Breastfeeding: a few facts and tips

As a pediatrician, who can have a better understanding of breast milk being the best nourishment for a growing infant than me? I have, as a matter of personal interest, made it a mission in my practice to promote the art and science of breastfeeding among the new (and old) mothers of India. Breastfeeding is one of the miracles of Mother Nature (or you can even say, God, Ishwar, Allah, Jehovah, Ahura Mazda, Khuda).

Breast milk begins to be made in the breasts of a mother-to-be from the sixth month of pregnancy. This milk is small in quantity till the baby is born, and remains small in quantity for the first few days of life after the birth of the baby. This milk is less in quantity, but it is a powerhouse of defense, nourishment and energy. No amount of it must be wasted, even if it looks dull and yellowish or watery in nature. It has high proteins, immunoglobulins that will protect the baby against many infections, and a lot of other good substances that are not even properly understood by modern science.

If the baby is suckled soon after birth, it also encourages great mother-infant bonding - a quality that will, over the years, make the baby less aggressive, more stable, more sensitive and more loving. Studies have even shown that the earlier the mother starts feeding the baby at the breast, the more reduced are the chances of the baby turning out to be a liar, a criminal or a socially maladjusted individual.

After a few days of this scanty milk, breastmilk begins to flow smoothly and copiously in 99.9% of all mothers by the third day; this is called as the "coming-in" of milk. Once this happens, both baby and mother get adjusted to a schedule of feeding over the next few weeks. The baby is mostly a night-time feeder, and both mother and baby are expected to stay awake for most of the night. In fact, I counsel the relatives to allow the mother and baby to sleep during the day so that they can allow them (the relatives) to sleep at night!

Did the readers know that the milk secreted by humans changes in texture, consistency, viscosity and colour as the feed progresses from the beginning to the end? If not, and if you are a mother, or have the opportunity to see a mother breastfeeding a baby (there is no shame and no stigma associated with a breastfeeding mother and infant pair ... and someone who feels a thrill to see a bare breast of a nursing baby's mother ... is a depraved individual, IMHO), then you will see that when the baby starts a feed, it laps at mostly watery milk that flows fast, and as the feed progresses, its feeding action changes to deeper and deeper, slower and slower sucks, so that it gets thicker and more nourishing whiter and fat-rich milk at the end. This is Nature's way of first quenching the thirst of a baby, and then, its hunger. This is indeed a miracle that can never be replicated by the most expensive milks, be they from a national or international food products company. In fact, this is the reason why breastfed babies do not need supplements of water in their first six months of life.

Do you have any questions/stories/experience etc. to share? Please do write back. To those who have not yet started the journey of raising a family, I do apologise for writing on this topic, but if you have someone in your family who is or has nurse (d) a baby, you sure are experienced too, and can join in the discussion!

Mothering: What is Quality time?

Time and again, I have had patients who have forgotten the meaning of parenting so much so that they will continue to provide sustenance but hold back love and attention in their child on an ongoing basis. Mothers who are so worried that their figure will spoil if they breastfeed their infant, fathers who claim that they love their child but will stay at their place of work from dawn to midnight (thereby ensuring that they never meet their child awake), parents who give expensive mobiles to their child, or X-boxes, or PS3, but will not be able to spend half an hour each day just talking to their daughter ... these are the sure prescriptions for disaster.

Quality time means devoting 1-2 hours every day for simply "being" with the child/children, with the T.V. switched off, the mobiles put away, no guests or visitors, no chiming door-bells to disturb the bonding and then, listening to your child. Listen. Don't unburden your problems when you meet with your child. Remain silent and attentive, and listen. Play, sing, dance, jump, or just ... listen. You will be surprised at the amount of information that really trickles in ... even a small toddler with a vocabulary of less than 100 words will tell you things you could not have even imagined.

Bonding begins at birth, but the process continues throughout the child's childhood, teenhood, and occasionally into adulthood too.

What are the pros and cons of seeing a specialist vs. a general practitioner for day-to-day illnesses of children?

The title looks forbidding, does it not? It must be first made clear that what I am about to write is most applicable for the kind of practice in India. You see, and this is for readers from places other than India, we have a two tiered private practice system in India, which is in addition to the practice that is available from municipal and government hospitals, which is collectively referred to as the "public" system. 

Going back to the private practice, we have general practitioners, or family doctors, who have the basic practice of seeing all ages of patients from a newborn baby to a onagenerian (that is someone who is over 90); he/she not only sees the patient, he/she may refer the patient to a specialist or to a lab or a diagnostic centre, and finally, if no referrals are done, he/she may, in the patient's best interest, even dispense a medicinal mixture of syrups and tablets. This is charged quite nominally.

