Moving On

I have move on to another blog post. Here is the link. http://www.malaysianhealthconomics.blogspot.com/ This blog will not be updated regularly cheers!

Reflux disease

I noticed that it has been 3 months since I updated my blog. To all my followers, i apologize. Too many things at hand
.
Recently I came across many infants in my clinic, where parents complained that their child is vomiting frequently. Of course after much probing, that vomiting was actually regurgitation.
Next question is how can we differentiate the 2. There are simple questions that we, as parents can ask ourselves and see if it's vomiting or regurgitation.

1. Is the child well?
2. Is the child gaining weight?
3. Is the child satisfied after feeding?
4. Does the child sleeps after feeding?
5. Does the amount of milk comes out from the mouth or nostrils minimal amount?

If the answer is yes to all the questions above, then chances are it's just regurgitation.
A small percentage of children, especially infants, will have recurrent regurgitation, sometimes to a certain extend that parents began to be very worried. The child may have GORD (gastroesophegeal reflux disease). Some of us may be familiar with GERD instead, well it's just American or British spelling.


There are essentially 3 types of severity for GORD, mild, moderate or severe.

For mild cases, symptoms will usually be just mild regurgitation. Sometimes milk can come out, not only from the mouth, but from the nostrils as well. Children with mild GORD do not have weight loss, still gain weight well, and eager to feed. To treat mild cases, we simply just need to prop the child up for a little longer and 'burp' them for a longer period of time. The commonest myth is people think that after burping once, then it's considered done. We can burp the child longer or even more than once!

For moderate cases, we probably need to change the types of feeds for children. There are in the market formulas that are AR (anti regurgitation). As long as we see the word 'AR', then that formula is specially made for children with regurgitation. If you are from Malaysia, AR formula can be brought from any hypermarkets. These children may not have adequate weight gain.

For severe cases, the child will usually have weight lost. For these children with severe reflux, then they need drugs to make them better. Sometimes, they need to be admitted to the hospital to stabilise them, push up their weight. To a certain children we may need to 'tube' feed them.

Next question is why does GORD occur? In our food pipe, called the 'esophagus' is connected to our stomach. Just at the point of connection, there is a 'door like' valve which we call 'sphincter' that helps to ensure that contents in the stomach do not goes up back to the esophagus. (see the diagram above). The function of this 'door' is to provide one way traffic for milk to go into the stomach. If this door is not 'shut' properly, then stomach contents will be able to move up back to the esophagus, and hence the term 'reflux'. In infants, this is particularly common. Reflux happens in adults too. Public term reflux in adults as 'heartburn'.

The good news is, for most of the infants, when they grow older, the 'door' will tend to function better and keep the 'traffic' of milk one way. Usually by the time, children reaches 8-9 months, that is by the time they started to sits on their own, the symptoms of reflux will gradually disappear. They 'grow out' of it.!

Facial Congestion in the Newborn

It seems to be sometime since I updated my blog. Well for personal reasons I did not have much time to do just that. And one of the reason is, my wife just delivered a beautiful baby boy, and there's something on this baby that I would like to share for my blog today, that is facial congestion.

Some babies are born with their cord round the neck. This is something that rarely happen, but do happen at times as well. It is not the cord is around the baby's neck when the baby is in the mother's womb, but only happen when the baby is delivered. As the baby is delivered, the cord got round the baby's neck and when the baby comes out, it will be as if the baby got 'strangulated'. Well, i say 'as if', meaning, it appears to be strangulated. Not always.

When this happen, there will be some sign of congestion on the babies face and this can sometime be mistaken as 'petechiae' or red spot on the body. When a baby (or any human being for that fact) has got petechiae, it is abnormal and tells us few things.

