What is an autoimmune disease?

The human body's own defence system is called the Immune system. It comprises many specialised tissues and cells such as blood, the bone marrow, the thymus (a gland located in the neck), the lymph nodes, the lymphatic tissue in large organs of the body such as the liver, the spleen and the gut. In the blood, it is the white blood cells or leukocytes, esp. the lymphocytes, that regulate the immune system. Control of immunity is also through the formation and secretion of many important substances such as the "lymphokines".

A key element of our immune system is its ability to distinguish between the human body’s own cells (referred to as ‘self’) and foreign cells e.g. bacteria and viruses (‘non-self’).

Each cell carries protein markers called antigens that allow it to be identified as ‘self’ or ‘non-self’ by the immune system. Antibodies (also known as immunoglobulins) are important blood proteins in the immune system that are produced by a type of white blood cell called B cells. Antibodies naturally develop during exposure to infection and by binding to foreign antigens, help neutralise and eliminate the organisms that caused the infection. 

Antibodies are especially helpful when a particular type of bacteria or virus is encountered for a second time. In this situation antibodies already present in the blood against the particular bacteria or virus, prevent infection from developing. Antibodies, though, are just one aspect of immunity. 

Our body also has another kind of white blood cells called the T cells. These are responsible for cell-mediated immunity. T-cell surfaces also have what is called histocompatibility antigens, which help us to accept or reject transplants of organs done to us.

Autoimmunity is a failure of the immune system to always correctly recognise ‘self’. As a result, the body’s own immune system attacks part of the human body. This leads to the formation of antibodies directed against one's own tissues - the autoantibodies. Autoantibodies may directly cause harm, by causing the body to malfunction.

There are many conditions with an underlying basis of autoimmunity. They include lupus, thyroid problems and many more. 

(Ref: Mark McClure's article in www.vasculitis.org.uk)

What is a "Lumbar Puncture"?

This post pertains to a particularly important procedure that doctors need to perform on children (and adults) with certain specific kinds of illnesses. 

The procedure is known as a LUMBAR PUNCTURE. In this procedure, we insert a needle under sterile, aseptic conditions into the spine of a child to extract a few millilitres of CEREBROSPINAL FLUID - the watery fluid that bathes our brain and spinal cord - to analyse it to diagnose neurological conditions and nervous system infections. 

In children, we do not remove the CSF with a syringe; rather, we collect as it drops into a bottle

The most common diagnosis we are trying to corroborate is MENINGITIS. This means infection or inflammation of the meninges - the covering of the brain and the spinal cord. Children with suspected meningitis present with a short illness of high fever, inability to stare or to look at bright light, a stiffness of the neck and, in cases where the doctor is not consulted acutely, other significant neurological symptoms like headache, pain in the limbs, inability to flex one's legs on to the abdomen, and, in severe cases, loss of consciousness, or even fits.

A non-blanching rash may also be a harbinger of a particularly sinister kind of bug - the meningococcus. See my OTHER post on this kind of rash. 

While the exact procedure for a lumbar puncture varies from country to country or system to system the general steps are the same. Consent from a parent/parents is required. This may be verbal or written, depending on where this is being done. For example, in India, we take written consent, while in the U.K., it is all right to take verbal consent. The consent must include the fact that not only is the procedure explained, but also its side-effects. 

The child is laid on a flat-topped bed or procedure bed. He is turned on one side. The doctor aims to puncture in the centre of the back where the spine is located; he must be adequately immobilised by helper members of the medical crew. Usually, parents are advised NOT to stay beside the child but to wait outside the procedure room. A support worker may be allocated to stay with the parents for support. 

After cleaning the back, a needle is passed into the space between two of the back vertebrae till it is inside the cerebrospinal fluid. As the CSF drops, it is collected into bottles for examination and for organism culture studies. The needle is then withdrawn and disposed of safely. The puncture site is sealed with "OpSite" a kind of plastic dressing spray. This is then covered over with a small, circular bandage and the child is handed over to the anxious parents. 

