PARENTS QUERY CORNER

HEALTH ask our experts,

        Parents Queries published in HealthyLife Magazine in Feb 2013 issue.

                                           
                            Baby`s Health

                                                                                                       
Q 1. My child is 18 months old and he is been vaccinated with all the government vaccine but I haven’t given him any additional vaccination. As we listen from our friends and relatives that there are lot more vaccine to be given and I have completely no idea about it, so could you please suggest on it, and please advice how important are those vaccines?

Answer:

Good that you have given all the government vaccines but there are many more vaccines available which is as important as the vaccines you have already given , the only problem is lack of public awareness regarding these newer important vaccines. And the other thing is the cost factor as these vaccines are little costly and is not included in the national immunization programme of Nepal. Hence we give these vaccines after one to one discussion with the parents. These newer vaccines are very useful to prevent your child from harmful diseases like: Mumps, Rubella, Flu, Pneumonia, Chickenpox, Typhoid, Meningitis, Hepatitis A and B infection ,Yellow fever, Rabies, Diarrhea some of which are communicable disease and are more common in school going children . This is to inform all the parents that these vaccines are available as: MMR, Influenza (Vaxigrip), Inject able polio (IPV), DPT booster, Pneumococcal, Meningococcal, Chickenpox (Okavax), Typhoid, Hepatitis A and B, Yellow fever, Rabies, Rota virus, Japanese encephalitis, Td booster, Human papilloma virus (HPV) vaccine. Thus by giving these newer vaccines, children are been protected against harmful infections before they come into contact with the infection in the community by using the body’s natural defense mechanism and by triggering an immune response to the disease without actually suffering from the disease. And stress should be given on booster doses as with period of time the effect of the vaccines goes on decreasing hence booster doses are required to boost up the immune response to a good level. And for other details on vaccination please check out my BLOG at 

http://www.drkabitakeyal.blogspot.com

Q2. I have a 1 year old baby girl and she usually suffers from pneumonia, whenever I land up with doctors they always comments that I was late for her check up and so the pneumonia is worsen and she requires admission. So could you please highlight on some important symptoms or signs by which I can early recognize her problem and take her to the doctor on time?

Answer:

Pneumonia is a broad term that is been used for most of the lower respiratory tract infection. It is more common in children less than five years of age. This being the commonest cause for seeking health facility in developing countries like ours it is important to know about some common signs and symptoms for its early recognition and treatment in time. Child with pneumonia will usually present with fever, cough, noisy breathing, fast breathing, poor feeding and vomiting at times. This is the time you should meet your pediatrician and get her treated before the disease become severe. But in case if child presents with fast breathing, restlessness, chest in drawing, (kokha hanne), wheeze, grunting, bluish discoloration of lips and skin, inability to drink/feed, Inability to rest properly then it indicates severe pneumonia and this is life threatening and requires urgent hospital admission without delay. My advice as a doctor is, since your child is just 1 year old, vaccinate your kid with pneumococcal and influenza vaccine for its prevention.

Q 3. My son is 7 years old and he usually suffers from constipation, he have difficulty in passing stools because of which he has pain and cries at times while passing stool. He also complains of passing blood at times when he have hard stool, which worries me? So doctor is there anything to be worried about and how do I help him?

Answer:

I know this is the common problem that we come across in our day to day OPD.

Most of the time constipation is just a habitual and because of improper dietary habits, but sometime it could be because of some disease like Hypothyroidism, some local anal problem like fissures or piles. So the most important thing for your son would be: give him a diet rich in fibers, green leafy vegetables, fruits, milk, increase liquid diet.

Help him to pass his stool comfortably by applying some Vaseline or lubricants around the anal area and examine locally for some wound,crack or some mass coming out per anus, which may be the cause of painful defecation. Finally get a surgical consultation to rule out some local anal problems and incase if your child is on chubbier side, with poor school performance, increase laziness then get his thyroid hormone tested after consulting with an endocrinologist.

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Parent`s Query Corner

Parents queries corner published in Healthy Life Magazine in Issue December 2012 

    1. My child is 10 months old and yet he has no teeth eruption, what shall  I do  and is there something to be worried about ?

