as expensive, hence while it is certainly the better vaccine of the two, the 10 strain vaccine (Synflorix) which is almost 80 % as effective gives value for money.

Newborn Parenting FAQs - No stool passed for 5-6 days, what to do?

Q: What if baby doesn't pass stool for 5-6 days?

A: In a baby who is exclusively Breast Fed, this is NOT a sign of constipation in the first few months of life. Nothing needs to be done, except may be simethicone drops (like colic aid etc.) if the child is uncomfortable or gassy. In almost all cases, this will improve with the passage of time without any medicines, and none should be used without consulting your pediatrician

Rapid TB blood test for children is the future - Lancet Infectious Diseases

In future, a rapid and accurate tuberculosis test for children may allow the illness to be better diagnosed. The approach proved to be successful in a TB-endemic region in Tanzania, report Swiss researchers in "The Lancet Infectious Diseases".

The method developed by the Swiss Tropical and Public Health Institute in Basel is called TAM-TB and is a sputum-independent blood test. The diagnosis is based on the immunological phenomenon during TB, when, in the course of an active infection, a specific surface marker (CD27) on mycobacteria specific CD4+ T cells is lost. The test result is available within 24 hours.

The test was carried out in real situations in two health centres in Tanzania. Children with TB symptoms were examined using standardised clinical methods and TAM-TB for the presence of an active infection. According to the scientists, the sensitivity and specificity of TAM-TB proved to be good.

"This rapid and reliable test has the great potential to significantly improve the diagnosis of active tuberculosis in children", said Klaus Reither from the Swiss Tropical and Public Health Institute, who coordinated the study. In cooperation with researchers from Munich, it is planned to refine the test further to use it in HIV-infected children and to make its application more cost-effective.

Source

Comment: TB diagnosis is making rapid strides in the last few years. We already have commercially available sputum test (GENEXPERT) in India that helps diagnose TB & even gives information on drug resistance within a day. If this tests proves to be useful, it would be a great help in children, since sputum collection can be difficult in many kids. 

Newborn Parenting FAQs - Is my baby not getting enough breast feed ?

Q: Sometimes baby looks fussy even after his meal..is he not getting enough breast milk?

A: In most cases the answer would be NO. There are three ways that you can easily use to try to establish if the breast feed is adequate.

1. Weight gain - Check the weight on a digital machine and see if the child is gaining weight properly. You can talk to your pediatrician when you go for vaccinations regarding this as well.

2. Urine color & frequency - If the baby is exclusively in milk, then ALL the urine is because of the water in the milk. Hence a large quantity of almost water color urine suggests that the breast feed is adequate.

3. Hungry after feeding - This is widely misinterpreted. A baby may cry or be fussy for many reasons, since he/ she is unable to communicate in any other way. You would need to see if the baby is consolable (not likely to be hungry), and if there may be some other reason - like they are bored, wet, thirsty etc. before labeling this fussiness due to a lack of breast milk.

Dengue vaccine shows promise in phase 3 trial in children - Lancet study

Specialists say the candidate vaccine is efficacious in children and has a good safety profile

Background

An estimated 100 million people have symptomatic dengue infection every year. This is the first report of a phase 3 vaccine efficacy trial of a candidate dengue vaccine. We aimed to assess the efficacy of the CYD dengue vaccine against symptomatic, virologically confirmed dengue in children.

Methods

We did an observer-masked, randomised controlled, multicentre, phase 3 trial in five countries in the Asia-Pacific region. Between June 3, and Dec 1, 2011, healthy children aged 2—14 years were randomly assigned (2:1), by computer-generated permuted blocks of six with an interactive voice or web response system, to receive three injections of a recombinant, live, attenuated, tetravalent dengue vaccine (CYD-TDV), or placebo, at months 0, 6, and 12. Randomisation was stratified by age and site. Participants were followed up until month 25. Trial staff responsible for the preparation and administration of injections were unmasked to group allocation, but were not included in the follow-up of the participants; allocation was concealed from the study sponsor, investigators, and parents and guardians. Our primary objective was to assess protective efficacy against symptomatic, virologically confirmed dengue, irrespective of disease severity or serotype, that took place more than 28 days after the third injection. The primary endpoint was for the lower bound of the 95% CI of vaccine efficacy to be greater than 25%. Analysis was by intention to treat and per procotol. This trial is registered with ClinicalTrials.gov, number NCT01373281.

Findings

We randomly assigned 10 275 children to receive either vaccine (n=6851) or placebo (n=3424), of whom 6710 (98%) and 3350 (98%), respectively, were included in the primary analysis. 250 cases of virologically confirmed dengue took place more than 28 days after the third injection (117 [47%] in the vaccine group and 133 [53%] in the control group). The primary endpoint was achieved with 56·5% (95% CI 43·8—66·4) efficacy. We recorded 647 serious adverse events (402 [62%] in the vaccine group and 245 [38%] in the control group). 54 (1%) children in the vaccine group and 33 (1%) of those in the control group had serious adverse events that happened within 28 days of vaccination. Serious adverse events were consistent with medical disorders in this age group and were mainly infections and injuries.