The common side-effect of a lumbar puncture is a minor headache. Usually, there are no other harmful effects. Theoretically, there is a risk of introducing bugs through the puncture into the nervous system. This is very rare, however. 

Results of the tests are usually available within the hour. Based on the initial results, doctors will advise parents on which way the treatment is likely to go ahead. Usually, if an infection was suspected, doctors will have ALREADY started antibiotics or antiviral drugs, or both, even before a lumbar puncture is carried out. Usually, such antibiotic or antiviral therapy is then continued till the culture results from the fluid are made available - which could be up to 3-5 days later.

To summarise:

1. A lumbar puncture is putting a needle into the centre of the back to collect cerebrospinal fluid
2. Usually, this procedure is done to prove/disprove the presence of infection of the nervous system organs or tissues, usually, the meninges.
3. The procedure needs verbal consent in most countries. 
4. It is carried out with the strictest antisepsis. 
5. The procedure is generally safe and tolerated well by almost all children,
6. Theoretically, there is a rare risk of introducing infection. 
7. Results of the test will guide further therapy. 

Thank you.

Rights of a Patient - Right to be informed of harm occurring to them because of the medical system

I am writing this post to make patients all over the world aware that there is a significant risk of harm occurring to themselves or to their near and dear ones who are receiving medical care in a hospital. This is because human error is always possible - even in the best hands. Apart from human errors, there can be machine-led errors, systemic errors and other forms of misfortune that can befall users of medical systems.

As per prevailing ethics, patients or their wards have the right to be informed about any and every form of such errors that cause them any kind of misfortune. This is called the duty of candour or honesty all over the developed world. In the U.K., where I work, this duty of candour has been in place since the past few years. 

Doctors are expected to contact you in person, be empathetic and inform you in detail about what happened, why it happened and what is being done to mitigate the effects of this mistake. They are also expected to report the event on their medical system through what is known as the "Incident Report". They will have to inform their line managers as well. A detailed conversation must include the assurance that the incident will be investigated thoroughly, and responsibility will be fixed. The patient/caretaker must also be told that this investigation would guide the hospital to take steps that would prevent a repetition of the same error in the future.

So, there you have it. You have a right to know if you/the patient you are responsible for has been harmed in any way through a preventable error made by a faulty system.

Invited Post on Cleft Lip Surgery options in India

Cleft - A Smile Is What We Need

Cleft is an orofacial condition where the baby is born with a gap in the lip (cleft lip) or roof of the mouth (cleft palate) or both. It is a birth defect during pregnancy when different areas of the face that developed individually join together, but fail to join properly near the mouth and the lips leading to a split or a cleft. If the separation occurs near the lips then it is known as cleft lip, and if it is near the mouth then cleft palate.
It may or may not be detected during pregnancy by an ultrasound test. One in every 700 children is found to have this birth defect.
A definite reason behind it hasn't been detected yet, but several cases related to clefts are thought to be a result of genetic and environmental combinations. Vitamin deficiencies like lack of folic acid during pregnancy along with consumption of alcohol, anti-seizure medicines and steroid tablets, and smoking are the most common cases why this occurs.
If not treated on time, Cleft can have multiple adverse effects on the child. Apart from feeding problems, the child can become susceptible to infections related to ear, nose, teeth and speech, along with psychological and social problems at a later stage. Special advice from feeding or speech therapist must be sought while breastfeeding the baby affected with the cleft lip as it may find it difficult to form a grip around the breast, and it may choke due to cleft palate if not positioned carefully.
Luckily there are affordable surgery packages in India for treating cleft lip and cleft palate deformities in India. Plastic surgeons can close the cleft by connecting the muscles of the soft palate and rearranging the tissues to close the palate. The surgery takes 1 - 2 hours to complete and requires 4 - 5 days of stay in the hospital for recovery.
Surgery can be conducted once the child is two to three months old. It is important to monitor the child's growth to ensure that it is ready for the cleft lip surgery and cleft palate surgery.

• Care must be taken with the child's diet to ensure that it is healthy and gains weight before the surgery.
• Child's blood type and count must be checked.
• A thorough physical examination of your child must be done along with complete medical history examination.
• Share all the details regarding the medicines consumed by your child with the doctor.
• Get complete clarity regarding the medicines that can be consumed on the day of, and post-surgery.

