How to use Serology (antibody tests) to diagnose Celiac Disease (Wheat Intolerance) - for the Pediatrician - a simple algorithm

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1. How to Use Serology to Diagnose Celiac Disease

Serologic testing for CD has significantly advanced during the past 2 decades. The long-used anti-gliadin antibodies have been supplanted by serology with better test characteristics.^[1]For example, endomysial antibody (EMA), used for more than 20 years, has specificity of 99%,^[2] although the sensitivity varies because of the technical issues inherent in direct immunofluorescence. This high specificity keeps EMA in use despite tissue transglutaminase (TTG) being identified as the targeted epitope. EMA is used primarily when discordance exists between other markers and histologic findings^[1] or when TTG immunoglobulin (Ig) A antibodies are equivocal.

TTG antibodies come in both IgA-based and IgG-based assays, which are performed with enzyme-linked immunosorbent assay by using human recombinant/derived proteins. IgA TTG has high sensitivity and specificity of ~98% and is the endorsed serologic marker for evaluating CD.^[3] It is well-known that IgA deficiency affects 2%–3% of CD patients and occurs in 1:131 patients tested for CD;^[4] thus, IgA-based assays alone are not always reliable. To avoid missing IgA-deficient CD, a serologic cascade testing starting with serum IgA level can be performed, and if normal, an IgA TTG is adequate; however, if the IgA level is low or absent, IgG-based testing with deamidated gliadin peptide (DGP) and/or TTG could be added/substituted^[5] (Figure 1). The accuracy of IgG TTG is poor (30%–70%) in IgA sufficiency, so this test in isolation should not be used for routine CD screening.^[6]However, IgG TTG performs well with known IgA deficiency, with sensitivity and specificity approaching 95%.^[2]

Point-of-care finger stick TTG antibody testing has been developed as a rapid screen for CD, and although the specificity was reportedly 100%, the sensitivity was only 82%. It cannot be recommended until sensitivity improves.^[7]

The newest serologic marker is the DGP antibody, which comes in both IgA-based and IgG-based assays and is significantly better than anti-gliadin antibody testing.^[6] Despite specificity that is close to TTG assays, the sensitivity of either the IgA-based or IgG-based DGP in isolation is lower;^[8] however, a combined IgA/IgG DGP panel has accuracy equivalent to IgA-based TTG.^[2]

In children older than 2 years, IgA TTG is the preferred test. Serologic markers may have decreased sensitivity in children younger than 2 years. The combination of DGP IgA/IgG with IgA TTG is the recommended strategy.^[3]

Should panels of serologic studies for CD be more widely used? The answer is no. The widespread use of panels would not be cost-effective as first-line testing; although it may slightly improve overall sensitivity, it reduces specificity, leading to unnecessary endoscopy.^[3]

Practical Suggestion

IgA-based TTG is the serologic test of choice for evaluating CD in patients consuming a gluten-containing diet. IgG-based tests are needed in IgA deficiency. The use of celiac cascade testing starting with serum IgA level could direct downstream serology. Equivocal or discrepant serologic tests should be interpreted with caution.

What's the difference between acetaminophen (paracetamol) and ibuprofen?

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Acetaminophen (paracetamol) and ibuprofen are both good medicines, and both provide the same basic relief from fever and pain, even though they have different chemical structures and side effects. Ibuprofen is recommended only for babies 6 months and older.

Ibuprofen
Ibuprofen works by limiting the body's production of fatty acids called prostaglandins. In addition to reducing fever, body aches, and pain caused by prostaglandins, ibuprofen reduces inflammation (swelling and redness).

It's slightly more powerful and longer lasting than acetaminophen. Because of this, it can be taken only every six to eight hours and no more than three times in a 24-hour period. In fact, the American Academy of Pediatrics (AAP) doesn't recommend ibuprofen for babies under 6 months, because it's harder to tell how ill a child is if his temperature and irritability are "masked" for an extended period.