Answer:

Normally the time for first tooth eruption is at 5-7 months of age in lower jaw. Well in some cases there may be delay in primary tooth eruption, but one can wait till 12 -13 months of age. First you can examine the baby for signs of tooth eruption by gently rubbing your finger over the gum along the jaw bone inside the mouth and feel for any hard nodule or examine the mouth under good light for any white spots on the jaw ridge which are the positive signs for tooth eruption . If so then we can wait as he will have tooth eruption soon, but if he has not even a single tooth eruption by the age of 13 months  then he must be investigated for certain diseases  like hypothyroidism , calcium and vitamin D deficiency and some local oral causes or  bony causes. In that case you should visit your pediatrician or a dental doctor and investigate your baby . But as of now for your baby, you need not  panic and you  can still wait for few months and baby can be given some vitamin and calcium supplements .

2.  My  baby is 1 year old and she keeps having loose motions many times. During the episode of diarrhea she always develop’s nappy rashes . How should I prevent these nappy rashes and what do you suggest  doctor?

Answer:

This is the frequently seen problem in our day to day OPD in children with diarrheal diseases, so the first and foremost important thing is to avoid putting Nappy to the baby in daily routine care at home, as by doing so the mother becomes  care free for hours and hour and the baby skin is in contact with the stool/urine and the area is moist, since baby skin is very sensitive it causes local reaction in the skin after which the child develops nappy rashes and  as the word itself is self explanatory Nappy rashes- i.e. rashes caused by Diapers, so instead one should use regular cotton cloth nappies at home and use of diapers should be restricted only if one is going outdoors. Another important thing is that the anal area should be cleaned softly with mild Luke warm water. Area should not be rubbed and keep the area clean and pat dry.  One can apply diaper rash free cream or some emollient cream as well if they have developed rashes or redness in that area and consult your pediatrician later. Avoid washing her underwear’s or  nappy  cloth with strong detergents  and make sure it is dried properly before use.

3.  I have a 5 months old baby girl and this is my first child, so could you please suggest me that when should  I  start weaning in her and until when should I breast feed her?

Answer:

Congrats for your lovely motherhood, You have been blessed with a princess. As your concern this is the right time when you can start weaning her. Start with simple homemade food like dal pani, thin Jaulo, litto, sarwotam pitho Or formula feeds available in the market as cerelac, farex / lactogen milk, and gradually go on increasing the volume, types and number of feed. Later  you can add on with fruits like small yellow banana, boiled apple, boiled mashed vegetables, egg white and so on. Introduce one item at a time like: slowly keep on adding one newer food every week as per the child tolerance, because by this you can know if child is allergic to some particular kind of food and his tolerance to that food. Slowly increase calorie by adding one spoon of ghee or oil to food and dense feed as you start feeding him from the family pot by the age of 20 months  to  2 years. If wanted start cow or buffalo milk only after one year of age that too non -diluted and continue breastfeeding preferably till 2 years of age after which you can completely switch over to top feeds.

4.   I have a 10 year old son who is very prone for  allergy cough and noisy breathing, he catches  cold very easily especially during the changing season’s  and winter. We have to go for a frequent doctor’s visit when he lands up taking frequent antibiotics and nebulization. So could you please guide us with some preventive aspect so as to decrease his illness?

Answer:

Good that you asked me this question and this is the right time when you should take special precaution for him to prevent him from frequent cold, cough and allergy as winter is inn. The worst thing in these children is they will develop noisy breathing soon as wheeze possibly if they have additional family history of atopy or asthma. The most important thing is these children is to prevent them from dust, smoke, pet animal  fur’s, hard perfumes/odours, coloring agents in food, cold drinks, iced foods. He should use regular mask while travelling on road, use blankets with cover which is washable, and avoid contact with pets. The most important of all is by vaccination which is available as Influenza vaccine and pneumococcal vaccine and consults your pediatrician for this. During the episode get a timely check up before his symptom  worsens by your regular pediatrician and preferably keep  some emergency drugs for immediate relief as per your doctor’s suggestion.

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Developmental Milestones related to Child’s Growth and Development

An article published in Healthy Life Magazine in Issue December 2012 

The best experience that any parent‘s come across watching their little one growing from a small dependent kid to a mature independent individual. 

Developmental milestones are a set of functional skills or age-specific tasks that most children can do at a certain age range.  Although each milestone has an age level, the actual age when a normally developing child reaches that milestone can very quite a bit. As Every child is unique! 

Child growth only refers to the child getting bigger in size while Child development refers to how a child becomes able to do more complex things as they get older and it mainly occur in four domains like: gross motor, fine motor, language, social-personal.