A pink light scar can be visible after cleft lip surgery. Soreness and irritability are commonly experienced after cleft palate surgery. Chances of infection while in the hospital can be minimized by prescribing antibiotics. Clear instructions for general care and feeding must be sought for from the doctor right after the surgery. The stitches need not be cut open surgically as it usually dissolves during the recovery period.
The cost difference between cleft lip surgery and cleft palate surgery in India and in the West is huge, where India charges only one-tenth of what is charged across shores.

There are numerous success stories behind these surgeries. Each child is entitled to an uninhibited smile so let's make that happen by taking action!

Welcome the bundle of joy

As a woman embarks on the journey of pregnancy, she brings with her a lot of hope and happiness for her family. Right from her food to her lifestyle directly or indirectly impacts the baby in the womb. The extra care that is taken during these intense periods of foetal development, go a long way in having a healthy baby. An expecting mother should always be treated with care and love by her near and dear ones, to keep her positive and happy. This combination of physical and mental wellbeing is imperative to create a positive pregnancy experience.

Here are some of the things the mother and her family can follow to prepare themselves in welcoming the bundle of joy.

·         Eat healthy foods rich in iron, calcium, vitamins and folic acid. Eat at regular intervals and do not stick to the three-meal a day regime. During the initial months of nausea, keep your body well hydrated and eat foods that are filling and healthy.

·         Practice a fitness routine by doing simple walking or pregnancy yoga. It not only helps to stay active but also helps in strengthening the muscles that are essential during childbirth.  Choose the exercises that are suitable to the corresponding stage of pregnancy and always learn it from a trained professional.

·         Always keep the mind and thoughts positive. Read books that are motivational in nature and listen to soft music to keep the mind always calm.

·         Do not skip any doctor visits and scans, as regularly monitoring the health of the mother and baby is very important.

·         Always verify facts or clarify from your doctor about any kind of myths related to pregnancy. Many varied opinions about what is the best food or what is the right sleeping position can be offered to the expecting mother. Clarify it with your doctor and understand the scientific basis behind the suggestions before following them blindly.

·         Towards the end of the third semester keep a bag of essentials ready to be taken to the hospital. It will be very handy to the caregivers during and after the delivery.

·         Try to find some help during the post-partum period as it can be overwhelming for the mother and the baby. Especially first-time mothers can choose a person who they are very comfortable with, to help them with the baby right after the delivery.

·         After the delivery, take the help of the doctor or a good lactation consultant to establish breastfeeding. Breast milk is the most nutritious fluid for a baby and mastering the art of feeding a baby can be tricky without proper guidance or help.

·         Family members and husband, in particular, can help the mother with the newborn and give her some much-needed rest. The entire pregnancy and childbirth can be a very energy draining process for the woman and helping her to get adequate rest can help her get back to normalcy quickly.

There are many world-class maternity hospitals in India today that offer premium pregnancy care for expectant mothers. Choosing the right hospital with proper pre and post-partum care can make the birthing experience very smooth and joyful. 

P.S. This is a sponsored post.

New Widget for all the information you need as a patient or parent

Dear Reader,

UpToDate is the most advanced medical information website in the world. While the information for doctors and healthcare workers is something that they charge the medical professionals for, the information for patients is available for free. There are two levels of information: Basics - which is appropriate for patients who are able to understand at the 5th to 8th-grade level, and Beyond the Basics - for more learned individuals. 

I have added the widget for this information on my blog. Check it out on the top right. Enter the search terms and you will be taken to the UpToDate website where there will be links to the information you need. You can simply print it out or email it to yourself. 

Nifty, isn't it? Do try it out!

The child with a learning disability

With more and more advances in the understanding of children with behavioural, mental and learning-related problems, it is becoming increasingly difficult to separate one disorder from the other. Thus, compartmentalising a child as one with, say, Attention Deficit, or, say, Dyslexia, is useful for classification, for stratifying data, and for planning individualised care, in reality, children often have a mixture of problems from more than one specific category of a disorder. 

