Information about common eye problems, including tips on home management, self care, and when to contact a doctor, for common opthalmologic problems. While the information is relevant to everyone, special stress will be given to issues that are common in India.

Hepatitis A - the common Jaundice
This is a post that I recent wrote for a newspaper due to the present scare in Shimla about hepatitis A epidemic.
Most of us are aware of and have probably been vaccinated against hepatitis B. Given the fact that so many of us are protected from hepatitis B, have you ever wondered why we still have so many cases of jaundice especially in the months of summers and monsoons? The reason is jaundice due to poor food, water and sanitation, meaning hepatitis A and hepatitis E virus.
The most important thing to realize that taking hepatitis B vaccination will not protect you against these forms of jaundice since they are caused by a different virus. Today we are going to talk in some more details about Hepatitis A.
Hepatitis means inflammation (swelling) of the liver. While there are many infections that can cause this, in India the commonest cause in children and one of the most common causes in adults is Hepatitis A. Hepatitis A virus is spread from person to person by putting something in the mouth that has been contaminated with the stool of a person with hepatitis A. This type of transmission is called fecal-oral. For this reason, the virus is more easily spread in areas where there are poor sanitary conditions or where good personal hygiene is not observed. Casual contact, as in the usual office, factory, or school setting, does not spread the virus. Persons with hepatitis A virus infection may or may not have any signs or symptoms of the disease. Older persons are more likely to have symptoms than children. If symptoms are present, they usually occur abruptly and may include

• fever,
• tiredness,
• loss of appetite,
• nausea,
• abdominal discomfort,
• dark urine, and
• jaundice (yellowing of the skin and eyes).

Symptoms usually last less than 2 months; a few persons are ill for as long as 6 months. The average incubation period (i.e., time taken from transmission from one person to the other) for hepatitis A is 28 days (range: 15–50 days).

The diagnosis cannot be made without doing a blood test (IgM Hepatitis A antibody- cost approx. Rs. 600/-), since the symptoms of all types of hepatitis are the same. Other tests like the liver function tests are useful in finding out the extent of the disease. The good news is that once you have the disease, you develop antibodies that provide life-long protection from future infections. After recovering from hepatitis A, you will never get it again and you cannot transmit the virus to others.

Treatment is essentially supportive, and with adequate rest and minimum use of anti-fever and anti – vomiting medicines a patient should generally recover within 15- 30 days. However 15 % of patients (mostly adults) may have a prolonged course of illness lasting even as long as 6-9 months!

Prevention rests on maintaining a good personal hygiene. Always wash your hands after using the bathroom, changing a diaper, or before preparing or eating food. Avoid outside food and water especially food that is undercooked/ uncooked (like salad etc.). Since proper food and water in India is still a pipe-dream, a more feasible way is to take the Hepatitis A vaccine. This is a very safe and highly effective vaccine (more than 90 % effective) with no major side-effects. It can be given to anyone above 1 year of age. Two doses are needed for life long protection and these need to be given 6 months apart. The vaccine is effective a month after the first dose is given.

With proper cooking habits, care about water and outside food and proper vaccination at the right time, we can ensure that we do not have to suffer Hepatitis A disease.

Dr. Gaurav Gupta, Consultant Pediatrician, practicing in Charak Clinics, Phase 7, Mohali.

Tips to get your child vaccinated painlessly
1. Choose a pediatrician you trust. A good doctor will have good nurses, and together, they will know how to administer shots quickly and correctly.
2. Present a blase, everything-is-routine attitude, and your child will be more relaxed during pediatrician visits. Trying to reassure her before she gets a shot is not terribly effective, especially for children under 8.
3. Let the doctor and nurse handle your child. Don\'t cling to her. The doctor and nurse know what they are doing, and their competence will instill confidence in your child.
4. Understand that the injection will most likely be given in the thigh because the fat in the thigh eases the discomfort of the shot.
5. Make a fun little noise to distract her from her shot.
6. Put special adhesive bandages over the injection site. Most pediatricians and hospitals awidth is.Apply child-friendly bandages, such as ones with Pokemon or Elmo pictured on them.
7. Give stickers as a reward.
8. Praise your child when you leave the pediatrician\'s office. Don\'t say, I know how awful it is to get a shot. Instead, say, You acted so grown-up in the doctor\'s office. I am so proud of you.
9. Keep some fun adhesive bandages in the bathroom cupboard. If she wants a fresh bandage over the injection site, give her one.