1. the person got some capillaries problem, therefore leading to petechiae

2. severe viral infection (like dengue)

3. Congenital infection (TORCHES infection). 'Congenital' means, infection acquired from birth

4. Low platelets due to whatever reason.

My baby has got some red spots but at the same time the baby's face appear darker compared with the rest of the body. This is facial congestion. This may be due to the delivery process (which is very stressful to the baby also) or because of cord round neck.

Facial congestions disappear after few days. However, if it is not congestion, then the red dots are petechiaes and need to be checked out by a doctor.

The photo on the right is my baby's photo that show's some red dots and darker colour face.

So, the next time anyone of you face this problem, don't worry. It's not permanent.

Diarrhea in Children

Happy New Year !

For the first post of the year, I was hoping this particular post will share some light for many of us as parents.

Diarrhea is something very common in children, especially during the toddler's age group.

Diarrhea, most of the time is due to a viral infection, affecting the intestine. Many times, the treatment is very simple, that is just hydration. In the clinic or hospital, we would always give salt water.

Most of the children with diarrhea will start off with vomiting. Most of the time, parents will bring their children to see us at this 'vomiting' stage. The treatment is also the same. After this vomiting stage, by the 2nd day, the diarrhea will set in.

There are however many myth and misconception on this simple childhood illness.

1) Concentrate feeds during diarrhea.

This is so not true. Some how, many parents told me this, that if they were to concentrate their feeds, there will be more nutrient to their babies as well as reduce the diarrhea (less water means less water coming out from the bottom!). Concentrating feeds will make the salt in the child's body go haywire and will definitely worsened the condition. So, feed like usual. On top of that, give rehydration salt (ORS). 

2) Must change to soy based formula.

This is also not true. Many GP will tell parents to change milk for their children to soy based, because soy based will lessen the diarrhea. There is no need to change any milk powder during the first week of diarrhea. However, there are some diarrhea will persists to more than 2 weeks. This type of diarrhea is call 'post infection lactose intolerance'. It is only by this stage, then a lactose free formula is indicated. When we start to give a lactose free formula/soy based formula for a child that is having diarrhea, this must continue for at least one month, then we can reintroduce normal milk powder slowly. There are risk of recurrence of the diarrhea after restarting normal milk powder in some cases.

3) Need to take medication to stop diarrhea.

Anti-diarrhea medications are NOT used in children. In fact, we don't give at all! This medication causes the intestine to slow down it's function and cause the child's tummy to be distended. This will cause more discomfort for the child. Moreover, the toxins in the intestine will be absorbed into the blood stream and cause a child to be unwell. These medications also will cause lots of side effects. So the next time your GP give you medications to stop diarrhea, think twice!

Children with fever

Fever in children is something very common. Fever, in medical term, is defined as temperature of more or equal then 37.5 degrees. Any temperature of more than 38 degrees are considered high fever.

I have got many parents bringing their children to us saying that their child is having a fever. When i asked 'How do you know that your child is having a fever?', the most common answer is 'I feel the baby is warm'. Well i'm not saying it's not right to feel the baby, it will be better if parents have their own thermometer at home to measure the temperature of their own child. Many times, these babies (that parents thought they are warm to touch) actually don't have fever. So parents are stressed for the wrong reason! Thermometer are very cheap. Get digital ones. Not the one that stick to the forehead and appear to change colour when there is fever. Some digital ones will require a person to hold the thermometer for at least 1 min. Some is almost instantaneous.
I won't suggest for the infra red forehead thermometer as their accuracy is not fully understood, especially for malaysian where our culture is so diverse.