This, on the one hand, complicates rendering simplified information to parents, and our ability to deliver specific modalities of therapy. On the other hand, it enables us to better deliver holistic care to the affected child, as many of the therapeutic modalities are dependent on simple but standardised principles. 

LD is the new compact form of addressing children with some or the other mental disability. This does not include the deficiencies resulting from acute illnesses that often causes complex mental problems and not just LD. However, it does include dyslexia, problems with maths, problems with praxis (the carrying out of tasks) - the latter being also called dyspraxia.

Often, children with minor epilepsies will seemingly not pay attention in class and we would mistakenly name them as dyslexics. In the same vein, dyslexics might get labelled as "retards"- a rather pejorative use of the expression. Thus, one can easily see why managing a child with a LD can be very challenging. 

Invited post on Pericardial mesothelioma

Pericardial Mesothelioma 

Causes

Many doctors and researchers consider that asbestos fibres and dust are the major pericardial mesothelioma causes. Pericardial mesothelioma originates from the heart’s lining or the pericardium. Everyone out of 20 mesothelioma cases would turn out to be pericardial mesothelioma. A healthy pericardium provides protection and support to the heart. However, pericardial mesothelioma leads to the buildup of fluid around the heart and this exerts a great amount of pressure on the patient’s heart, which leads to pain and numerous symptomatic problems.

Asbestos Fibers and Pericardial Mesothelioma

Doctors and researchers are yet to establish or understand the causal relationship between pericardial mesothelioma and exposure to asbestos fibres or dust fully. Nevertheless, most patients that are diagnosed with pericardial mesothelioma have an asbestos exposure history. However, the rarity of pericardial mesothelioma hinders researchers from analysing this causal relationship comprehensively. Based on the reported cases, however, researchers have come up with an explanation for this relationship. 

How asbestos fibres and dust cause pericardial mesothelioma

Asbestos fibres are inhaled or ingested during asbestos exposure after which they travel through the bloodstream and become lodged in the pericardium or the membrane that surrounds the heart. Once lodged in this membrane, the body finds their elimination extremely difficult. Thus, the fibres remain stuck in this membrane for a long period. However, they cause the cells and tissues to undergo changes during this period and this causes cancer.

Ideally, the lodged asbestos fibres turn normal cells into cancerous cells. Cancerous cells divide abnormally or more rapidly without restraint or regulation as it is the case for the growth of normal or healthy cells. Continuous growth of mesothelioma cells lead to thickening of the heart’s lining and eventual development of tumours. Changes in the pericardium lead to fluid buildup between pericardial layers. When fluid buildups and thickening of the pericardium are combined, they exert more pressure on the heart. 

Symptoms

A patient may experience the following symptoms of mesothelioma once fluid builds up around the heart and starts exerting pressure on this vital organ:

ü  Heart palpitations

ü  Chest pain

ü  Persistent coughing

ü  Shortness of breath

These symptoms are similar to those of other ailments such as heart failure. As such, there are many cases of misdiagnoses which lead to the discovery of this disease at its advanced stages. Nevertheless, pericardial mesothelioma diagnosis can be done after a careful examination of the patient to determine whether additional testing is required. Generally, pericardial mesothelioma diagnosis is confirmed after tests like fluid and tissue biopsies which enhance the detection of mesothelioma cancer cells. After diagnosis, doctors determine the stage or progress of mesothelioma. This includes determining the extent to which the cancer has invaded tissues and organs that surround its point of origin. All tumours are located before appropriate treatment methods are determined.

Treatment Options

Since pericardium rests closely to the human heart which can easily be damaged by most therapies, pericardial mesothelioma has limited treatment options. Although surgery is mostly used to treat mesothelioma cancer, most pericardial mesothelioma patients cannot undergo surgery. Nevertheless, there are cases where this cancer is diagnosed in its early stages and surgery performed to remove the localised, small tumours. Other treatment options for pericardial mesothelioma include chemotherapy and palliative treatment.

