When should one worry about an illness?

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

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

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

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

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

and so on.

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

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

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

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

Wrap tight or loose?

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

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

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

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

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

About a baby's sleeping behaviour

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

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

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

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

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

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

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

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

Is the Pneumococcal vaccine necessary?

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

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

In short: Take it if you can afford it.

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

Read this excellent discussion on the PCV: Click this.