The individual level of functioning  of a child depends upon its level of growth and development in his childhood and it depends on both Genetic (nature)  and Environment (nurture), hence biological psychological and social factors play a major role to shape development  of any child.

Your baby will go through many changes in terms of growth and development during the first year of life before you know that your tiny helpless newborn will be a person in his own right. And growth being  an indicator for overall well being, chronic disease and interpersonal and psychological stress, it is very important for the parents to know some age specific milestones for a normal full term baby which is given in short as below:

Age of a child	Age appropriate milestones
New Born	Sleeps most of the time and drink milk. Continue Exclusive Breast feeding.
6-9 Weeks	Starts smiling and turn head towards sound.
10-13 Weeks	Neck holding, Cooing sound, recognizes mother.
14-19 Weeks	Head control present. Smiles and plays with hand and feet.                            Grasp rattle and rings and bring to mouth.
20-24 weeks	Sits with support. Kicks and roll over. Enjoy mirror.
6-7 Months	Start sitting without support.  Transfer object from one hand to other.  Speaks Ma, Ba.  Teething starts (lower central incisor).  Start Weaning.
8 Months	Starts crawling. Hold toys with crude grasp. Stranger anxiety develops. Upper central incisor teeth erupts.
9 Months	Stands with support. Waves bye – bye. Speaks – Mama, Baba.
10-12 Months	Walk with support. Responds to oral command. Lower lateral incisor teeth erupts.
12-15 Months	Stands without support Tries to feed himself Sits on toilet Speaks 2 words with meaning Upper lateral incisor teeth erupts
15-18 Months	Walk without support Make tower of 2-3 cubes Feed himself with spoon
18-24 Months	Runs Feed himself with cup Scribbles on paper, Make tower of 4-6 cubes  Speak 8-10 words with meaning
2-3 Years	Walk upstairs slowly Draw a lines, Make tower of 8-9 cubes,                         Makes simple sentence, point to body parts, name pictures Start toilet training Start feeding child from the family pot
3-4 Years	Ride a tricycle, Walk downstairs, Broad jump. Can dress himself and brush teeth.                     Draw a circle, Knows gender, Give name, Name colors, Group play Can post pond his toilet.
4-5 Years	Walk up and down steps with alternate feet. Copy a square (box). Can undress himself , throw ball over head, role play present, Locate person and place. Tells story, goes to toilet alone.
5-6 Years	Skips. Copies triangle, counts till 10-15. Knows number of fingers, Names a week. Repeat five digits, Ask questions regarding meaning of the word.

Thus, milestone is the phases in the growth and development in all domains that any child grows

through from a dependent kid to an independent individual.

Every baby develops at his own pace and that the age listed above are not set in stone for development of the healthy baby who was born at full term. But a baby who was born prematurely would meet these milestones a bit later than a full term baby. There are certain diseases where child growth and development may be abnormal like: preterm babies, IUGR babies, metabolic disorders, malnutrition, genetic disorders, chronic systemic disorders, CNS abnormalities i.e.cerebral palsy etc. In these children the milestones could be delayed, abnormal or sometime even the regression of the attained milestones could be seen. In case of the above child may be subnormal, abnormal or they may not be able to do their normal day to day activities.

Now parents being the first teacher of any child and since they play a supreme role in the proper growth and development of any child it’s very important for any parents to watch closely the normal and it should strike them if there is any deviation from the normal like abnormal or delay in their milestones and ask these to their pediatrician when they visit them for vaccination especially during the first year of life. That’s why the time when you vaccinate your child is the right time when you can have your baby’s milestones checked in the Well Baby Clinic.

Now as a pediatrician we play an important role in examining the child for their age appropriate milestones when they come to us regularly for the vaccination till five years of life especially during the first year and advice parents for any abnormality seen so that the timely investigations early diagnosis and treatment can be done to prevent further deterioration and complication and giving a chance to every single child to live a normal and healthy life.

Note: As a Pediatrician I would request to all the parents to consult their pediatric doctor while vaccinating your kids, to examine for their age appropriate milestones.

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Preventing Disease An ounce of prevention is worth a pound of cure.

A word so simple, yet difficult for any mother to see her child being poked right from their birth in the name of vaccination but yet so courageous to face the present and make her child fit for the future and boost them with strong immunity so that they can fight from their future sufferings in the name of disease — that’s what immunization/vaccination Is! Immunization protects children and adults against harmful infections before they come into contact with the infection in the community. Immunization uses the body’s natural defense mechanism - the immune response - to build resistance to specific infections. 

