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Wednesday, June 01, 2016

Building a strong immunity in children

A lot of people worry about this issue, so I thought I should tackle this here. The most important thing to know is that our body;s defensive abilities lie in the correct structure and function of our immune system. This system consists of several specialised organs including the bone marrow, lymph nodes, spleen, thymus and so on. These structures are all present even in a pre-term baby, but their functioning is not something that is optimal at that time. It is over a period of months inside the mother's uterus and then years in the world outside that the immune system develops into a mature system that can prevent and fight infections and other assaults on our bodies.

A strong immune system that can prevent the child from falling ill depends 
upon many things. One of these is the maturity of the system itself. As I have said, the more preterm a baby is, the less his/her immune system's development is, so that it makes sense to prevent premature births. The second most important thing is breastfeeding by the mother. This is so important that its significance cannot be underestimated. The milk of the mother is precious at all times, but even more so during the first few days after the baby has delivered. This milk is called COLOSTRUM. It looks yellowish, watery and not at all like the milk we see in bottles and in packs in the supermarket. It is very small in quantity, perhaps about 60-100 ml in all - but it is packed with antibodies and many important ingredients that help the baby to arm up against several kinds of infections right up to the end of the first year of life. We are still learning about the magic of mother's milk, and I won't be the least surprised if we discover that the benefit of mother's milk goes substantially beyond the baby's infancy.

The next most important factor that determines a child's immunity is their diet. A diet that is well-balanced and contains adequate amounts of all the essential food elements goes a long way in keeping the baby or the child fit and fine. Among the various factors in food that are important from the immune system's health point of view are the amounts of micro-nutrients and vitamins in the diet. Such adequacy can only come if the child is given substantial quantities of salad, fruit and dry fruit and protein-rich foods in the diet. 

Yet another potent immune-protector is proper hand washing by the child. While hand washing does not actually boost the child's immunity, it helps to prevent a lot of infections that can be spread through our inanimate environment.

And, to end this story, I am going to chip in a few lines on immunisation. This means vaccinating the child against a myriad range of infections. Most such activities take place during the first few years, but periodic immunisations continue throughout a child (and then, young person)'s life.These vaccines provide a mix of active as well as passive immunity against infections of all kinds. 

Acute Bronchiolitis in Infants and Young children

Most people have not heard of this exact word in developing countries. The word "bronchiolitis" means inflammation of the BRONCHIOLES. What are bronchioles? These are the smallest size airways in our lungs. They lead out from bigger airways known as bronchi and end into our air-sacs or what we call the ALVEOLI, where the crucial gas exchange of oxygen and carbon dioxide takes place thousands of times in a day, and throughout our life. 

Because infants have small bodies and small lungs, they also have very small bronchioles. These bronchioles catch infection with viruses very easily, and when they do, they get swollen, their internal diameter gets smaller, and their ability to allow effective gas exchange to take place gets reduced dramatically. 

When this happens, the baby becomes short of breath, as he/she can no longer breathe in and out without effort to push open the bronchioles with each breath. The breathing rate goes up, the baby works hard, and soon, he/she becomes tired. This chain of events is known as acute bronchiolitis. While usually a self-limiting condition, infants with this problem can sometimes become really sick and need hospitalisation. We will come to that a little later.

Acute bronchiolitis is an illness most commonly seen during the coldest months of the year. It begins with a simple cold - a runny nose, sniffles, a mild cough and perhaps a bit of a temperature. Over the next few days, the virus descends downwards from the upper airways into the lungs. When it reaches the smallest airways or the bronchioles, it produces inflammation - swelling and secretions in the tubes. This is when the child begins to be short of breath. He/she breathes more rapidly. At this stage, the illness can either remain static, and the child will have the breathing difficulty but not look very sick; or, it can become progressively more severe, and the child may become so breathless as to be unable to feed, sleep or look well. The severity may be such as to make the child's carers reach out to the doctors, with a visit to the hospital in the more serious ones. 

As this is a viral illness, and most of the times resolves by itself, doctors attending to infants and small children with acute bronchiolitis don't usually admit the child unless his/her blood oxygen levels are falling or the child is getting progressively more and more tired. Once admitted, such infants are treated with oxygen and nutritional support. Little else is helpful or needed/ Some infants may be given additional forms of treatment with medicines that open up their airways and make them breathe more easily. However, this is an exception and not the norm. 

