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GENKI GENKI!
By Dr. Miriam Sun-Arenas
The natural history of cervical cancer starts with infection by the human papillomavirus (HPV), which degrades the cervical epithelium down to the basement membrane where the HPV becomes embedded into the basal cells. When the cell starts to replicate upward for skin reproduction, HPV also begins its own replication cycle.
The expression of HPV genes depends on level of their location in the epithelium. At the topmost superficial layer, the entire new HPV particle is assembled, which makes for a new infection HPV virion. This virion can now spread to other sites or fall right back into the damaged epithelium of the woman and reinfect her, or be passed on to other individuals. It is when this infection stays and becomes prolonged and persistent that the virus is integrated into cells, eventually giving rise to precursors that can lead to cervical cancer.
Pap smear is an effective screening tool to detect these early changes and alert the physician to prevent the cancer from further developing. Vaccination against HPV assumes an even greater role at cervical cancer prevention and control by actually preventing the infection from happening.
The efficacy of these new vaccines is remarkable, approaching 100 percent in preventing CIN (cervical intraepithelial neoplasia) 2 and
3 caused by the oncogenic HPV strains 16 and 18 especially in a setting where the women recipients have not had previous HPV infections.
The two currently available vaccines, however, not only differ in the HPV types they protect women against; they also differ significantly in how well they protect against CIN 2 or 3.
In early reports, Gloxo Smith Kline's (GSK) Cervarix (a bivalent vaccine, against types 16 and 18) was 70 percent effective at preventing all CIN 2 or 3 lesions of any HPV 16 or 18 infections at the time of vaccination. The other vaccine (quadrivalent; fidhts HPV 6, 11, 16, and 18) on the other hand, was only about 50 percent effective among women without any prior HPV 16 and 18 infection.
Incidence rates for HPV infection do not seem to favor any specific age groups. The infection can be seen in women of all ages, and they run the risk of contracting high risk HPV types. Thus, vaccinating children and young women becomes a prudent measure to prevent initial exposure to HPV.
Specifically, females between 10 and 15 years old carry the highest antibody levels compared with any other age group. This is when they have the most prolific immune responses, which is a good time to vaccinate prior to any HPV infection.
As women age, however, they continue to have the risk of exposure, and actually contract HPV 26 and 18 infections at a rate of about one percent per year. More importantly, the lesions acquired at an older age are also more likely to be the persistent types.
Recent data suggest that women beyond over 30 are 20 percent more likely to acquire persistent HPV 16 infections, while also 15 percent more likely to have chronic HPV 18 infections.
Prof. Harper emphasized: "It is critical to understand that even though you have had a past HPV infection, it doesn't (necessarily) protect you from future episodes, and you are still at risk for auto- inoculation and acquiring new infections".
In light of these age-related issues, many public health programs are aware that older individuals do not trigger as much of an immune response as younger people. With the HPV vaccine, however, this does not seem to pose much of an efficacy issue.
From the younger age groups to the 46-55 groups, cervarix remains to have an excellent immune response; vaccine-induced HPV serum titers are still nine times higher than the natural infections titers. Thus, the antibody titers of older women compared to those of younger groups hardly make a significant difference in terms of providing adequate antibody protection.
Source: Medical Observer, Year 17, Issue 5, June 28
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PREVENTING AND MANAGING OSTEOPOROSIS
Brittle bones. Curved upper spine. Hip fractures. For many Asian women, the burden of osteoporosis is a daily reality, one that's built on a lifetime of inadequate calcium intake. Perhaps it's due to the gastronomic culture, where milk and dairy products occupy less auspicious positions in the dietary ladder. Perhaps the restrictive palate is in response to a genetic kink that has made many Asians lactose intolerant. Whether it's the chicken or the egg that came first, experts are convinced the primary cause of the disease, an insufficient calcium deposit in the bone bank, combined with a typically slight frame or a low body-mass index (BMI), has tipped the scales against Asian females, more than their Caucasian sisters.
The imbalance becomes pronounced during menopause when the ovaries cease to produce estrogen, the same hormone that's crucial to bone formation. From then on, it's constant stream of calcium withdrawal from the bone bank. And putting the plug on the deficit, usually requires more than dietary changes and nutritional supplements. The patient may be getting 1,200mg of calcium and 400-800 IU of Vitamin D everyday, as recommended for 65-year-olds and above, but the rate of nutrient absorption cannot keep up, much less outpace, the rate of depletion. An ageing body's nutrient uptake is not as efficient as it used to be, either.