Sources

https://www.ncbi.nlm.nih.gov/pubmed/25590007

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC325154/pdf/thij00037-0062.pdf

http://www.cancer.org/cancer/malignantmesothelioma/detailedguide/malignant-mesothelioma-risk-factors

What to do when you see a rash on your child

Rashes are any spots or blotches that appear on the skin. They can be of different kinds. Each kind of rash has a medical name, but we will try and talk about this without using jargon.

This post is about rashes that occur in an ill child. We are going to ignore rashes that have been present for a long time, and most probably represent a skin condition needing the attention of a skin specialist (dermatologist). We are also going to stay away from spots that occur due to any condition in the newborn period.

Having said that, this discussion is mostly about spots or rashes that appear acutely, and are a hallmark of an acute medical condition that needs urgent attention. We will be speaking about rashes that indicate infection, and rashes that are actually bleeds in the skin and may indicate EITHER an infection, an immune condition, a bleeding disorder or even a malignancy.

Let me begin by talking about spots that occur in a child presenting with fever, reduced feeding, or/and vomiting of acute onset. There are TWO main kinds of rashes - from the point of view of their being harbingers of something serious. A BLANCHING rash is rash that disappears when you press it with a transparent item such as a plastic or glass plate. A NON-BLANCHING rash is one that DOES NOT similarly disappear. Between the two, a blanching rash is more likely to be a benign one, and may suggest a viral infection. A non-blanching rash is the one to be taken seriously. It may be a harbinger of infection with a particularly fast-attacking germ that is called the MENINGOCOCCUS. It can cause sepsis or meningitis very very quickly and can kill the affected child within hours when it is severe. This infection is more common in the west, although, with time, its incidence is likely to decline since vaccination is now available against most of the kinds of this deadly organism.

The test described above to differentiate between the two kinds of rashes is called the GLASS TEST. Every parent should be aware of this test and know how it is to be done.

Source:meningitisnow.org - The Glass Test

Important disclaimer: A rash is harder to see and understand in someone with dark skin. Always contact your doctor if you are unable to understand the rash.

Coming to bleeding rashes in the skin. These can be pin-point like or large blotches that are raised above the level of the skin. Both  these rashes can be the rash of meningococcus described above. However, they can also indicate a bleeding condition such as a defect in the function of the coagulation system of the body, a platelet disorder or a blood cancer. Whenever you see someone who has one of these skin rashes, please contact the doctor or your health representative urgently, and within an hour if feasible, especially if the child has been unwell.

I hope this helps you to understand rashes on the skin of an acutely unwell child better. Thank you for reading this post. Do leave your comments.

Remember  to click on the links above for more information on the subjects therein.

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.

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: 

1. http://www.autismspeaks.org
2. http://www.autism.org.uk
3. http://www.autism-society.org/

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. 

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. 

Fever is a symptom and not a disease, but ...

As I have mentioned in my earlier post, fever is not a disease by itself. Treating it with paracetamol merely causes the fever to subside, without actually affecting the underlying cause of the fever. It is important to know the following additional facts about fever:

1. High fever can produce fits in infants and toddlers; although these fits look very dangerous to parents and care-takers, they are merely a reflection of the immaturity of a small child's brain and nervous system pathways; no long-term medicine is needed except in the rarest of circumstances.
2. In children (and adults) of all ages, fever increases the thirst and fluid requirements of the patient; thus, febrile children or adults must be given extra liquids - usually 10% more than the usual for every degree Centigrade the fever is above 38 degrees.
3. A patient who is running a fever should never be force-fed food; nor should food be withheld from one who desires it. In short, let the patient decide what, how much and in what form he needs. Starving a child with fever is a criminal act, since it further weakens his/her body and prevents it from fighting the underlying cause of the fever (usually an infection with bacteria).
4. Very high fever (more than 105 degrees Fahrenheit) is termed malignant hyperpyrexia ... and in the extreme case, it can be potentially fatal, i.e. kill the patient due to complete derangement of all systems in the body.