One drawback to ibuprofen, assuming your child is old enough to take it, is that if he isn't eating well and he takes it regularly, it can irritate his stomach. If he seems to have a sensitive tummy, you might want to give it to him with food or a feeding.

Acetaminophen
Like ibuprofen, acetaminophen reduces fever, body aches, and pain. Unlike ibuprofen, it doesn't reduce inflammation. Acetaminophen is milder on the digestive tract and causes no stomach problems, so you don't need to give it to your child with food.

In large doses, however, acetaminophen is very toxic to the liver. Doctors recommend giving your child the fewest number of doses needed to keep him comfortable – at most, every four to six hours, and no more than five times in a 24-hour period.

If your child is also taking another medicine, avoid a potentially fatal  overdose by making sure that medicine doesn't also contain acetaminophen.

Getting the dose right
Parents sometimes accidentally overdose their children by using the wrong dispensing device. For example, infant drops should only be given with the dropper that comes with the product – using a spoon makes it too easy to give an overdose. And some forms of the medicine are stronger than others. Infant drops are stronger than "children's elixir," for example.

(Editors' note: Acetaminophen infant drops are being phased out and replaced by an infant liquid that's less concentrated. Find out how to tell the difference between old and new infant acetaminophen, and use ourdosage chart to find the correct dose by weight.)

Whether you give your child acetaminophen or ibuprofen, giving the correct dose (based on weight) at the correct intervals is crucial. This can be trickier than it sounds, so call the doctor if you're unsure. And do ask the doctor before giving it to your child if he's younger than 3 months. A baby that young needs to be checked for serious illness.

Comment: In India acetaminophen is available commonly as Crocin & Calpol. There can be confusion between some brands like Babygesic (Acetaminophen) and Ibugesic (Ibuprofen) hence this article differentiating the two medicines is important.

It is also important to remember that while acetaminophen (paracetamol) is available in drops , there is no such preparation for Ibuprofen. 

Simple steps you can take to combat dengue fever mosquitoes - Tips from China

• CNA
 
• 2015-09-11
 
• 14:13 (GMT+8)

Patients in an emergency room at a hospital in Tainan, Sept. 10. (Photo/Cheng Ping-chang)

The dengue fever outbreak in Taiwan has now climbed to over 7,000 cases, according to the Centers for Disease Control (CDC).

With the rapid spread of the disease, there has been a secondary outbreak of old wives' tales, false tonics and cures, but to really make a difference, you'll need a proper understanding of the vector mosquitoes and the most effective prevention measures.

30 minute rapid screening:

The CDC is currently offering free tests for the rapid diagnosis of dengue fever in Tainan and Kaohsiung and the results are available after only 20-30 minutes. A single line indicates no infection, while two lines means a positive result for the disease. Rapid screening is not considered necessary for those who do not have any clinical symptoms of the disease.

Suspected dengue symptoms:

The symptoms of dengue fever include fever, bone and joint pain, back pain, muscle pain, retro-orbital (behind the eye) pain, rashes, fatigue, nausea and vomiting.

High-risk groups:

People with chronic diseases such as diabetes and hypertension and the elderly, are especially vulnerable to complications or death as a result of the disease and should be given extra attention during a dengue outbreak.

Life cycle of dengue fever mosquito

Get to know your enemy:

The current dengue virus in Taiwan is being spread by the yellow fever mosquito, which is characterized by a black body, white markings on its legs and a marking on its thorax in the shape of a lyre.

To a lesser extent, the tiger mosquito, characterized by black and white striped legs and a vertical white stripe on its chest, can also spread the disease.

The yellow fever mosquito (aedes aegypti) is a container-inhabiting mosquito that thrives in urban areas and often invades people's homes. The mosquitoes usually can be seen perched in dark, damp, unventilated corners in areas such as the kitchen and the bedroom and on dark curtains and dark hanging clothes.

The tiger mosquito's (aedes albopictus) habitat is mainly outdoors and it favors cool spots such as potted plants, piles of old tires, trees and bushes near its breeding site, bamboo groves and empty premises.