Whenever a child has got high fever, parents must do all they can to bring the temperature down, by whatever means. Medications are the best choice. Paracetamol or layperson term will be 'panadol' can be given either by mouth or 'backside'. Both are as good, the only difference is, the 'backside' way will be a little uncomfortable but the fever will come down within 15mins after administering parecetamol the backside way!
Majority of doctors will advice for medication every 6 hrs. However, if children's fever start to come back up before the 6 hours period, then, we can give earlier but not less than 4hrs.
In between medication, if the child is still hot, then sponge them. Bear in mind, NOT to use cold water, but just normal tap water. If water is cold, the child will shiver and will worsened the condition. If hot water, then the child will be scalded! (obviously)
Some children will have a seizure during fever. In medical term, this is call febrile convulsion. Seizure will only happen if the temperature of the child goes up drastically.
Take for example, if the temperature of the child goes up from 37 to 40 degrees in 15mins, the child child WILL fit. However, if the child's temperature goes up to even 40 over period of hours, the child won't fit. So, by all means, we need to make sure to bring the temperature down, and if can't make sure that the temp don't go up to drastically.

Of course, bring your febrile child to see the doctor. A child with fever, don't take for granted.

Some help for lactating mothers!

Most of the time, when I'm treating a child or baby with dehydration, I always asked the child's mother if she is breast feeding her baby well or not. Most of the time, mothers will tell me that they don't have much milk and this is especially so during the first 3 days immediately after delivery.
When I asked, why they don't give supplemental feeding, they all say this " I thought we should breast feed the child as much as possible? And we shouldn't give bottle feeding?"

Yes, what they say is so very true. Mummy's milk is ALWAYS the best. No doubt mummy should breast feed as frequent as possible. But, if a mother has got not enough breast milk (which is normal at the beginning), then she should not force herself into it. If a lady try to breast feed too hard, this is detrimental to the flow of breast milk. Ultimately, there will be less milk. Our brain is very awesomely made. If we are stressed, then the brain will 'tell' the breast to stop producing milk by secreting hormones.

So, the rule of the thumb is this. Breast feed as much as possible, and supplement feeds if there's not enough of breast milk. This way, your baby won't be dehydrated. If you consult your doctor, there are medications that can help to increase milk flow. These medications, to me, actually work wonders. There are lots of mothers, came back to me, thanking me for giving them the 'wonder drug' to make their breast feeding experience a success.! It's a simple drug and of course won't affect your baby even if you are taking it during breast feeding. It's very safe!

Jaundice babies

Neonatal jaundice, or in lay term, a yellow discoloration of the skin in newborns are a very common condition. In fact, almost every week, I will be treat, either directly or indirectly at least 20 babies a week. That's how common!

Most of these babies are jaundice because of one common problem, that is dehydration. This happen especially during the first few days of life, where the child's demand for milk is inadequately supply by his or her mother. This happen more frequently in breast fed babies. Many mothers want to breast feed their baby, and this is a good thing. However, many force themselves so much, that they just refuse to use supplemental feeds, that is, formula milk. Since it's normal for mothers to have less milk within the first 3 days after pregnancy, then the baby will be dehydrated. So, for these children, the treatment is essentially, rehydrate them! Very simple.

When any mothers see that their babies are jaundice, they need to bring them to seek medical help and have the babies blood checked. There are certain levels of 'jaundice' in the blood, where if it reaches a certain level, will damage the brain. This is called 'kernicterus' in medical term. Nowadays, this clinical condition is rare. Kernicterus is permanent. And the child will have delay in physical development. Though rare, we should not take neonatal jaundice for granted.

If any baby, are admitted to the hospital for jaundice, most of the time we will treat them with a special blue light, just like the one shown here. This blue lights has special frequency and wavelength to reduce the 'jaundice' in the blood and this will help to bring the jaundice level down.

There are other causes of jaundice. Some are due to infection, which need prompt treatment. So, if your babies are jaundice, then don't hesitate to bring them to see a doctor.

Most commonly, in our culture, mothers that just delivered, starts to take some 'traditional medications' during confinement. Some of these 'medications' have a certain biochemical substance, that can cause jaundice to happen. So, it will always be our advice to stop any 'traditional' stuff during that few critical weeks of confinement. I'm not saying that all traditional medications causes jaundice, some of them do, the problem is, no one on earth know which one! So, as always, prevention is better then cure, just stop and wait till at least the child is 2-4 weeks old. By then, even if the child got high jaundice, it won't cause any brain damage!