Interpretation

Our findings show that dengue vaccine is efficacious when given as three injections at months 0, 6, and 12 to children aged 2—14 years in endemic areas in Asia, and has a good safety profile. Vaccination could reduce the incidence of symptomatic infection and hospital admission and has the potential to provide an important public health benefit.

Source

Comment: With the increasing incidence of Chikungunya & Dengue worldwide, candidate vaccines for these diseases are essential to reduce morbidity & mortality, especially in children of the developing world.

Parenting FAQ - How long to breastfeed a baby ?

Q: For how much time should i feed my baby in one sitting?

A: A majority of children will empty a significant proportion of the breast within 5 to 10 minutes. Hence a total time of say half an hour is the maximum that would be needed for breastfeeding the baby.
However, babies love to use the breast as a pacifier, and they may want to stay latched on for hours! So try to just cuddle them up next to your chest after the feeding is completed, rather than allowing them to stay latched for a long time.

Parenting FAQs - How much time between feeds in a baby?

Q: How much gap should i maintain between every feed? Specially when baby is not demanding feed on his own for long?

A: For a normal good weight healthy baby the recommendation is to feed them ONLY on demand. This means that if the baby is blissfully sleeping for 6 hours .... the mother should grab this opportunity to get some much needed rest as well :)
There is no reason to wake up a healthy baby to feed them at some artificial time (like 2 hours, 3 hours etc.)

Daily breakfast may lower diabetes risk in children

Having breakfast daily could protect children against developing type 2 diabetes later. This is the outcome of a British study published in "PLOS Medicine". Above all, if the food is rich in fibre, it has a particularly beneficial effect on the diabetes risk profile.

Researchers at St. George's, University of London as well as the Universities of Oxford and Glasgow, studied the breakfast habits of 4,000 school children (aged nine or ten years). They also evaluated blood samples and other physical measurements as well as dietary data.

The results showed that children who ate breakfast daily had better diabetes risk profiles than children who only had breakfast irregularly or not at all. Body fat, socioeconomic status or activity levels had no impact on the results.

According the scientists, a high-fibre meal was the most beneficial. These children had the lowest insulin resistance.

The results would once again confirm the long-term importance of a daily breakfast. "It is concerning to note that more than 1 in 4 children in our study reported not eating breakfast every day. For children, eating a sensible breakfast every day, one which is high in fibre, may well help to reduce future risk of developing type 2 diabetes", says study leader Angela Donin from St George's, University of London.

Source

Comment: Another reason why we should NOT skip breakfast for ourselves and our children too.

Measles vaccine causing 15 deaths in Syria - Human error to blame

GENEVA (Reuters) - A muscle relaxant appears to have been mixed mistakenly with measles vaccine, killing 15 children in Syria this week, the World Health Organization (WHO) said on Friday, calling it the biggest such tragedy in memory.

The WHO said it could not completely rule out sabotage, so the measles inoculation campaign remained suspended until the investigation was finished.

Fifteen children died after being vaccinated against measles in northern Syria, aid workers said on Wednesday, a tragedy likely to damage trust in health services in opposition-held areas.

The manufacturer, who has not been identified, shipped the vaccine in powder form with a diluent to a hub in Syria where it was stored and then sent to Deir al-Zor and Idlib provinces for the campaign to vaccinate tens of thousands of children that began on Monday, WHO spokesman Christian Lindmeier said.

"In the hub apparently, (from) what we know so far, the diluent was kept ... together in the same refrigerator with a muscle relaxant. The relaxant is called atracurium. This got mixed in some cases instead of the diluent with the vaccine powder," Lindmeier told a news briefing in Geneva.

Pointing to human error, he said: "So the ones who packed it obviously put the wrong ampoules with the vaccine powder into the package. Then it gets shipped in the vaccine carriers to the facility, there it gets unpacked, mixed and then it has to be used within 6 hours.

"So both at the packing and at the unpacking there had to be gross negligence," Lindmeier said.

The muscle relaxant, usually administered as an anaesthetic for surgery, works according to weight, so all the children who died were under the age of two, he said. Older children survived after vomiting, diarrhea and anaphylactic shock.

Lindmeier said: "It seems very clear that it was not the manufacturer's fault, not that the vaccine is contaminated, but it's a fault on the ground, again not established whether it's human error or deliberate, but the fault lies on the ground as per indications."