Feeding habits:

An infected female yellow fever mosquito is mainly active during the day when it hunts for blood. The mosquitoes primarily seek human blood and are at their peak in the afternoon from 4-5pm, with a lesser peak from 9am-10am.

Tiger mosquitoes have two peak feeding times, 1-2 hours before dawn and 2-3 hours before sunset. They are most ravenous during the evening period.

Yellow fever mosquitoes are mainly found in cities and counties south of Chiayi, including Tainan, Kaohsiung, Pingtung, Taitung, and Penghu, while tiger mosquitoes are most prevalent in Taiwan's island plains and areas below 1,500 meters at the foot of the mountains.

Tried and true methods:

Home Protection:

1. Homes should be fitted with window screens and screen doors. It's best to hang mosquito nets while sleeping. Spray area repellent on the screens and screen doors to further keep the mosquitoes at bay.

2. Remove unneeded containers and unused flower pots, and turn all containers that could collect water upside down.

3. Dark areas in the home and basement should be inspected on a regular basis.

4. Use mosquito lamps.

5. Flower pots and water containers in the home must be cleaned at least once a week. Remember to scrub the insides clean.

6. If you are growing aquatic plants indoors, in addition to changing the water often, you can also place small stones in the bottom of the pots. The water level should be higher than the top of stones, as this will prevent larvae development.

Outdoor protection:

1. Reduce the amount of time you're outdoors in the early morning and at dusk.

2. Wear light-colored, long sleeved clothing.

3. Spray all exposed skin with insect repellent that contain DEET (diethyltoluamide), as this is the only product that has empirically been proven to repel mosquitoes.

DEET:

Products containing DEET (diethyltoluamide) and that have been approved by Taiwan's Food and Drug Administration (FDA) have been tested for effectiveness, safety and quality pre-market. It has been established that normal use does not produce toxicity, can affect mosquito olfaction and has smear efficacy that can be maintained for a few hours. It is the recommended product for those spending long hours outdoors or in areas where mosquitoes proliferate.

Other products such as citronella:

Essential oils have are popular for those seeking a "natural" option. Common products include citronella oil, lemon oil and other amines, typically come in the form of herbal oils, sprays and wrist rings. Such products offer only short-term protection at best and mainly serve as supplementary protection to products with DEET. The effectiveness of such products in repelling mosquitoes is still unconfirmed.

In addition, some Chinese Indonesians have claimed that eating red guava will help repel the yellow fever mosquito and stave off the disease, but the CDC said that this only aids rehydration. As a high fever and low blood pressure can lead to dehydration, the CDC recommends drinking lots of water and unsweetened fruit juice.

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Vaccination FAQs - Influenza Vaccine in india - Which Brand to use?

Q: My kids are 9 and 6 years of age ...they received vaxigrip vaccine for influenza last year ...I`d like to give them this year the flu vaccine ...is it o.k to take any brand name like influvac or should it be always vaxigrip like the one they received before?

Ans. 

All brands are equally effective, you can take anyone.

Also there is a Nasal Flu vaccine available (Nasovac S) that can be used as well this year.

When & how to tell your child that he/ she has been adopted?

Five ways to keep the lines of communication open - Tips from the Parenting Magazine

 Tags: Raising an Adopted Child

By Karen Miles312

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When Katy Mobley was 3 days old, her parents sent out adoption announcements to their family and friends. Early on, they also made a point of regularly telling their daughter how wonderful it was to have adopted her. "From the moment we brought Katy home, we wanted her to feel that her adoption was a positive event," says her mother, Marilynn, of Marietta, GA.

Katy, now 14, feels comfortable asking her mom and dad questions about her biological parents. The Mobleys are convinced that they can communicate so freely because they were open about their daughter's adoption from the get-go.