According to an obstetrician-gynecologist, our bones are like hollow blocks. Sand, pebbles, rocks, water and cement are needed. If one component is lacking, the result is not good and sturdy. Same thing as our bones, calcium, vitamin D, manganese and other nutrients are needed to improve calcium absorption. Sunlight, exercise and estrogen are likewise needed.
To get around the law of diminishing nutrient returns and to fight off the degenerative effects of the disease, the patient may have to rely on medications as well.
Pharmacological options for osteoporosis are basically classified into two types: the antiresorptives which are bone-loss-preventing and the anabolics which are bone-forming.
The most controversial agent in the family of antiresorptives is estrogen therapy. Its link to breast cancer has discouraged many physicians from prescribing it to their patients particularly when the indication is osteoporosis and not menopause. Estrogen-replacement therapy, also endorsed by the International Menopause Society, works at relieving hot flashes, headaches, and other symptoms associated with menopause.
Once the menopausal symptoms have disappeared, some doctors would shift to other antiresorptives, like selective estrogen-receptor modulators (SERMs) and biphosphonates which bind to skeletal tissues to slow down bone erosion. The newest biphosphonate is zoledronic acid which is the only once-yearly treatment for post-menopausal osteoporosis recently approved by the US and European FDA.
Bone growth-stimulating anabolics are the other class of drugs. Unfortunately, a form of parathyroid hormone can only be given for a maximum of 18 months because long-term effects have not yet been established, although side effects like muscle weakness and breathing problems have been noted. To some doctors, this limits its application to patients in their latter years, around mid-70s or 80s, when protection is needed the most. Whereas other experts who are convinced by the superior action of the parathyroid hormone over the antiresorptives, recommend the former as first-line treatment for high-risk patients.
As it is in medicine and non-medical fields, science eventually comes up with a solution designed to outdo its predecessors. In this case, it's the fusion of anabolics and antiresorptives in one promising drug, called strontium ranelate. It replicates osteoblasts or bone-forming cells, synthesizes collagen and thickens the outer cortical bone. When taken for five years, it effectively decreases vertebral fractures by 25% and nonvertebral fractures by 15%.
Public awareness of osteoporosis has soared in recent years, a phenomenon spurred largely by the marketing efforts of pharmaceutical companies and milk manufacturers. Managing osteoporosis is not a one-pronged strategy, nor is alleviating aches stemming from osteoporosis - related fractures just a matter of replenishing calcium from a glass or a tablet.
When fissures and cracks appear, when the structural integrity of the bones are undermined, the bone-jarring truth is, you will need a more aggressive approach that goes beyond diet and exercise.
Source: Of Brittle bones and Curved spine:
Preventing and managing Osteoporosis
by Sunly Coo, MedicaObserver,
year 17, issue 5, June 2008. Makati, Phils.
SEXUALLY TRANSMITTED DISEASES
What are symptoms of sexually transmitted diseases (STD)?
Some of the symptoms of sexually transmitted diseases mimic other diseases; some of them might be noticed by men, others by women. Let's take a closer look at symptoms that might be caused by sexually transmitted diseases. Men usually have fewer symptoms of STD than women do. Because a man's sex organs are not as moist as a woman's, the STD germs do not proliferate as rapidly and therefore are less likely to present a problem for a man. For this reason, men often do not know they have an STD. Women often do not know they have an STD because their genital organs are internal and the infection can hide inside their bodies.
Some of the possible signs or symptoms of STD that a man might notice (or that you might notice about a man) include the following:
1. Discharge from the penis
Any fluid (pus, discharge, secretions) from a man's penis other than urine or semen (ejaculate) is a cause to see a doctor. This symptom almost always indicate sexually transmitted disease. Gonorrhea or Chlamydia or non-specific urethritis would usually be the cause.
2. Burning with urination
A burning sensation during urination often indicates a sexually transmitted disease. A doctor should be consulted because Gonorrhea and even Chlamydia can cause this.
3. Growths in the genital area
Any growth on the penis or scrotum or in the anal area may mean venereal warts or other sexually transmitted infections. (Any new growth, anywhere on the body should be seen by a physician, although those in parts of the body other than the genitals are less likely to indicate a sexually transmitted infection.)