On the second tier, of course, are the various specialists, and they include, not just the basic specialists like pediatricians, but also super-specialists like cardiac surgeons, neuro-surgeons and the like. These doctors, some of whom have their own hospitals or nursing homes to manage in-patients, are those who have studied further and specialised in a particular area. They are generally known to see the patients and write down medicines which have to be purchased from the pharmacy. Their practice is more in the nature of a consultation, and hence, their charges are also higher.

The question that many parents do NOT ask is: should I go to the G.P. and get the medicines opr should I seek an appointment with a specialist? Now, this post is not meant to denigrade G.P.s or shower enconiums on specialists, since I have known G.P.s who are really good at diagnosing and treating illnesses on a day-to-day basis; conversely, I have seen specialists who are bad ... bad enough to jeopardise the life of their own patients because of errors of omission or commission. 

Generally, however, the benefits of going to a specialist increase as the age of the pediatric patient comes down ... in the youngest of the young, it is always better to visit a specialist. This is not only because G.P.s have less knowledge about how to manage the baby-patient, but also because babies cannot speak, and the index of suspicion of a major illness has to be very high so that no problem is missed out. Action must also be that much more prompt; for example, a child of 10 years with a mild cough can be managed by the G.P., but the same complaint in a small 1-month old baby may be associated with a potentially bigger problem like a pneumonia and may need even hospitalisation. 

In addition to this age-related difference, there are a few more advantages of going to a specialist: as the medicines are prescribed, there is no secrecy of the prescribed medicines, and this allows the patient to cross check the treatment with any other doctor of his own choice (something like a second opinion, but without the formality of a request sent by the first doctor - a thing that is very normal in India). Also, the complete course of therapy is written down, so that the patient does not have to go to the doctor every day. Whereas, with the G.P., only 1-2 days' treatment is usually dispensed,  and often, as there is some relief, the patient is then NOT taken back to the doctor.

This is not to say that G.P.s are not at all advantageous! They are! Sometimes, they are the only doctors available, for example, late in the evenings when the consultants have already left. At times, they are better able to understand the dynamics of a disease as they know the entire family, they have visited the patients' homes, and so on. This helps them to easily decipher environmental or epidemiological clues to a possible infectious illness. Also, they probably have known 2-3 previous generations of the child and know which illnesses prevail in a particular family, what kind of thinking (howsoever much abstruse or crazy it might be) prevails among the senior members of a family and so on. Finally, as they have seen the treatments of many different specialists in their years of practice, they are often able to pinpoint the better specialists from among the many who are practising in that area.

Does this make the decision making easier or more difficult? I don't know, but it is for you, dear reader, to understand what I am saying.

What is the Injectable Polio vaccine?

Several of my patients have been asking me about the recently made available vaccines in the Indian market, and one of them is the Injectable Polio vaccine or the I.P.V. So what is it, really?

Well, in India, the government is currently struggling with the final stages of eradicating poliomyelitis, a crippling disease that now occurs in less than ten countries all over the world. Although the incidence is falling every year, we are still having to conduct special rounds of pulse polio immunisation and mop-ups to take care of the cases of poliomyelitis that are still being diagnosed - mostly from the state of U.P.

Having said that, today, we give 2 drops of the Oral Polio Vaccine or the OPV to all the children. However, this is the case only with the few countries where cases of polio are still being diagnosed. In all the other countries of the world, whether from the Western world or the third world, the vaccine that is administered is the more effective and less problematic IPV.

It is more effective because giving three shots of this vaccine to all children below the age of one year and a booster each at 18 months and 5 years will probably wipe out poliomyelitis sooner than the oral vaccine will (or can!)

I currently give IPV only after a one-to-one consultation with the relatives of the patient. In such cases, the routine doses of OPV can be avoided.

When should one worry about an illness?

I have often wondered about what makes a parent who is nursing a sick child decide that it is time to take her to a specialist. In India, we often have people who cannot afford the specialist's fees: but then, I believe the same is the case even in developed countries when the family does not have insurance. So there.