While most causes of fever in children are easy to manage and not life-threatening, fever accompanied by any of the following additional symptoms should be considered as "not just fever" and such children should be referred to a Paediatrician immediately:           

• High grade fever
• Uncontrolled or repeated or very large-sized vomiting or loose stools
• Irritable, excessively jumpy or crying child
• Older child who remains in bed all the time and refuses to drink liquids or appears inactive, dull or lethargic
• Has had fever-associated fits in the past, or during the present illness
• There are significant symptoms pointing to a serious infection such as arching of the back (meningitis), dark coloured, blackish urine (malaria), stomach bloating (typhoid) or moist, hacking cough with sputum and chest pain (pneumonia)

Learn to understand fever and try not to panic.  Check out the link to my earlier detailed post on fever to learn how to manage fever at home. When in doubt, go to your child's doctor immediately.

My Child Care book is now available off the net

Dear Readers,

I have updated and revised my original child care book that I first wrote a decade ago, and have now made a soft copy available on the internet for sale at a very low price. Do check out the link below: 



Click here or see the full link below, copy and paste it into the address bar of your browser and click "go".

http://pothi.com/pothi/book/ebook-dr-taher-y-kagalwala-child-care-birth-eighteen

I trust that you will like it and will buy it. Proceeds will be shared between the marketing site and me, and I will use the money to help children from poor communities in Mumbai and around Mumbai to realise their true potential. Thank you very much. 

If you do buy it, please write a comment about this in this blog and I will be sure to add you to my prayers. Also, after browsing through it and using it for a few months, do write to me a testimonial, telling me how you found the book and send it to my email address drtaher@gmail.com

Thank you.

Hidden Disabilities

I am writing this post to sensitise my dear readers about disabilities in people (here, I will stay with children, since this blog is about them) that are not obvious, but need attention all the same.

First of all, disabled people are also people. Just because a child is deaf, or visually challenged, does not mean he/she has no other aspects to his/her character; such a child can, and does, have emotional needs, ambitions, desires, etc. They still experience pain when hurt; they still laugh, cry, express anger, feel depressed, agonise, enjoy, and so on. We must look beyond the disability and express not just sympathy, but also try and understand what they need and how they must be integrated into society.

This post is about children whose disabilities belong to one of the following categories:

a) They are not routinely symptomatic, but can develop symptoms when stressed - e.g. a child with epilepsy, or one with allergy
b) A child who is physically normal but has neuro-developmental issues - e.g. a child with attention-deficit-hyperactivity disorder (ADHD), a child with autism spectrum disorder (ASD), or a child with behavioural issues related to a neurological disease (e.g. a child with sensory perception disorder (SPD)
c) A child with visible disability, but who is ignored or misunderstood - e.g. a dyslexic child is punished for getting poor grades because the teacher and parents think he is faking, or is naughty, or anti-social.

What is needed here is to understand that such children are all children with special needs. They need understanding of their condition. A sensitive healthcare policy at the national level, a sensitive person who is bearing the brunt of facing such a child, and a sensitive family are all important, nay, pivotal, to the well-being of such a child.

What such children can undergo are the following:

a) aggravation of their medical problem if they are not understood
b) violence and injury at the hands of disciplinarians, peers and parents
c) misdiagnosis leading to improper treatment
d) humiliation and ridicule - sometimes worse than physical violence
e) loss of opportunity/time/ etc. because the society has not begun to modify their environment for such children.

To prevent these from happening, let us all decide to try and be more empathetic towards children with hidden disabilities; let us be sensitive and non-judgemental towards them; let us be sincere and honest about our knowledge gaps and try and learn more about these problems; and, if we are caring for such children, let us be more caring and careful while dealing with them.

I welcome your comments. Thank you.

Taming the Throat

Throat infections come in different forms in children, and toddlers are especially vulnerable to them. While bacteria cause major infections, viruses are not to be left behind in the frequency with which they occur and the misery which they cause. The commonest throat infection is the SORE THROAT, or what is called as PHARYNGITIS. Caused by bacteria or viruses, this infection is so common all over the globe that it ranks as the COMMONEST respiratory tract infection among children.