Once the breathing difficulty is under control, infants and small children with acute bronchiolitis are ready to go home. Some of them will need medicinal support for slightly longer. A few of the infants who recover from their first attack might develop recurrences of a similar attack repeatedly. A very small percentage of such repeat-afflicted ones may develop an asthma-like chronic problem.

To summarise: Acute bronchiolitis is a frequent problem characterised by a breathing difficulty with a self-resolving natural course. Caused by viruses, it is not an illness that usually causes much distress or loss of productivity on the part of parents. Treatment is directed at maintaining the oxygenation and hydration of the affected child and allow him/her to recover on their own.

Tuesday, December 15, 2015

Understanding Autism

Autism is primarily a developmental and behavioural condition. A lot of parents worry about whether their child is autistic. There are several important symptoms that comprise the autism spectrum, and parents should always approach a proper health professional to seek guidance on the behaviour of their children before starting to panic. Remember, like other illnesses of the mind, autism is a spectrum that varies from a near-normal intelligent child with some specific odd behaviours to a mentally challenged child who needs complete ongoing educational rehabilitation in addition to all-round care to help the child cope with the daily challenges of life.

The main problems in autism include:

  1. Disorders of social interaction
  2. Sensory disturbances
  3. Disorders of communication, both verbal and non-verbal and
  4. Some kind of repetitive and stereotypic behaviour.
The above major issues lead to a complex behaviour in which the affected child is seen to be aloof, not interacting appropriately with others (such as eye-contact, showing interest in others, playing in group games or not paying attention to his/her surroundings) and uncomfortable with normal noise and sudden sensory stimuli like a breeze or contact with an unexpected surface. In addition, autistic children are seen to have seemingly non-purposeful hyperactivity, not pointing to things, have difficulty in expressing their emotions, have delayed language development and/or inappropriate language development, dyslexia (incorrect use of words, letters and phrases), and seemingly occupied with self-stimulation in the form of spinning or rotating around themselves, or doing repetitive actions with their hands and legs. 

On the other hand, autistic children, in spite of their having variable degrees of mental backwardness are often good at certain aspects of learning - some may be good at numbers, others at singing nursery rhymes or songs, and still others at remembering trivia that others of their age would find completely boring. 

The earlier autism is diagnosed, the higher are the chances of an improved progress and outcome for the affected child. Behavioural psychologists and developmental paediatricians are usually consulted in such cases. There are tools to reach a diagnosis. These tools include scoring tools that help parents to give the right information to the professionals, who, in turn, would find the going easier for diagnosing autism. One such tool is the Modified Checklist for Autism in Toddlers (M-CHAT), and this can be easily accessed HERE

Autistic children tend to improve as they grow older, and especially so if they are being regularly treated by the team of experts that includes the family paediatrician, the developmental paediatrician, the school counsellor, the educational counsellor, the behavioural psychologist, the occupational therapist, the neurophysician and other healthcare professionals working as a team in a special care centre. However, autism is a life-long illness, and adults with autism also need ongoing care from professionals. 

The aim of treatment is to allow the affected individual to be included as much as possible into the mainstream of society, whether it is at home, at school or in the public domain. 

Many internet sources talk about unconventional modes of treatment such as dietary modification, chelation, and so on, but these have not passed the acid test of predictability and reproducibility in the scientific arena.

Some useful websites for learning more about autism are given underneath: 
Thank you for reading. Please do take the time to comment on this blog entry. If you have questions, do not hesitate to ask me through the comments form. 

Wednesday, June 03, 2015

Violence against doctors

The rising knowledge base on the internet, growing awareness of the limitations on healthcare professionals, and a general rise in intolerance levels among lay people, combined with adverse publicity through insensitive media have made violence against doctors a "daily" affair - especially in India. The trend is disturbing, to say the least. Had it been limited to angry shouting or shunning the particular doctor, it would have been all right. The problem is, the violence is now actually causing harm to doctors and their hard-earned property. 

