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 The needle is then withdrawn and disposed of safely.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.

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!

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. 

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.

How to give medicines to a child

Several of my patients used to come back to me within a day or two of the consultation, complaining the child wasn't taking the medicine willingly, and had to be forced to take it, whereupon, it so happened that the child cried and vomitted out the medicine along with his/her previous meal. I made it a part of my consultation, therefore, to advise the parent/care-giver on how to give the medicine to a sick, unwilling, often hungry and irritable child. Let me share these tips with you.


The first thing to remember is that the sick child is often an unco-operative subject. It is, therefore, worthwhile to taste a little of each of the medicines you are going to give her and decide which of the medicines is the most bitter, which is less so, and which is definitely palatable. If possible, tell your pediatrician at the outset to choose palatable medicines if you know your child is fussy about this aspect of treatment. Often, however, the doctor is helpless as the medicine in question does not come in a more palatable form, and is irreplaceable in the prescription. Your doctor may choose to give one or more medicines in another, less troublesome, formulation: some medicines can be given as rectal suppositories, for example. This is a form of medicine that looks like a long-nosed bullet. It has to be inserted from the anal side, and it starts to work within 5-10 minutes after administration. Paracetamol is often available as rectal suppositories.


There are several oral formulations, such as suspensions (they come as a powder in a bottle, and the patient has to add water to the bottle up to a certain mark on the bottle. Once made in this form, the medicine needs to be stored in a cool dark place, or preferably, in a refrigerator.), syrups, tablets, drops, etc.


Okay, so now you know the medicine. How do you give it? The first thing to know is that the younger the babv, the more it will depend upon or trust the care-giver. Your attitude should always be that of a smiling and encouraging elder. Never get annoyed or frustrated as that can directly affect the baby's willingness to open its mouth to swallow the medicine, regardless of its taste! If the baby just keeps rolling the medicine in its mouth without swallowing it, use a dropper to slowly give the medicine the next time. You may, if needed, hold the baby's jaws open with your thumb and first finger and wait till the medicine is properly swallowed. DO NOT CLOSE THE BABY'S NOSE TO AID THE SWALLOWING. This can prove to be a dangerous tactic!


For an older child, the best posture to give the medicine is with her sitting upright. This prevents irritation by the medicine of the back of the throat, allows gravity to assist in swallowing the medicine downward, and removes the anxiety that older children feel when they are forced to lie down to swallow the medicine.


It may be worthwhile to make the child drink a little water BEFORE being given the medicine. This will definitely help her retain the medicine after she has managed to swaow the medicine. This is very useful to give tablets in older children.

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.

Read this excellent discussion on the PCV: Click this.

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.