4. Sores on the genitals
Small, tender sores on the genitals may be Herpes ulcers. If they are painless, firm and thickened, they may indicate Syphilis. Such sores should be promptly evaluated by a doctor.
Possible symptoms of sexually transmitted disease that both men and women might have are:
1. Skin rashes or sores
Both Syphilis and AIDS can produce skin sores or rashes, and scabies can cause a very irritating rash. Any body rash should be evaluated by a physician.
2. Enlarged lymph nodes
AIDS and Syphilis can cause enlargement of the lymph nodes all over the body. Some of the more unusual STDs can cause enlarged lymph nodes of the groin.
3. Long-lasting infections
Any infections of the skin, lungs or other parts of the body that do not clear up quickly should be checked by a doctor. AIDS and some other STDs can cause such problems.
4. Inflammation of a joint
If inflammation, redness and swelling are present in a joint (such as a knee or an elbow), a physician should be seen. Gonorrhea can cause such infections. If there is a possibility of a sexually transmitted infection, this should be mentioned to the doctor.
5. Yellow eyes and dark urine
Signs of hepatitis include the whites of the eyes turning yellow or the urine turning cola colored. Hepatitis B is one of the most common sexually transmitted diseases in the world.
6. Itching of the pubic hair
Pubic lice can cause such itching.
Some of the female symptoms of sexually transmitted disease include:
1. Vaginal discharge
Although a vaginal discharge does not always indicate sexually transmitted disease, if it is excessive, it itches, or it has an odor, it always should be evaluated. If the discharge could possibly be caused by sexual contact, that should be mentioned to a physician. Vaginal discharge could be a symptom of Gonorrhea, Chlamydia, Herpes, or even HPV (cause of venereal warts).
2. Sores on the genitals
Ulcers of the vulvar area, especially if urination causes discomfort, may include Herpes. If a sore is slightly thickened and painless, it could be Syphilis. Any sore or lump should be evaluated.
3. Growths in the genital area
Growths around the vulva, inside the vagina, or around the anus, may be venereal warts. Treatment is most important, because the virus that cause these warts is the most common cause of cervical, vulvar and vaginal cancer.
4. Burning with urination
Normally, a burning sensation with urination merely indicates a bladder infection. As the urine pours out over herpes ulcers, however, the burning may be quite intense. Whether the burning is caused by herpes or by bladder infection, it should be diagnosed and treated by a doctor.
5. Lower abdominal pain especially with fever
A woman with a Gonorrhea or Chlamydia infection may carry the germs for many months without symptoms. When either of these germs begins actively spreading in the body, pelvic inflammatory disease (PID) is usually the result, causing abdominal pain and fever. These symptoms should be checked by a doctor immediately. The sooner an infection of this type is treated, the less likely it is that sterility will result.
Source: Health-care Questions Women Ask by Joe Ms Ilhaney, Jr., M.D.
July-August 2008
MORNING SICKNESS
What is morning sickness? Does every pregnant women have it?
Morning sickness is real. Don't let anyone tell you it is imagined. Though researchers do not know the cause of it, they do know that morning sickness is due to changes in the body during pregnancy.
More than half of pregnant women experience nausea and vomiting to some degree early in pregnancy. Morning sickness usually appears soon after the first period is missed, and usually spontaneously disappears after the third month. When the nausea goes away, the accompanying tiredness usually disappears.
The term morning sickness is usually misleading, physicians prefer to label this complaint "nausea and vomiting of pregnancy". It may occur anytime of the day or night and the severity can vary greatly. The nausea may be so mild that it does not interfere in any way with a woman's schedule or diet. She may have no vomiting. Other women may have more severe nausea with occasional, or even daily, vomiting. Then there is a small group of women who gets very ill from this nausea and vomiting. They lose weight and can become dehydrated from lack of or loss of fluids. Sometimes the problem is severe enough to require hospitalization and then it is called hyperemesis gravidarum. The treatment of nausea and vomiting during pregnancy depends on its severity. A woman does not need treatment until her nutrition and body fluids are significantly affected. She may want it before that occurs.These hints may help a pregnant woman experiencing nausea and vomiting:
- Nibble on toast or crackers all day. Have crackers at your bedside. Start nibbling when you awaken
- Eat smaller, more frequent meals.