warm regards
Dr. Gupta

Masturbation in preschool children

I recently had a 3 year old child from Canada. The parents that thier child had possibly a recurrent pinworm infection (as stated by their health care provider). On detailed questioning it was found that the child enjoyed rubbing her genitals againt any surface, as opposed to scratching with her fingers. This suggested a diagnosis of masturbation.
The following information is by Dr. Barton Schmitt, and taken from the Virtual hospital website. This may come as a shock, but it is estimated that almost 30% of toddlers and preschoolers masturbate. Masturbation is self-stimulation of the genitals for pleasure and self-comfort. It is a normal, healthy activity at any age. During masturbation, children usually rub themselves with their hands. Girls may rock against an object such as a stuffed animal or pillow. Children usually appear dazed, flushed, and preoccupied while they are masturbating. These children have discovered masturbation during normal exploration of their bodies and it continues because it feels good. Masturbation becomes frequent only if the child is pressured to stop. That invites a power struggle.

• First, set realistic goals. It\'s impossible to eliminate masturbation. All that you can control is where it occurs. Accept it in the bedroom or bathroom or at nap time.
• Second, ignore masturbation at naptime or at bedtime. Don\'t check on your child at these times.
• Third, distract your child from masturbation at other times. Try a toy or a new activity. If this fails, send your child to his room. You can\'t ignore it, or your child will feel he can masturbate anywhere. Your child will catch on to privacy and modesty somewhere between the ages of four and six.
• Fourth, be sure no one punishes your child for this. It\'s counterproductive.
• Finally, if you\'re having trouble accepting this normal behavior, talk with your child\'s doctor.

Please remember that there is no sexual element in preschooler masturbation, it is just a pleasurable sensation generated by self-exploration, do not let your guilt, feeling about sex influence your atitude towards the child. Try to be nonchalant about the whole thing, and inform the child that it is inappropriate to carry out this activity in public. In a way, it would be equivalent to thumb-sucking or any similar activity that the child indulges in while he is bored or alone. You can get more information about common pediatric disease at Charak Clinics

How do vaccines work?

Parents are constantly concerned about the health and safety of their children and they take many steps to protect them. These preventive measures range from child-proof door latches to child safety seats. In the same respect, vaccines work to safeguard children from illnesses and death caused by infectious diseases. Vaccines protect children by helping prepare their bodies to fight deadly diseases..

There are a series of steps that a person's body goes through in learning how to fight off a vaccine-preventable disease:
First - A vaccine is given by a shot or liquid by mouth. An alternative needle-free route is the use of inhalation by aerosol and powder. Most vaccines contain a weakened or dead disease germ or part of a disease germ. Other vaccines use inactivated toxins. Some of the bacteria that cause disease do so by producing toxins that invade the bloodstream.

Next - The body makes antibodies against the weakened or dead germs in the vaccine.

Then - These antibodies can fight the real disease germs, which can be lurking all around ? if they invade the child's body. The antibodies will know how to destroy them and the child will not become ill. Most vaccines don't cause the diseases that are usually caused by viruses and bacteria.

Finally - Protective antibodies stay on guard in the child's body to safeguard it from the real disease germs.

After exposure to a live, weakened, or dead germ, the antibodies or memory cells fight infectious diseases and usually stay in a person's immune system for a lifetime. This protects a person from getting sick again. This protection is called immunity.

• It is true that newborn babies are immune to many diseases because they have antibodies they got from their mothers. However, this immunity only lasts about a year. Further, most young children do not have maternal immunity from diphtheria, whooping cough, polio, tetanus, hepatitis B, or Haemophilus influenzae type b.
• Immunizing individual children also helps to protect the health of our community. People who are sick will be less likely to be exposed to disease germs that can be passed around by unvaccinated children. Immunization also slows down or stops disease outbreaks.
• If a child is not vaccinated and is exposed to a disease germ, the child's body may not be strong enough to fight the disease. Before vaccines, many children died of diseases vaccines prevent, like whooping cough, measles, and polio. Those same germs exist today, but babies are now protected by vaccines and so we do not see these diseases as often.