Breast Feeding

To many mothers, especially new ones, this is the first challenge she needs to go through. To some, breast feeding is challenging, to some, it's just second nature. More than often, there are many questions by my patients asking about breast feeding or EBM (expressed breast milk). I hope I can share something over here maybe to clear some confusion and myths about breast feeding.

Breast milk is always the best for our babies. This is a fact and no doubt about that. All parents want to give the best to our children and therefore many try hard to breast feed. Some fail, some succeed wonderfully.

The commonest problem in breast feeding is latching and positioning. Many fail in breast feeding because of poor attachment and position. I will not be able to tell how to position and attach here because of obvious reasons, so, for those that want to know proper way of breast feeding, you need to get yourself a lactational nurse.

Next question is, when to stop breast feeding? Never! As long a women lactate, then breast feeding continues. In Malaysia, i've seen children at 6 yrs old still want their mother's breast, and of course, this 6 yrs old will have to 'fight' with his/her younger sibling for the breast!
The minimal duration of feeding is 6 months. The reason is simple, that is because children start weaning at 6 months. If your child don't wean at 6 months, then you need to start doing it! It's abnormal to just drink milk alone, let alone, the breast without any weaning.  Take note, that I didnt say stop breast feeding, it's weaning on top of breast feeding!

Working  mothers has got lots of problems in feeding their children. They got to work and by the time they are back home, they either too busy with cooking or house chores or just too tired. When they are at work, they can't bring their newborn to work! Though some employers allow their workers do that, something that I must commend.
Working mothers can choose to express their breast milk, then store in the fridge. When the time comes, the care giver will just need to bring it out from the fridge and thaw it. Remember to put them in separate containers, each containers have adequate amount of milk for ONE feed. Never refrigerate a thawed milk.

Expressed breast milk (EBM) can be given in few ways. Either using small cups or bottle. Some hospital uses syringe for small premature babies! Cups are good so that, the baby will be able to suck from the cup and swallow. Bottle does the same too, however, there will be one greatest problem with those babies that bottle and breast fed, NIPPLE CONFUSION. The nipple of a bottle is artificial and most nipples are silicon and they flow milk even without sucking! So the clever child will want to be lazy, to get milk without sucking too! When these bottle fed babies are put back to the breast, they refuses to latch. If this occur, then it will be very unfortunate. It will be very difficult to put the child back on the breast if this occur. If this occur, the we have to settle for the 2nd best, that is EBM and feed with bottle.

Nipple confusion don't occur every time.
Working mothers need to frequently express milk too. Ideally every 2-3 hrs. So, mothers will need to excuse themselves from work every 2-3 hrs and start expressing. This will prevent 2 things
1) reduction of milk production
2) prevent engorgement of the breast, that subsequently will lead to infection (ie mastitis)

I hope this short note will help lactating mothers and feel free to drop comments!

Pneumococcal Vaccine

This vaccine, I must say, by far the most important add on vaccine ever. If any parents, has got only a couple hundred bucks to spare for vaccine for their children, this is the one that they should buy. Not that, the other ‘add-on’ vaccine is not important, but this is the MOST important.

There are 3 types of pneumococcal vaccine (correct as of the time this article is written).
1) Prevenar – The earliest pneumococcal vaccine available. It protects against 7 serotypes of pneumococcal.
2) Synflorix – The newer vaccine, that protect against 10 serotypes
3) Prevnar 13 – Protect against 13 serotypes.

Basically, ‘serotypes’ means ‘types’. The bacteria pneumococcal has got many many types, and specific types are the one that is causing diseases in children. So of course, the more types, the coverage of the vaccine, the better it is.