It was not clear who was in charge of the refrigerator and investigations continue, he said. The WHO and UNICEF supported the campaign but were not directly involved due to insecurity and the "politically-charged" situation in the area, he added.

"There is still a slight possibility that it's not only human error, but an intent, that has to be cleared up definitely before anything can continue," he said.

More than 50,000 children in the two provinces received the vaccine before the campaign was suspended, he added.

Prior to Syria's civil war, some 99% of children were vaccinated against measles, a highly contagious disease that can cause serious complications such as meningitis and pneumonia, becoming much deadlier in difficult conditions.

Source

Comment: Measles vaccine deaths have been reported in India as well, and many of these are again due to a similar situation - mixing a muscle relaxant in place of diluent, or sometimes due to bacterial overgrowth if the vial is kept out for a long time. It is important to find the reason for such issues so that the vaccination campaign that can prevent countless death does not suffer in the long run.

Parent Vaccine FAQs in India - Extra doses of Hepatitis B vaccine given accidentally

Q: My son is now 6.5 years old. we came to US last year. My son got Hepatitis B vaccine at 6,10,14 weeks{3 doses} in India. These doses were not recorded by mistake in immunization report. And he was again given Hepatitis B vaccine last year{on august} and this year{in September}. He got two extra doses of Hepatitis B. Do I need to really worry about this Doctor?

Ans. No, the extra doses of Hepatitis B vaccine does not lead to any harm. Your son is likely fully protected from the previous doses as well, but the extra doses will further ensure that he stays protected for life :)

Parent FAQ - Last date for BCG Vaccination?

Query : 
Is it compulsory to give a 1st dose of Bcg between 0 to 15 days_?
What if the 1st dose delayed for 40 to 45 days
Cause our pediatrician said that there is no problem if Bcg 1st dose given after 45 days
Ans: 

Your pediatrician is correct.

While it is certainly preferable to give BCG within the first 15 days of life, if not given for some reason, you can easily administer anytime during the first year of life.

Regards

Dr Gupta MD

ADOPTION: Adopting children from India in the USA, list of things you need to know - A pediatrician's perspective

I just had a call from an NRI couple in USA who are planning to adopt these two beautiful young sisters from a government facility in Panchkula, Haryana, India. They wanted me to examine these children, and that got me thinking about all the things we need to look at as a pediatrician for making sure (as much as possible) regarding the health of these international adoptees.
Here is what I found regarding adopting children from developing countries in to USA, from a pediatrician's perspective.
International Adoption - CDC Travelhealth

Items to consider during medical examination of an adopted child include the following:

• Temperature (fever requires further investigation)
• General appearance: alert, interactive
• Anthropometric measurements: height/age, weight/age, weight/height, head circumference/age
• Facial features: length of palpebral fissures, philtrum, upper lip (fetal alcohol syndrome: short palpebral fissures, thin upper lip, indistinct philtrum)
• Hair: texture, color
• Eyes: jaundice, pallor, strabismus, visual acuity screen
• Ears: hearing screen
• Mouth: palate, teeth
• Neck: thyroid (enlargement secondary to hypothyroidism, iodine deficiency)
• Heart: murmurs
• Chest: symmetry, Tanner stage breasts
• Abdomen: liver or spleen enlargement
• Skin: Mongolian spots, scars, Bacillus Calmette-Guérin (BCG) scar
• Lymph nodes: enlargement suggestive of TB
• Back: scoliosis and neurocutaneous findings
• Genitalia: Tanner stage, presence of both testicles

In addition, all children should receive a complete neurodevelopmental examination by a clinician with experience in child development. Further evaluation will depend on the country of origin, the age of the child, previous living conditions, nutritional status, developmental status, and the adoptive family’s specific questions. Concerns raised during the preadoption medical review may dictate further investigation.

SCREENING FOR INFECTIOUS DISEASES

The current panel of tests for infectious diseases recommended by the American Academy of Pediatrics (AAP) for screening internationally adopted children is as follows:

• Hepatitis B virus (HBV) serologic testing (repeat at 6 months if negative)
• Syphilis serologic testing
• HIV 1 and 2 serologic testing
• Complete blood cell count with differential and red blood cell indices
• Stool examination for ova and parasites (3 specimens)
• Stool examination for Giardia intestinalis and Cryptosporidium antigen (1 specimen)
• TST or IGRA (repeat at 6 months if negative)

Additional screening tests may be useful, depending on the child’s country of origin or specific risk factors. These screens include HAV, hepatitis C virus (HCV), and Chagas disease serologic tests; malaria smears; and Helicobacter pylori antigen screening of stool if there is persistent abdominal pain or refractory anemia.

Some other useful resources ...

Health considerations for adoption - US State Department

Recommended Immunization list for USA

International Adoption: Health Guidance & Immigration Process - CDC