Imagine, for a few minutes, if you may, that your child has started having a runny nose. I don't think you are going to run to a specialist with just THAT, are you? Now think what you will do if she has a slight cough AND a little temperature. At this point, if you have seen such a thing before, or if your child is a little older than being a baby in arms, you are probably going to do one of the following (in increasing order of anxiety):

1. Ignore the problem and say - it is no big deal, she will soon be all right
2. Make a concoction of home-based stuff like ginger tea, honey and ginger drops, an inhalation of an aromatic substance like Vicks VapoRub or roasted seeds of "ajwain"
3. Give her one of the previously prescribed cough and cold mixtures that your child's specialist had given on a previous visit
4. Go to the local chemist and ask him to give you a suitable cough and cold medicine
5. Call up your local family doctor and ask him if the medicine you have in your medicine cupboard is all right to be used
6. Go to the local family doctor and ask him to "give" you some medicine for cough and cold for your child, or at least prescribe it
7. Go to the local family doctor with the child and seek a proper check-up and prescription
8. Call up the specialist and ask him to either suggest some medicine for cough and cold or ask him if the medicine he had given to your child previously will be all right this time too
9. Go to the specialist with the child for a professional consultation

Now, based on the list above, where are you likely to be? And what has made you decide that position? In my opinion, people do an action after a lot of confounding variables are taken care of:

• Is the child really sick?
• Does she really need a professional consultation or is a phone call going to be enough?
• Can I afford a pediatrician's fees or should I make do with a local doctor?
• How old is the child?
  
• Can I afford to take a risk with this child after already having lost one to pneumonia?
• Did I lose that child with pneumonia because I neglected it or because my wife did not take her to the doctor in time ....

and so on.

Thus, as you can see, parents do not often think alike in these matters.

So, here is a guide: take the child to a specialist if:

1. She has been ill for more than two days and the medicines that you have been giving her (whether herbal, home, local doctor or specialist's previously prescribed medicine) does not seem to be working
2. She has very severe symptoms - lot of loose motions or vomiting, dry hacking cough with chest pain, severe headache or stomach pain that makes the child cry, she is unable to breathe because of a blocked nose, etc
3. She has dangerous symptoms such as bleeding from any orifice, dark coloured urine, blood in stools, a fit, a difficulty in using any part of the body - muscles and bones, I mean, a loss of consciousness however brief, a change in voice or speech, a swelling that is very painful, a very high fever more than 39 C or 101 F, change in vision or hearing, and so on.
4. She has recurrence of symptoms within a few days of stopping the medicines for the same problems
   
5. She develops fresh symptoms like a rash, high fever, visual disturbances, headaches, bodyaches, bloody vomiting, difficulty in breathing or blood in the urine etc. soon after taking a certain medicine
6. She has acute vomiting or loose motions or both within hours of consuming food - esp. in a restaurant or at a community dinner
7. She is not the only one with a particular set of symptoms: many of her school mates have the same problem, or many others in the family

Of course, this list is not conclusive, but I am sure it will be a help to parents who often get stuck about what to do next.

Wrap tight or loose?

I have, over the years, advised many mothers to leave their babies loose - i.e. unwrapped; the mothers, and indeed their extended families, have often secretly disobeyed my advice, for who wouldn't like their baby to be snugly wrapped in pink and lacy wraps?

What the parents are missing is, of course, the logic behind my advice. Unable to understand, even when I have explained that keeping the baby open allows her the freedom to move her body, hands and feet in whichever direction she wants, they continue to wrap the baby, and to do that tightly, which means that not only does the baby not get to move her limbs here and there, she does not even get to move them one tiny bit ... even when she has an urgent desire to do so!

Now, the fact remains that sensory input is THE ONLY WAY to encourage neural development in an infant. Babies who are constantly stimulated do much better at older ages than those who are not. This is reflected in their acquiring motor milestones earlier, their ability to be more dextrous and flexible and their speed of development of finer motor milestones as well.

In addition, in tropical climates, and particularly in the summer and autumn months, and to some extent in the months of monsoon (with extremely high humidity), the child who is tightly wrapped can get rashes such as heat rashes, chapping of the skin inside the arm-pits, groins, buttocks, and so on, and can also get itchy rashes that cause a lot of discomfort and excessive crying.

Thus my recommendation: Do not tie the baby tightly; rather, if it is cold outside, cover her up with a blanket, but by and large, let her sleep well by her own self.

About a baby's sleeping behaviour

I have many parents coming to me and asking me questions about a baby's sleeping behaviour. Now, a normal baby who is less than three months of age sleeps for almost 14-16 hours a day, though some may sleep less. During the time that the baby is awake, and this is most often at night, the baby wants to be constantly fed. Even immediately after she has completed her feed, she will continue to be awake and will often be irritable/playful in turns. To a mother who feels harassed that her baby is keeping her awake at nights, I have only to say this: the baby is programmed to stay up at nights because her mother gets the maximum breast milk output only at night. This is true not only for humans but for most mammals.

As the baby grows older, the sleeping hours gradually start falling. By the age of six months, the sleeping hours have declined to 12-14, by one year, to about 10-12 and by five years, to about 9-10 hours per day.