A child with pharyngitis will usually have a soreness of the throat, be unable (to some degree) to swallow food, liquids, or even his own spit, have fever, body pains, throat pain (expressing itself as a feeling of "pins and needles" when he attempts to swallow something) and, sometimes, a cough. 

Most of the times, such infections are imported through day-care or nursery schools. A pediatrician would, when asked to examine such a child, look at the back of the child's throat, his tonsils, his neck glands, take his temperature, and then take a call on what level of urgency and which kind of treatment is thought necessary. Bacterial sore throats would need to be investigated by a throat swab to look for "strep" and if positive, the child would receive oral penicillin or other alternatives (if the patient is allergic to penicillins). The duration of treatment must be up to 10 days to completely eliminate the germs from the body. If the sore throat is deemed to be viral in nature, an antibiotic is not usually required, but the child must be given good supportive care such as rest, increased intake of liquids, steam inhalation if there is blockage of the air passages, etc. 

The next form of throat infection is something that rarely occurs nowadays, but it has not yet been eradicated from the US of A. This is whooping cough, an illness that is pretty ancient. It is caused by the pertussis bacteria. This was a killer disease in pre-vaccination times, but, thankfully, with universal immunisation of children with the pertussis vaccine, it occurs rarely. However, it can still be potentially fatal, especially when it occurs in smaller infants less than 3 months of age.

The child with a whooping cough has a whoopy sound at the end of each bout of cough. The bouts can be really long, very tiring, and be very taxing on the rest of the body. The huge cough bouts can exhaust the child; they can cause haemorrhages in the conjunctivae of the eyes, tear chest muscles (the ones involved in breathing), paralyse the nerve that supplies the voice box (and cause difference in the voice) and so on. 

Patients with whooping cough are diagnosed with blood tests and with a nose swab that is cultured in the microbes laboratory to discover the pertussis bacteria. Treatment is with an appropriate antibiotic (though it does not much work) and with cough syrups that can suppress the cough. In addition, nutrition must be looked after as well as addressing the fluid needs of the child.

The last common infection I am going to discuss is infection of the tonsils, or tonsillitis. We all have several tonsillar tissues in our throats, but the one I am referring to are the pair located just behind the tongue on either side of the mid-line. When the child is an infant, they can swell up especially in bottle-fed babies; when a toddler, they can get infected by cross contamination in a day-care school or the nursery. 

A child with tonsillitis presents in much the same way as the one with pharyngitis; however, the pain and discomfort is usually greater with tonsillitis. Usually, the child with tonsillitis has enlarged neck glands in addition to the swelling of the tonsils. 

Treatment is once again with antibiotics used for at least 7-10 days. Some children keep getting repeated attacks of either pharyngitis or tonsillitis. In the latter case, they sometimes become candidates for a form of surgery where the doctor removes the tonsils (most of the time with the other pair of tonsillar glands - the adenoids - that are situated high in the roof of the mouth). There is a clear trend nowadays to NOT REMOVE THE TONSILS as they have a key role to play in defending the body against bacteria, viruses and other offending organisms.

I hope you liked this primer on throat infections. If you have to ask any questions, feel free to ask me through the comments section.