In Malaysia, 1 and 2 is available to date. (3) is not here yet. The price is about Rm200 per dose for prevenar and Rm 280 per dose of synflorix.
The commonest questions I’ll get when parents asked me about this vaccine is, how good is this, and is this worth the money??

The vaccine protects agains 3 types of common infection. It protects against infection of the ear, lung and brain. So, with just one vaccine, there will be 3 diseases that is being prevented. So, I would say, it’s worth the money!
If your child is less than 6 months old, he or she needs 4 doses of the vaccine. The first 3 are 2 months apart, then the last MUST be at 2nd yr of life.
If your child is between 6-12 months, then only 3 doses are needed. And the last dose MUST be at the 2nd year of life

If your child is more than 1 yr old, then he or she only need 2 doses.

The next question I’ll get is this, “Doc, can I just wait till the child is more than 1 yr old, then only I give the vaccine? At least i can save some money!”

Well the answer is ‘Yes”, but your child won’t be protected during the 1st yr of his/her life. Bear in mind that, these type of bacterial infections are worse if the child is younger. So, essentially, it’s like buying insurance. You can wait, till you are 50 yrs old then only start getting insurance!

Another important point of this vaccine is this. The vaccine should and must be given, within the same week with other vaccines (given by govt hospitals/clinics). Do not give prevenar vaccination this week and then give the ‘usual’ vaccine the other week. This will defeat the purpose of both vaccines! So, either, give together or at least 1 month apart.

I hope you, as readers, understand the importance of the vaccine!

Immunization

I would personally say that this is the most important for any people who take care of children, either directly or indirectly.

The above is the immunization schedule by our Malaysian Government. It is very simple to see and understand and I hope everyone can understand!

Many times I personally see patients being admitted to the hospital for infective disease that is very much preventable with the immunization program that is being lay out by our ministry. It is given free of charge in any health clinic. So, any parents will just need to walk in to any of the clinic, and get their babies checked and immunized. Isn't that simple?

Yes, I must agree, that there are many parents opt to send their babies to be immunized in the private clinic. This is good and I encourage it. I must say one thing however, that is the vaccines given by the government and the private clinics are the SAME. There are no difference at all! Of course, as with any govt hospital or clinic, the patients need to wait. This is the norm. So for many of us that don't want to wait, then we pay! Many however, don't want to pay and don't want to wait! This is impossible. We can't be lazy and want the govt to give us free stuff and we want NOW! Beggars can't be choosers right?

There are few other 'additional' vaccines, that are not available in the govt clinic. This additional vaccines are good to be taken, and the patients will have no choice but to get them in the private sector. Many asked me this question before "Doc, why the govt don't want to give us this additional vaccines as well?". Well the answer is, "The govt don't have money!"

Hospitals and govt clinics are collecting a mere RM5 for treatment, consultation, and drugs. We don't need to be an economist to know that the govt don't earn any  money and will in fact loose money and be in greater debt if the ministry give every vaccine free!
I will talked more on these additional vaccines in my next post. These vaccines are important, and to me a MUST for any parents with children.

The very first post!

Indeed! Hello world!! It is my utmost desire to see all the children in this world is healthy and free from any diseases. Though this may sound to be impossible, however, it's not impossible to achieve.

Being a medical doctor working with children for the pass 7 years, there are just too much sick children in the hospital. Having experience in 2 large government hospital in those years, I see that many illness or diseases in children is very preventable.

Many of those children, got themselves admitted to the hospital are mainly due to the lack of care by their care giver and lots of misunderstanding and misconception as to how to properly care children. This is my ultimate aim of this blog/post, that is to educate, either parents or potential parents as to how to prevent their children from getting themselves admitted to the hospital!

Being a father of 2 boys and having working experience with sick children, both in Malaysia and UK, I can humbly say and give myself 'license' to comment!

Of course any of you think that what ever i blog is not true, or feel you wanna to debate a certain fact, feel free to comment or provide feedbacks!

Cheers and God Bless!

Dr Paul Chan