Bedwetting is an extremely common pediatric problem. This is underdiagnosed due to unecessary shame and guilt associated with it among parents and even children.
Common Facts & Myths about Enuresis

First the stats
Almost 10 % of 10 year old kids wet the bed occasionally, you are not alone!
After the age of 5 years only 15 % children wil become dry every year without treatment.
In most cases treatment of bedwetting should begin between 6-7 years only, anything before that and there is good chance that your kid will grow out of it.
Bedwetting is a develpomental issue, something the child does during sleep without prior knowledge. Do NOT blame / punish the child or yourself. Your kid is not being lazy or stubborn, he really does not know. What the child needs is reassurance and encouragement.
Bedwetting tends to run in families, so if it is true, telling the child \'daddy used to do this\' may help increase their self esteem.

TREATMENT Options simplified:

Before going to the doctor Sleep half an hour early - a less tired child is going to sleep \'light\' and therefore is more likely to wake up to go to the bathroom.
Lots of water in the day, restricted fluid at bedtime (not more than half a glass 2 hours before sleeping), avoid caffeine (carbonated fizzy drinks).
Star chart and positive reinforcement - Put stars (or stickers) on a calendar in the child\'s room for every dry night. IF the child remains dry continuously for a few days, give him some small reward (if this does not work for around 15 days, get a doctor\'s opinion).

Just what the doctor ordered
Remeber that any bedwetting beyond 6-7 years can have a lot of social consequences like other kids making fun of the child, difficulty in sleeping over with friends and relatives etc. More importantly only about 1 in 6 kids every yeare will outgrow this problem after this age spontaneously, therefore get it treated.
3 major treatment options are:

DDAVP - It is a hormone that is usually present in th body and this leads to a decreased urine production at night. It is said that a deficiency of this hormone may lead to bedwetting, therefore treating the child with a tablet or a nasal spray may be useful for preventing bedwetting. This is especially very effective for \'emergencies\' like social occasions nightouts etc. where rapid control is needed. The only problem is that long term treatment is needed since on stopping this medicine there is a high chance that bedwetting will recur.
Bedwetting alarms are now available at leading pharmacies in India too, and over a period of around 3 months they are very useful in decreasing/ stopping bedwetting altogether. For quicker relief these may be combined with DDAVP.
Imipramine tablets are a cheaper treatment option however these have significant side-effects like nervousness, tiredness and intestinal problems.
Remeber for most kids bedwetting is nothing more than an inconvenience or at worse a social problem.

WHEN TO WORRY?
If a previously dry child starts bedwetting
Daytime bedwetting in an older child amy be because of Diabetes, Urinary tract infection or psychological problems like sibling rivalry etc.
Any other associated symptoms like urgency while passing urine, fever, abdominal pain etc.
Based on an article in medicinenet

Reducing pain from vaccination - A pediatrician\'s perspective
May 7, 2007 — An evidence-based review published in the May issue of Pediatrics provides recommendations to help reduce the pain children experience during immunizations.
The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them.
The current Centers for Disease Control and Prevention schedule recommends immunizations against 14 diseases, which translates into 14 to 20 separate injections before the age of 2 years, depending on the number of combination vaccines available. Therefore, immunizations are the most frequently occurring painful procedures performed in pediatric settings.
The recommendations divide the injection process into 2 periods: before the injection and during the injection. Before the injection, important aspects of the immunization include preparing the child and family, selecting the site for the injection, selecting the needle length and gauge, and specific properties of the injectate.
During the injection itself, key elements include parental demeanor, use of sucrose, use of topical anesthetic agents, nonpharmacologic and physical strategies, and specific aspects of administration technique. Before the injection, preparation of a child older than 2 years reduces anxiety and subsequent pain. For children younger than 4 years, the preparation should be done in close chronological proximity to the injection itself. Based on limited data available, intramuscular immunizations should be given in the vastus lateralis (anterolateral thigh) for infants and toddlers younger than 18 months and in the deltoid (upper arm) for children older than 36 months. Although site selection for 18- to 36-month-old children is still controversial, some studies suggest that the ventrogluteal area is the most appropriate for all age groups. Using longer needles usually causes less pain and less local reaction. During the injection, parental attitudes clearly affect the child\'s pain behaviors. Excessive parental reassurance, criticism, or apology appears to increase distress, whereas humor and distraction may reduce distress. The age, temperament, and interests of the child, as well as personal style of the parents, will determine which distraction techniques will be most effective. These techniques may include storytelling, reading to the child, deep breathing, and blowing. Although it seems counterintuitive, children often are more distressed when parents are more rather than less involved, the authors write.
Therefore, a matter-of-fact, supportive, nonapologetic approach is endorsed. In children younger than 6 months, sucrose solution given directly into the mouth or on a pacifier reliably reduces evidence of distress and should be used routinely, in part because it is relatively inexpensive. Given the high cost and time needed for administration, routine local anesthetic administration is not necessarily appropriate. Despite the absence of a perfect topical anesthetic available at this time, selective use is recommended for children who are particularly fearful, who have had previous negative experiences, or who will require multiple procedures in the future.
Pressure at the immunization site decreases pain, whether applied with a mechanical device or manually with a finger. Furthermore, it is noninvasive, inexpensive, and without adverse effects.
Although properties of the injectate itself can exacerbate pain, there has been almost no sophisticated research in this area, and this issue should be pursued further. In the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available, the authors write. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.
However, they also note that dread evoked by painful immunization procedures may create feelings of persistent tension in future clinical encounters, thereby interfering with optimal delivery of healthcare. Pediatrics. 2007;119:e1184-e1198.