- Do not eat spicy food unless you know it does not affect your stomach.
- Avoid foods that seem to cause nausea.
- Eat foods that seem soothing to your stomach.
- Do not cook if that upsets your stomach.
- Use medications if your problem is especially bothersome, i.e, if you don't seem to be able to keep much food down and are sick most of the time.
- Consult with a nutritionist. The hospital at which you will deliver probably has a nutritionist would be happy to help you choose a diet that you cannot only tolerate but also one that is nutritious.
- Do not take prenatal vitamins until the nausea is gone, they can aggravate nausea.
As long as you are not becoming dehydrated and are not losing weight, the problem is "awful", but not dangerous.However, when your symptoms are severe and hyperemesis gravidarum results, your doctor will probably want to give you some medications. You may need to go to the hospital to get fluids in your veins. If you do go into the hospital, your doctor will want you to rest. You will be allowed few, if any, visitors. Your room may be kept cool and darkened. You will feel much better with such medical care.
Medications can be helpful. Usually Vitamin B6 is a safe medication. Many women have a negative attitude toward taking drugs for morning sickness. As long as this attitude is not carried to the extreme, it is a healthy position. Unfortunately, I have had patients who were so afraid of such medications that they refuse to use them when they should have and as a result began to lose weight and become dehydrated. At this point poor nutrition would seem more likely to hurt a developing baby than any medication a careful obstetrician might prescribe.
May-June 2008
Q. What is premenstrual syndrome (PMS)?
A. Premenstrual syndrome (PMS) is the name used for a variety of physical and/or emotional problems that occur prior to a woman's menstrual period. Symptoms of PMS may occur only one day or as long as two full weeks before the period starts. A woman may have only one symptom of PMS, or she may have many.
Because it is the production of progesterone at the time of ovulation that seems to be associated with the onset of PMS, it can only occur during the time from ovulation until the menses begin (about fourteen days). Problems that occur at other times during the month cannot be PMS.
Q. What are the symptoms of PMS?
A. While as many as a hundred symptoms may be associated with PMS, no one of them is unique to the syndrome. The key to determining whether or not a symptom indicates PMS is whether or not it occurs primarily during the two-week period before menstruation begins.
PMS may include the following physical and emotional symptoms:
Physical symptoms:
Abdominal bloating, fullness and aching in the lower abdomen, generalized swelling of the body, tightness of rings, shoes and fingers, numbness of hands, breast tenderness, headaches, acne, skin rashes, eye irritation, sinus congestion, backaches, dizziness, tiredness and fatigue, clumsiness, lack of coordination, fainting, easy bruising, heart palpitations,
increased problems with pre-existing asthma, epilepsy, heart disease and
hypoglycemia, poorly fitting dentures, outbreaks of herpes, increased vaginal secretions
Emotional symptoms:
Tension, irritability, depression, anxiety, mood swings, outbursts of temper, shouting, throwing things, paranoid, self-blaming, forgetfulness, desire to withdraw from others, suicidal feelings, compulsive activity, change in sexual interest, aggression, lethargy, sleeping disorders, insomnia, nightmares, unnatural fears,
argumentativeness, increased use of alcohol, indecisiveness, inability to initiate activities, marital conflict, food cravings, difficulty in concentrating, increased appetite
Q. What is the treatment for PMS?
A. Treatment of PMS includes non-medical and medical methods.
The non-medical measures that can be adopted to control PMS are as follows:
1) Adjust your life to your cycle. Women should be aware of when they will have their premenstrual symptoms. Hence, this time should be reserved for quiet activities of life, such as reading and activities that that do not require interaction with other people. Do not plan big parties and the like at the time of premenstrual symptoms.
2) Talk about PMS. Discuss PMS with your family and close friends. This will help them be aware of what is going on.
3) Cut calories and eat more frequently. Decrease intake of calories will help control body weight thereby decreasing swelling during premenstrual days. Eating small meals every three hours will help decrease hypoglycemia.
4) Increase physical activities.
5) Cut salt intake. It will decrease swelling and bloating.
6) Discontinue use of caffeine. Caffeine will only increase level of agitation.
The medical measures which are non-prescription drugs are as follows:
Vitamin B6, Magnesium and Calcium and evening Primrose oil and acetaminophen.
If the above over-the-counter drugs do not work for you, prescription drugs will require that you should see a physician.