Rules for Using Antibiotics

When it comes to treating bacterial infections, antibiotics are THE main form of treatment. Most patients have heard the word "anti-biotic" but do not clearly know what they are and how they work.
To make a long story short, antibiotics are made from bacteria themselves; they are special agents that prevent the multiplication of, or actually stop the growth of other bacteria, or even kill them. As you know, anti- means against, and bio- means related to life; hence, antibiotics are "against life".
Some examples of antibiotics which are frequently used by Paediatricians for sick children are the penicillins, drugs like erythromycin, drugs like the tetracyclines, and so on. To this list must be added some synthetically derived chemcals that also perform as well as the antibiotics - they too can either stop the growth of, or actually kill, disease causing germs (bacteria). As the term implies, antibiotics do work to stop bacteria, but they do not act of other forms of microbes like viruses, fungi, etc. For these other types of disease-causing life-forms, we have anti-viral drugs, anti-fungal drugs, and so on. These medicines are not our focus, so I will, simply, move on.
Patients and their care-givers are never too happy to receive antibiotics, since these are often bitter, induce side-effects like nausea, vomiting, loose bowels, etc. in addition to rarer but more troublesome side-effects like falling hair, blisters in the mouth, rashes on the skin, and so on. Also, antibiotics must, once begun, be continued for the entire prescribed duration. This increases the risk of side-effects even more.
It is therefore imperative to know what rules and principles govern the use of antibiotics. Here is a basic list. I hope readers go through this basic list and then seek more information should they desire it through a comprehensive source such as an internet search or access to a text-book of pharmacology.
1. Use an antibiotic only after consulting a physician.
2. Never use an antibiotic for a period longer than that told to you by the physician. A shorter period than that advised will probably not hurt the child, but it, still, is not the correct thing to do. Most common illnesses need use of an antibiotic for about 5-7 days, though the period can vary from just one day to as many as 42 days, or even longer, depending upon the characteristics of thei llness as well as the drug being used.
3. Store an opened bottle of antibiotic inside the refrigerator, or, if that is not available in your home, in a dark and cool area of the house, such as in the bathroom wall cabinet, or a special drug cabinet, or whatever. Exposure to heat can cause denaturation of the active medicine inside the bottle, so that, at the very least, it may change colour, or at the very worst, it can cease to be effective.
4. Do not repeat an old prescription thinking that :what worked for the patient the last time will also work this time. This almost always never happens, as illnesses that look alike in appearance and manifestation may actually be two different illnesses, needing different medicines.
5. Even worse, do not use antibiotics used by other friends or neighbours; for the same reason, of course, but also because as they may not be related to the patient genetically, the same medicine may not just not work; it may even prove to be harmful to you or your child.
6. Antibiotics should not be used for viral illnesses, fungal infections and so on, as, clearly, they won't work in such illnesses.
7. Dosing and frequency of use should be strictly adhered to, as germs and antibiotics complement each other: for example, if the recommended dose is 5 ml twice a day, do not arbitrarily change it to, say, 3 times a day. This can prove to be disastrous to the child.
These are the basic rules. There are many others, such as whether to have them before a meal or after, which other medicines to avoid taking WITH it, and so on. Do ask the treating physician about the relevant questions and be guided by the light of knowledge.
Thank you for the read. Do leave your comments.

The most effective prevention against diseases

Returning to this blog after several months, I found, happily, that people continue to visit my blog as before. I decided to re-enter the world of advising lay people and this entry is a step in that direction. 

Most readers would agree that there are many measures to prevent diseases; some include making major changes in life-style, some involve taking expensive vaccines or medicines; some involve relocating oneself from a harmful environment, and still others call for expensive investigations to detect the harbingers of an illness that is yet to affect you. However, the most beneficial and most inexpensive method to thwart diseases - specially infective illnesses, which are a significant cause of illness and death all over the world - is correct hand-washing. 

As doctors, we all do it countless numbers of times every day during our busy office practice. Surgeons wash their hands so thoroughly that they sometimes spend minutes on this pre-op preparation. It stands to reason, therefore, that the medical fraternity is convinced that hand-washing is extremely important. The reason is simple: our bodies are colonised by billions of bacteria, some harmless, but many, the cause of skin infections as well as more deadly internal infections that have the potential to kill. 

About 2.2 million children under the age of 5 die each year from diarrheal diseases and pneumonia, the top two killers of young children around the world. Handwashing is not only simple and inexpensive, but remarkably, handwashing with soap can dramatically cut the number of young children who get sick. Handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 6 young children with respiratory infections like pneumonia. Although people around the world clean their hands with water, very few use soap to wash their hands. Washing hands with soap removes germs much more effectively. (From: http://www.cdc.gov/Features/GlobalHandwashing/)

The Center for Diseases Control, USA has several articles on hand-washing, and THIS ARTICLE forms the important backdrop. THIS ONE is the one that details when and how hand-washing must be done. Be sure to click on the "Show me the Science" link on the left to better understand the rationale behind hand-washing. 

I hope this entry helps you to understand how important this simple method of disease prevention is. Be blessed.