Fever in Infants
Fevers are fact of life for most children. In most cases they are nothing to worry about, but it is important to monitor the symptoms closely and to seek medical advice if they persist. What is a fever? Fever has been defined as a body temperature elevated to at least 1F above the \'normal\' of 98.6F (37.0C). A baby\'s temperature normally varies by as much as 2F, depending on the temperature of his surroundings, clothing worn, degree of stress, level of activity or time of day. What prompts a fever? In most cases a fever is the body\'s reaction to an acute viral or bacterial infection. Raising the temperature helps create an inhospitable environment for viral or bacterial invaders, it also stimulates the production of disease-fighting white blood cells. Why are babies prone to fevers? The body\'s temperature control system is not well developed in babies. Infant and childhood fevers can be caused by a number of different factors including: * Overexertion * Dehydration * Mosquito bites * Bee stings * Allergic reactions * Viral or bacteria infections What are the symptoms? Typical symptoms of a fever include coughing, aches or pains, an inability to sleep and shivering. Other symptoms include poor appetite, lethargy and prolonged irritability. In some cases breathing may be difficult. What are the treatments? Dehydration is a risk for infants, and a feverish baby should always be given lots of fluids. A child with a temperature of less than 102F (38.8C) does not always require immediate medical attention. The child should be observed, and help sought if the symptoms appear to get worse, or the fever does not subside within 24 hours. A child with a temperature of 102F or higher should be given paracetamol. A doctor or pharmacist should be consulted for a recommended dose. A doctor\'s advice should always be sought for a child whose temperature is 104F (40C) or higher. Children should not be given aspirin. Several studies link aspirin use in children with Reye\'s Syndrome a severe illness that often is fatal. Are there danger signs? Certain symptoms, when combined with a fever, warrant an immediate call to the doctor. These include: * Red spots on the skin, sensitive eyes and runny nose (measles) * Red, itchy spots (chicken pox) * Stiffness in the neck or headache (a sign of a more severe infection) Febrile seizures Occasionally, a child with a fever will have a seizure. This is called a febrile seizure, and it demands immediate attention from a doctor. The seizures do not seem to be related to the height of the fever, or to the rapidity with which it rises, but a small number of children seem to be predisposed to attacks. About 50% of the children who suffer one febrile seizure will go on to have another one. About 33% will have a third one. While waiting for a doctor to arrive, it is important to follow basic instructions: * Keep the child upright and make sure they are breathing well * Stay with the child and talk reassuringly * Watch for changes in breathing, and make sure that the airways are kept open * Clear the area to prevent injury * Do not restrain as this can cause additional injury * Try placing a soft pillow or blanket under the child\'s head * Loosen clothing to prevent injury and ease discomfort * If vomiting occurs, turn the head to the side so there is no risk of his choking on inhaled vomit This page contains basic information. If you are concerned about your health, you should consult a doctor.

Vaccinations
Vaccination(Latest Immunisation Schedule)

IAP Immunisation Time Table
Recommendations of the IAP Committee on Immunisation