March-April 2008
Bladder Infections
Q: What causes bladder infections and why do they occur more often in women than in men?
A: Bladder infections (Cystitis) are caused by germs that invade
and infect the bladder. These germs cause the lining inside the bladder
to become red and inflamed, just as your throat does when it gets
infected. Since pus cells and germs from the infection are passed in
the urine, it is often easy to diagnose a bladder infection by the
urinalysis.
Bladder infections occur frequently in women because the urethra, the tube
through which the urine leaves the bladder and empties to the outside, is so short
(about 2 inches long). This makes it easy for germs from the vulva to get up through the urethra to the bladder.
Germs can be massaged into the bladder with
intercourse, and most women do not have bladder infections until they
start having intercourse. Poor toilet habits can also introduce germs
into the bladder. For this reason a woman should wipe her vulva from
front to back after urinating or having a
bowel movement.
Q: What are the symptoms of Cystitis or bladder infections?
A: A bladder infection usually comes on suddenly. A burning
sensation when urinating and the need to urinate frequently are common
symptoms. Other symptoms are blood in the urine and pain in the
lower abdomen, behind the pubic bone. When she first notices these
symptoms, a woman should immediately call and see her doctor to get a
medication. If she dos not, she can
get extremely uncomfortable.
Q: What is “honeymoon cystitis”?
A: Honeymoon cystitis is a term applied to a bladder
infection that develops after a woman first starts having
intercourse. This type of cystitis is often merely an irritation in the
urethra, but sometimes it is an irritation of the bladder also. Many
times, this is not a true infection and all that is needed is a drug to
soothe the urethra and bladder.
Honeymoon cystitis can also occur when a
woman resumes intercourse after several months of abstinence. It does
not necessarily occur immediately but sometimes develops several weeks
or months after resuming sexual activity.
Q: How is cystitis treated?
A: Treatment of cystitis is classified into three categories:
1. First cystitis episode
You should see or call your doctor immediately when you have symptoms
of cystitis. A routine urinalysis will be requested. The usual
medications will be antibiotics like Cotrimoxazole or Nitrofurantoin or
Ampicillin or Ofloxacin to kill the germs. The antibiotics will be
taken for seven to ten days.
2. Repeat episode of cystitis
It is common for cystitis to return, even though it has been treated
properly. Most doctors want a urine culture done if a woman calls back
with another infection within a month or two of the first infection.
This is done to determine which germ is causing the infection and which
drug is most likely to cure it.
This time though, your doctor may encourage you to drink more fluids
and Vitamin C. This promotes an acidic urine in which germs grow
poorly. Drinking more water will promote flushing of the bladder. You
should also urinate after each act of intercourse to wash any germs
from your bladder and urethra, and to keep stagnant urine from staying
in your bladder.
3. Recurrent cystitis infection
If you continue to have bladder infections, you should see a urologist.
The infection may actually be coming from germs that
have infected your kidney and are coming down in the urine to infect
your bladder. Of course the reverse could happen in which there is
continued presence of germs in your bladder that could eventually
result in your kidneys being infected.
Recurrent bladder infections may be caused by
a stricture of the urethra, a condition wherein the opening of
the urethra is so tight that it prevents complete emptying of the
bladder. Stagnant urine can provide excellent culture media for the
growth of germs.
If you have recurrent infections and you see a
urologist, he or she will normally check to see if your urethra is not
too small. The doctor may also look inside your bladder by cystoscopy
to make sure that you do not have a growth that might be causing the
infection, and will order a kidney x-ray (IVP) to make sure your
kidneys do not show signs of chronic infection.
You will then be treated and kept under the
urologist’s care for repeat treatment of your bladder or kidney
infection if that is necessary.
There are many patients on dialysis because
their kidneys were destroyed by neglected kidney disease. There is no
need for you to risk
this.
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January-February 2008
EXERCISE REGULARLY
Is exercise an important part of good health?
It is my opinion that
exercise is a foundation for good health. It is probably the most
important choice a person can make to ensure optimum health now and for
the future. This seems to be supported by statistics that show that
since more and more of our population started exercising, there has
been a decrease in the number of deaths from heart disease.
What are the immediate benefits of exercise?
There are several direct rewards
for anyone who starts a regular program of exercise. They are as
follows:
1) feeling better
2) increase in mental alertness
3) weight is easier to control
4) less illness and fewer accidents.