It would be difficult to trace the time-line of this process. Doctors were, at one time, perceived to be honorable, noble professionals whose only avocation in life was to save lives. Changes in society have caused this thinking to get eroded over time. And, it is not just doctors who are responsible for the decline in moral values. Today, the medical education sector is completely at the mercy of immoral, dastardly businessmen and politicians, who have increased the cost of learning to unthinkable levels. When I did my M.B.B.S., the cost of the entire course to me was less than Rs. 3000/= ... which, even 30 years ago, was not a very big amount. We earned back our investments during our internship, which paid us Rs. 450/= per month as stipend. Thus, there was no angst, or desire to earn back my investment, and doctors in my time turned out to have good morals and a more altruistic attitude towards sick people. Post-graduate education was almost free; we just had to buy our books. In fact, as house-physicians and registrars, we got paid every month for the hard work that we put in. 

Today, the investment is in lakhs of rupees, and for post-graduate entry into the choicest of branches, the investment amount is in multiples of 1 crore! (1 crore is 10 million, and 65 Indian rupees is equivalent to 1 USD). How can society then expect today's newly graduating doctor to be altruistic, to treat patients at low cost, to be charitable? Their first goal will be to get back their investment, not to give free treatment, right? Thus, society has reaped what it sowed. Today's doctors are not the brightest students either ... those who have deep pockets, regardless of their intellectual levels  are doctors today, while the truly deserving student with an economic disadvantage is often the one who misses out on becoming a doctor. So, you not only have avarice, but also incompetence added to your pot of miseries. 

Coming now to the media: in India, doctors were at the receiving end when one Mr. Aamir Khan, in his signature program on changing society, painted all doctors in the black. Falling short of calling them blackguards of today's India, he messed up the minds of his millions of viewers by convincing them that doctors over-investigated, over-referred, over-treated and over- everything in their bid to bleed their patients dry of money. This may be true of about a percent of doctors, and you will find that most such doctors are actually in this profession only for business and profit, and not for doing any good to society. The damage Mr. Khan caused to the image of the entire medical profession is yet to be mitigated. A small episode within a recent movie again showed doctors to be the modern scourge of society (Akshay Kumar in Gabbar Is Back, 2015). 

The negative media exposure that doctors got through the above few examples raised the intolerance of patients. Often, they do not know the effort doctors put in to save the lives of their near and dear ones. Do they realise that often they are the guilty ones: they bring their patient late ... just so as to try some alternative therapy, so that admission  and its higher costs can be avoided. Sometimes, they are actually not interested in saving the old parent or grand-parents' life, and make a show of causing violence to hide their dark deeds when the old person dies due to late arrival. Again, I am not saying that all care-takers are bad, but over 20% are in fault, regardless of their intention ... mostly because they do not have the finances necessary to bring their sick family members or friends in for emergency care.

In the last several months, tens of attacks have taken place in various parts of India, Pakistan, Bangla Desh and other South Asian countries. These populations have similar ethnic and ethical backgrounds; they have the same access to media; they have the same mental make-up. Is it therefore surprising that similar attacks are taking place in each of these countries? However, the problem is most serious in India, where doctors have been brutally and mercilessly beaten up for being the messenger of bad news rather than being negligent. Swift justice is meted out by a crowd of the relatives of the patient, accompanied by the student wing of recognised political parties (read hooligans) who break the hospital's furniture, create mayhem, beat up the doctor and his staff (including helpless nurses who are from the same society that the patient and their relatives are), and file a police case and a consumer court complaint against the doctor and his nursing home. Harrowing stories of doctors getting critical injuries and getting admitted to ICUs have emerged. 

But, I hear that doctors are now organising themselves to hit back at the belligerence with more of their own. When an attack of such nature is anticipated, doctors send out messages to all the other doctors of their area, and a group of doctors assembles at the venue before the news of a patient's bad turn or demise is communicated to the relatives. The relatives are clearly told that violence of any kind will be recorded on cameras installed at different locations of the hospital or nursing home, that there is a law that will punish the perpetrators with heavy fines and imprsonment plus recovery of the costs of the damage caused to the property and the treatment costs to healthcare staff who get injured in the attack. 

In the coming months, the entire issue will be more and more clear as society and doctors are at loggerheads with each other. I hope that good sense prevails. 

Thank you for reading this article. Although it does not directly address a health issue, it is highly relevant and appropriate that we are even discussing it in a public forum. 

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Dr. Fuhrman