The first few months of night-time awakenings are gradually replaced by the baby learning to sleep during the nights and staying awake in the day. However, this transition period may get prolonged in some babies, and I have seen babies even as old as one and a quarter years of age who haven't learned to sleep well at night. One of the factors responsible for such a delay is the institution of bottle-feeding - esp. the bottle that is offered to the baby when she is going to sleep. The baby associates the bottle in her mouth with the sleep to such an extent, that if the bottle is not provided, she just won't fall asleep.

My advice to all mothers is not to encourage the night-time bottle at all - in fact, to never use a feeding bottle at all, if possible.

During the first few hours of a full night's sleep, both children and adults pass into deeper and deeper sleep till they are in deep sleep within an hour to ninety minutes. After this first spell of fitful sleep, which ends around 2 - 2 1/2 hours, the baby/child/person gradually emerges to a near conscious state and passes into her first dream-stage sleep, the so-called "REM" (Rapid Eye Movements) sleep. During this sleep, the brain is active (alpha waves), as are the muscles (tight), the mouth (chewing movements with or without a tightly held lower jaw), the eyes (moving side to side rapidly with blinking of the lids ... hence the name REM) and almost the entire body ... internal organs and all.

After the REM stage, which lasts for 15-20 minutes, the baby/person passes into the second bout of ever-deepening sleep. This, however, is not as long as the first bout, and may get over in less than an hour. A repeat REM follows. This alternation between deep sleep and REM sleep continues throughout the night. However, the REM phases come sooner and sooner, so that by the early hours of the morning, REM stages are repeated with just half an hour gaps in between. Finally, after the last spell of REM, the baby/child/person wakes up, fresh and eager for the day.

Understanding the above pattern is extremely useful for both, the person who sleeps and the others who look after that person. If, for example, you were to disturb a person who is still in the REM stage, the baby/child/person will wake up irritable, sleep-deprived, tense and uninclined to arise and shine.

To understand sleep is to understand rejuvenation of the human body. Every night, the tired individual sleeps, rejuvenates, and wakes up in the morning, relaxed and refreshed, ready to face the hurdles of life anew.

Is the Pneumococcal vaccine necessary?

I have been approached by many patients in Mumbai, India, where I practise, as to whether one must give the Pneumococcal conjugate vaccine (prevenar) or may one skip it on account of its extremely high cost (it costs Rs. 4000/= or nearly 105 US dollars per dose). Well, let me say that while the vaccine is indeed costly, the Government of India, along with the Bill Gates Foundation and GAVI are trying to make this vaccine universally available through its primary immunisation programme. Whether or not this actually happens, the PCV is, as of today, a most important vaccine in the armamentarium of pediatricians and patients' parents to keep their child free from deadly diseases like pnuemonia and pneumococcal meningitis.

I suggest that patients go for the vaccine if they can afford it. I am even willing to foot about Rs. 200/= per patient if they cannot afford the full amount. However, the final decision is theirs and theirs alone. This is because, in the primary series, three such doses need to be given. Additionally, the child will need a booster after 15 months. Hence, the total schedule will cost Rs. 16000/=, a not so small amount for a middle-class person.

In short: Take it if you can afford it.

See this link for more on the vaccine: Click Here or here.

How to Manage the Trots (diarrhoea) at home

Diarrhoea is one of the most common childhood diseases all over the world. While infectious gastroenteritis (i.e. diarrhoea caused by germs) is the commonest condition leading to loose stools, or the "trots" as this is called in some parts of the world, non-infectious conditions such as the traveller's diarrhoea and diarrhoea due to food poisoning are also the causes in a small percentage of children.

When your small child gets loose motions, it is more often than not of the infectious variety, and in over 80% of such cases, the offending germ is a VIRUS, a type of microbe that is normally only visible when seen through the lens of an electronic microscope. Viruses, unlike bacteria, cannot be "killed" by using common antibiotics; rather, one has to bide one's time and wait till the body's own fighting power overwhelms them and leads to recovery of the individual.

Diarrhoea, by itself, is not necessarily a dangerous thing; the problems it causes are due to the loss of water and vital electrolytes from the body into the stools. This loss of vital fluid and electrolyes is called "dehydration".

Therefore, the most important thing that parents can do is to prevent the occurrence of dehydration by a two-pronged strategy:
a) Remove the cause of the diarrhoea by taking the child to a medical facility and check-up and treatment by a pediatrician or a trained pediatric assistant or nurse and
b) Give the child sufficient electrolyte enriched fluids (=containing salt and sugar) so that on-going losses are faithfully replaced and there is no net loss of fluid from the body.