Infectious diseases

Infectious diseases are one of the leading causes of death in children especially below one year of age. It is estimated that at least two million children die each year from the disease that could have been prevented by already existing vaccines. In addition to this high death toll, millions more suffer disability and illness because they have not been immunized. This problem is most significant in low income countries with health disparity between the rich and the poor. Infectious disease includes large number of diseases that may produce various symptoms like fever, mild rashes, cold, cough, muscle weakness, jaundice but it may be severe at times producing life threatening complications like: pneumonia, meningitis, paralysis, septicemia, respiratory distress, liver failure, infertility and many more — hence, the introduction of the vaccine has revolutionized prevention of child health.

Immunization and Vaccines

Vaccines are the only public health tools available to prevent a vast majority of infectious disease. A vaccine is defined as a preparation used to prevent a particular disease by triggering an immune response to the disease without actually suffering from the disease. As a parent and a doctor we must be conscious of the fact that the immunization needs of the children are quite dynamic. There is always a need to update knowledge and concepts especially in the field of immunization. However, to get the most benefits for any vaccine in a community, adequate immunization coverage is required. Unfortunately, in countries like ours, the routine immunization coverage rate has slipped down, which is a major obstacle in any disease eradication programme. And this is a matter of great concern for all of us. A vaccine which may not be considered important today may become necessary in the future as more information about the epidemiology of the disease will
be known.

Vaccines were first introduced in 1974 to reduce morbidity and mortality caused by certain diseases. At that time there were only a few vaccines but with growing knowledge about diseases and their epidemiology, newer vaccines are coming up with the ultimate aim of controlling diseases in communities and if possible, eradicating them altogether. The future holds lots of promise as far as the prevention of disease through vaccination is concerned.

Step by step protection against childhood infection is what your child needs. So, follow the steps of vaccination your doctor advices you.

Immunization as per Nepal immunization programme

Age	Vaccine
At Birth	BCG Hep B1
6 Weeks	OPV1,DPT1,Hib1,Hep B2
10 Weeks	OPV2,DPT2,Hib2,
14 Weeks	OPV3,DPT3,Hib3,Hep B3
9 months	Measles

Optional Vaccination

Age	Vaccine
15 Months	MMR
18 Months	DPT  ,Hib,OPV Booster
>1 year	Varicella
>2 years	Hep A
6 months apart 2nd dose	Hep A
>2 years	Typhoid (Booster every 3 years)
>2 years	Pneumococcal  (Booster every 5 years)
>2 years	Meningococcal A+C(Booster every 3 years)
>1 years	JE Single Dose
>6 months	Influenza (Booster every year)
5 years	DPT Booster
10 years	dT/DT

Side effects

Side effects of vaccination in general are: fever, pain and swelling at the site of injection, mild rashes. Some severe but occasional side effects may be: inconsolable crying, fits, local abscess at the injection site, anaphylactic reaction, meningitis, BCG lymphadenitis. In such cases, see the doctor immediately or visit the nearby hospital. Still, remember that the benefits of protection against disease through vaccination far outweigh the very small risks of vaccination.

Contraindications (when vaccination should not be given)
1. Severe adverse reaction to the previous dose of vaccination like: seizures, hypotonic hypo responsive episode, incessant cry (pertusis)

2. Progressive neurological disease (DPT)

3. Immunodeficiency stat, HIV, Recent history of immunoglobulin transfusion (live vaccines: BCG.OPV,JE,)

4. Egg allergy (mumps, influenza, yellow fever)

5. Neomycin allergy (MMR,varicella, IPV)

Some do’s and don’t’s <br>
1. Inform your doctor if
Your child is suffering from some chronic disease or illness
Your child is on long term medication
Your child had received immunoglobulin transfusion within last 6 months

2. If immunization status of a child is unknown, there is no harm in giving appropriate vaccines again.

3. Lapse in the schedule of immunization does not necessitate reinstitution of the total course.

4. A minimum of 4 week interval is better between two types of vaccine administration.

5. Mild cold and cough are not contraindications for vaccination. 

Finally, many people have not yet realized the importance of other vaccines which are not supplied by the government. But it is important that such vaccines are made available so as to provide good vaccine coverage and decrease disease occurrence and suffering.

As a doctor, I want to ensure that all children have every opportunity to grow up healthy and are vaccinated against those diseases that can so easily be controlled.

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