Most experts agree with the Mobleys' approach and suggest that parents talk openly about their child's adoption, even during infancy, to set a good tone for later on, when children will want to explore their feelings on the issue. Ultimately, an open atmosphere helps them to grow into self-assured adults, says Lois Ruskai Melina, author of Raising Adopted Children.

Of course, a child's understanding of adoption changes as she matures. Most kids don't start to grasp the concept until age 5 or 6, but if they've been prepared, they won't be shocked when the story does click.

Here are five ways to keep the lines of communication open:

-Use the word "adoption" regularly. The word shouldn't become your primary focus, but say it when it feels natural. This way "adoption" never becomes taboo.

-Share stories. Read books about adoption, such as The Day We Met You, by Phoebe Koehler, and Let's Talk About It: Adoption, by Fred Rogers. Or weave your own tale: Richard Gellerman, of Tucson, AZ, told his 1-year-old daughter, Kayla, about a little squirrel whose parents didn't have enough nuts to give her, but were able to find another mother and father who did. "Kayla didn't yet grasp the fact that she was adopted," Gellerman says, "but the story helped to introduce her to the concept."

-Create a memory book. Little kids love seeing what they looked like as babies and learning about their own history, even if they don't understand every aspect. When Katy Mobley was 1, her mother showed her photos of the day they brought her home. There was even a snapshot of the adoption agency.

-Take cues from your child. If she asks, "Did I grow in your tummy?" explain pregnancy and birth in the context of her own experience. Say, "You grew inside your birth mother, another woman, and then you came to live with us." If your child doesn't express much interest in her adoption, don't dwell on it. You can be sure at some point she'll need to learn more. Once a 5-year-old becomes fascinated with the human life cycle, she'll want to know everything—from where she came from to how she relates to her immediate and extended family.

-Be patient. While your child might acknowledge that she's adopted, she won't really know what that means until she understands conception and pregnancy, says Sharon Kaplan Roszia, an adoptive mother, and a program manager for the Kinship Center adoption agency, in Santa Ana, CA. So don't become frustrated if your child doesn't seem to "get it," Roszia notes. It's perfectly natural for her to ask questions—sometimes even the same ones over and over again.

Who Else Should Know?

Doctors: Supply your pediatrician with the birth parents' medical records, if you have them. Also let him know about the quality of prenatal care received by the birth mother. Both could have an influence on your child's health.

Teachers: Tell them on a need-to-know basis. For instance, if your child has a genetic tendency toward learning difficulties, informing teachers might help to make sure his educational needs are met.

Friends and Family: Share the full story with them only after your child knows it.

Saying the Right Thing

When your child asks about his adoption, be honest, but don't think that you have to explain everything at once. It's fine to wait until he's older to tell him more, especially if you think the truth might confuse or hurt him (which could be the case if he was abandoned). Just don't say anything untrue, because you may have to contradict it later.

DO...
Emphasize that there's nothing wrong with him. Explain that he was given up for adoption because his biological parents were unable to care for a baby at that time.

Stress that adoption is permanent, so your child won't worry that you'll give him up someday, too.

Talk about your child's birth mother and father. Otherwise, he might conclude that his adoptive father is his birth father.

Encourage your child to discuss his emotions.

DON'T...
Tell a child that she was given up "out of love." She may worry that if you love her, you'll give her up, too.

Say that you "chose" her. In order to be chosen by you, she might conclude that she was unwanted by someone else.

Denigrate the birth mother or father. They have a real connection with your child.

Expect her to come to terms with her adoption immediately. Many kids surprise parents with emotional reactions at age 7 or 8.

Comment: As a Pediatrician and an Adoptive Father, this is something that is close to my heart, and understandably tough for many parents.

In India, we have an additional problem of taboo surrounding the word "adoption". Thus many parents completely refuse to tell this to their adopted child.

While every case is different, I would agree with most child caring experts in that we should tell about adoption to children, and start this in a natural way, so that there is no sudden shock if they learn about this unexpectedly from someone else..

I would love to hear the opinion of Indian parents about this sensitive topic.