To give the salt -sugar water, take a 2-finger pinch of salt and add it to a medium glass full of clean water (approximately 200 mL); next, add 1 teaspoon of sugar to the same and stir the mixture thoroughly with a clean spoon. Once the sugar has dissolved properly, the "Oral Rehydration Salts" (ORS) solution is ready. This solution can be given repeatedly, till the child is taken to a medical facility, or, in milder cases, till the diarrhoea gets resolved.

The ORS should be given with a spoon in infants and with a cup or glass in older children. For infants, each large stool is considered equivalent of 40-60 mL, and hence, the baby should be given at least a quarter cup of ORS between each pair of loose stools.For older children, the quantity needed should be half to three-quarters of a glass per stool. A similar allowance can be made for vomits passed in the interim.

All through the rehydration, the child must continue to be fed, whether breast milk or top milk or other foods. Feeding the child prevents the child from losing weight and becoming undernourished.

Managing fever at home - II

Having outlined the essentials of fever management in the previous post, let me go ahead and tell you exactly what needs to be done when your precious child has fever. For the purpose of this discussion, I will exclude babies less than one year of age in whom fever can be an emergency and medical attention by a doctor or a trained nurse or medical assistant is of paramount importance.

First of all, you should know that the normal body temperature varies between 97 and 99 degrees Fahrenheit depending upon the age of the person and the climate and environment in which the person resides. The mean normal body temperature is 98.6 F. A temperature rise of more than 1 degree F from this mean is defined as fever.

Considering this basic point, please remember that a slight body warmth in the middle of the day, or after you have brought the child in from the outside heat, or after the child returns from active play is NOT fever. Neither is the body said to be "febrile" if the child has an ear temperature (taken with the ear-thermometer) of about 99.8 F or less. The internal body temperature is about 1 F higher than the temperature of the arm-pit (axilla), which, in turn, is 1 F higher than the temperature of the skin over the toes or lower legs.

A rise in body temperature in an otherwise well-looking child may or may not mean that worse problems are on their way, and hence, careful monitoring is necessary in every child with fever. Fever is generally due to infections, but may be secondary to other forms of inflammatory diseases, systemic (general) diseases and occasionally, a disturbed central nervous system (read "brain").

The best treatment for fever is SPONGING. To sponge means to continuously wipe the child's torso and upper half of the legs with a hand towel dipped repeatedly in lukewarm or tap water. Sponging is a serious type of treatment that overcomes the disadvantages of giving medicines; however, it can prove to be difficult if the child is restless or refuses to cooperate. Using lukewarm water helps to get him/her to allow you to remove his/her clothes and to mop the torso without the fear of this causing a chill or any other form of discomfort. Try and keep at the sponging for a time that is proportional to the original temperature rise. Approximately, it takes atleast half an hour of sponging to reduce the temperature by 1-1.5 degrees F. During this procedure, keep giving sips of water or electrolyte rich fluids to the child as he/she feels more thirsty than usual with fever.

Keep monitoring the warmth of the skin by pushing your hand in between the child's back and the mattress; this is one area of skin that is not being sponged and hence reflects the actual fever position. Alternatively, you may check his/her temperature with a thermometer placed in his/her mouth/ear.

If the original temperature is between 99.6 and 102, sponging alone might prove to be effective. If, however, the temperature is higher, you might have to place an ice-bag above his/her head and also administer a fever medicine like paracetamol (Crocin, Adol, Metacin, Calpol) in a dose of 3-6 ml as often as needed (but with an interval of 4-6 hours between successive doses). For older children who are heavier, these brands have adouble strength formulation also available, at least in India, where I live (Crocin DS, Metacin Soorsa, Calpol Plus).

Other effective fever medicines include Mefenamic Acid (Meftal - p, Ponstan), Ibuprofen (Motrin Jr, Ibugesic, Flamar) and Nimesulide (Nise, Nimulid) - the last one being not licensed for use in the U.S.A. and many other developed countries because of the fear of some side-effects.

In addition to the foregoing, let the child rest, eat only light and soft food that is easy to digest and allow him/her to do restful activity like reading, viewing television etc.

However, the most important thing to do is to go as early as possible, but definitely not later than 48 hours, to a doctor. He/she will examine the child, perhaps order some tests (investigations) and try and arrive at the cause of the fever. Unless the cause is found and treated appropriately, the fever may not subside in almost 30% of the cases. The other 70% may, if they have a mild problem, resolve on their own without a diagnosis.

A word of caution here: if the child is apparently sick, that is, he/she does not look well, see that doctor right away. Waiting for 48 hours in such cases can be dangerous.