Sunday, August 31, 2014

Pediatric OPD is a Challenge: Treating the Child and Meeting Parents expectations


" A concerned mother brings her 3 yr child to the Outpatient Clinic, the child has had fever for 1 day, running nose and cough for 2 days. There are no other serious complains and findings on examination are all normal, except for running nose and low grade fever. A case of common cold that is very common in childhood.
The mother is really concerned about the child contracting a Pneumonia , well there were no symptoms as such and pediatrician counsels her on that, but she wants an antibiotic for safe-side. Doctor explains the condition and hazards of erroneous use of Antibiotics, she is convinced.

She is equally concerned about the cough. She has been giving the child Anti-tussive from Over-the-counter prescription that is pandemic in our country. Doctor advice her to stop the drug as current research does not recommend its use in below four years children. She is not convinced this time, in-spite of counselling"
In such a Scenario either doctor keeps trying to convince her, either he loses the follow-up or he has to go with the flow an prescribe Anti-tussives and Vitamins as the trend is in Private practice.

Pediatrics is a bit different subject to doctors in many sense. Specially in Pediatric out patient department or in private clinics, doctors will often find a mildly ill child but more skeptical parents who might constantly test you with their queries and doubts.
Pediatrics is different in that , not just treatment of the sick child is important but also meeting of the parents expectations, counselling them well and taking them in confidence. Often doctors meet lot of patient who are already on Antibiotics for Viral URTI , so the dilemma sets in- to continue or to stop the medication. The trend in the private practice is so wide-spread that antibiotics are prescribed for cases without any indications. The fault is not just in doctors here but in parents as well who often switch doctors when doctor prescribes less drugs. However it is what the nature of care-taker is, they always want to be on the safe side, while unknowingly they may be harming the child.

Erroneous and Erratic use of Antibiotics have led to Antibiotic resistance.There was a time when Penicillin was Jack of All, a shot of it could treat almost everything,today plain Penicillin rarely can treat any condition. These are the outcomes.

Meeting the Expectations of Parents-
What parents generally expect is that their child should be well with a day of treatment, which is rarely a possibility, because most antibiotics take at-least 24-48 hours to get working.  Counselling about the need and expected time of resolution can convince the parents to be more patient.
They want all their Queries fulfilled and all their doubt cleared. Because they are on behalf of a child patient who cannot express many things and they are guardian to such delicate human beings. Show then the empathy and that you care equally for the welfare of the child. Be patient and answer all the queries they have. Doctors should put themselves in the place of parents and try to fulfill their queries.

They may search for your qualifications and experience , face them confidently and without hesitations. Getting angry at it will not mask the thing, but will cause you to lose a rapport and trust.
They always want best among the pediatrician to treat the child, so they may test you with several questions, doctor must let them know that you are equally good and take them in confidence.
And last of all, ethically don't give up and prescribe medications to satisfy the parents, do it only when you know it is required. And the question is " Is this a possibility?"

I may not be totally right as I have a long journey to go, if you have a different opinion, I welcome your feedback.

Friday, August 29, 2014

What the child feels about Doctor ?

What child feels about Medical books and Medical Education

What child thinks about being Sick

What shocks the child most

How child feels when the doctor is on Leave

What child really hates

Some Parents are more Childish

Thursday, August 28, 2014

Pavilizumab Prophylaxis for RSV Bronchiolitis: Recommendation

Palivizumab is a humanized monoclonal antibody directed to an epitope in the A antigenic site of the F protein of RSV. It is a composite of primarily human antibody sequences (95%) and murine antibody sequences (5%). Palivizumab provides both neutralizing and fusion-inhibitory activity against RSV, resulting in inhibition of RSV replication. Although resistant RSV strains have been isolated in laboratory experiments, no resistant clinical isolates have been identified at this time.

Her are some updates- UPDATE on RSV prophylaxis

The updated policy recommends that RSV prophylaxis be considered in:
  • infants and children younger than 2 years of age who have required medical therapy for CLD within the 6 months prior to the start of RSV season; patients with severe CLD may benefit from prophylaxis with palivizumab through 2 RSV seasons
  • infants born at or prior to 32 weeks gestation
  • infants born between 32 and 35 weeks gestation with known risk factors, such as birth within 6 months of RSV season, child care attendance, school-age siblings, exposure to environmental pollutants, airway abnormalities, or severe neuromuscular disease
  • infants and children younger than 2 years of age with hemodynamically significant CHD, particularly patients with pulmonary hypertension or cyanotic heart disease, and those who require medication for congestive heart failure.
Source - AAP through Medscape 

Friday, August 15, 2014

10 Danger signs of illness in babies every parents should know

Neonatal period is a period of great delicacy and concern to born the newborn as well as parents. After more than 9 months of all the preparation and hope, a baby is born and soon it becomes the entire attention of the family. Even normal behaviors of newborn may seem strange to the parents, as often the physiology and phenomenon of the infants are unknown to many parents.
In this sensitive period, newborn might acquire an illness and parents should know the danger signs that an infected neonate may show. Early detection is very important as delay can compromise the outcome in the baby.

Here are list of Danger sign's listed by WHO- IMCI ( 0 to 2 months )

Possible serious Bacterial infections

1. Convulsions - uprolling of eyes, paddling movement of limbs (involuntary), vancant staring, sudden bluish discoloration with cessation of respiration, head drops, sucking like movement, flickering of eyes.
Convulsion may be sign of hypoglycemia, meningitis, sepsis or bleeding inside the cranium.

2.Fast breathing - More than 60 breaths per minute is cut off point for fast breathing in < 2 months baby. Fast breathing is seen in Pneumonia, Sepsis and metabolic acidosis.

3. Severe chest indrawing- Indrawing of lower chest and upper abdomen with respiration is a sign of respiratory problem most commonly Pneumonia and Metabolic acidosis.

4. Nasal flaring- is a sign of respiratory difficulty.

5. Grunting- sound produced during breathing typically is seen in lower respiratory tract infection including pneumonia.

6. Bulging Anterior frontanel- Frontanels are the open areas on the cranium covered only by skin and soft tissue. It is present in anterior portion of scalp as well as posterior. Bulging and tight anterior frontanel is a danger sign and may indicate meningitis, or intracranial bleed in sick infant.

7. Skin pustules- 10 or more skin pustules over the body or single boil 1cm , indicates need of medical attention.

8. Fever and hypothemia- Fever is less common in infants even when they have infection, more likely that they develop hypothermia ( cold clammy temperature ). It may be sign of hypoglycemia, sepsis or shock.

9. Lethargic or unconscious.

10.Less activity than normal.

Local Bacterial infection- 3 signs

1. Umbilical redness or draining pus

2. Pus discharge from ears

3.Less than 10 skin pustules.

One very remarkable sign both the parents and doctors have noticed in sick infant is, poor sucking of breast milk or cessation to feed on breast milk. Sometimes they may get irritable and difficult to console with excessive crying and recurrent vomiting.
Know these signs and be a Informed and Responsible parent. Only loving your child is not enough, you need to protect and know about them as well.

- Author- 
Dr  Sujit Kumar Shrestha, MD Pediatrics ( IOM, TUTH)