What are the long-term benefits of exercise?
1) Less heart disease
2) Less hypertension
3) Less diabetes
4) Fewer accidents in later life
5) Increased chance of independence and good health in later life
6) Less pain from job-related demands
7) Less pain from everyday life
How do I begin an exercise program?
Choose an exercise you think you
can enjoy and will be able to do from now on. Start slowly at the level
that will depend on your present state of conditioning and your age.
Checking this out with your doctor is a good idea.
Arrange your schedule so that you
can exercise regularly for the rest of your life. If at all possible,
start exercising with someone else. This will help your discipline in
maintaining regular exercise, especially in the beginning.
Studies have shown that twenty
minutes of active aerobic-type exercise three times a week is enough
for proper body conditioning. The important thing is that the exercise
be done strenuously enough to produce a heart rate that is 70-80% of a
person’s predicted maximum safe rate. The calculation is quite
simple. Subtract your age from 220 and multiply by 0.7 or 0.8. For
example you are 25 years old. 220-25 = 195 x 0.7 = 136. This means that
your heart rate should be at most 136 beats per minute for a 25 year
old person in order to be at the safe level.
The mistake that most people make
which often leads to failure, is choosing an exercise that they do not
like. Very few people have the discipline to spend from one to three
hours a week doing something that they do not enjoy. As far as exercise
is concerned, there is no need for this to happen, because a person may
choose from so many different types of good exercises. Find something
you like and do it from now on.
Another mistake made when
people start a fitness program is that they forget to plan a realistic
schedule for exercise because they fail to make exercise a top-priority
activity.
You should consider a reasonable
amount of exercise an absolute priority in your life. You will need to
use your ingenuity to decide how you can do it, but it is possible.
A common mistake people make is to
let the weather keep them from exercising. Find an alternative exercise
for the days that will keep you from exercising.
Are there any limitations on beginning an exercise program?
No, because whatever your age, you
should start an exercise program of some sort. A study done by Dr.
James M. Hagberg of Washington University found that he could
successfully “rehabilitate” people over sixty years old. He has them
start their program by walking for half an hour everyday for six
months before beginning a more vigorous activity like bicycling. These
patients were able to tolerate this exercise program and their
heart performance improved by as much as 30% as time went by.
If you are over forty years old
and has been sedentary, you should see a physician for a check-up
before beginning an exercise program. If you are thirty-five years old
and have a health problem such as hypertension or heart disease, or if
you are a smoker, you should have a physical examination before
starting exercise.
November-December 2007
INFANT COLIC
Infant colic is described as spells of irritability, fussing, or
excessive inconsolable crying lasting more than 3 hours a day,
occurring more than 3 days a week, and continuing more than 3 weeks
during the first 3 months of life in otherwise healthy infants. Colic
is usually self-limiting in nature and recovery is spontaneous by the
time infant is 3 or 4 months old. Overall incidence ranges from 5-20%.
The causes of colic are not well defined but the following etiologic factors are considered:
1. Nutritional factors: Cow’s milk protein in formula fed infants and
in breast-fed infants whose mothers drink cow’s milk are suggested as
possible causes of colic. Infants ingesting cow’s milk have been found
to have increased serum levels of motilin, a vasoactive intestinal
peptide. Also, the excessive gas production due to incomplete
absorption of carbohydrates like lactose found in lactose intolerance,
leads to fermentative effects of colonic bacteria producing gas.
2. Biologic factors: Bottle-fed infants spend less time feeding
allowing more time to sleep as compared to breast-fed infants. However,
bottle-fed infants have more colic episodes because of the consumption
of excessive air associated with bottle feeding. The high incidence of
colic during 2-6 weeks of life is related to the increased rate of
growth at this time period.
3. Psychological factors: Mothers of colicky infants have more
psychological stresses, partner conflicts, unwanted pregnancies, and
conflict with parents. Maternal functioning is compromised leading to
depression which decreases maternal response to infant’s needs.
Only 5% of infants with colic have organic causes. The cry of
these infants do not follow the age pattern of infant colic. These
infants tend to cry throughout the day and they are more prone to show
weight loss, vomiting, diarrhea and the like. The pediatrician should
be consulted once these signs are observed.
The parents should be educated and counseled as to the reasons
why the infant is crying. Probably the infant is hungry and wants to be
fed, or is wet and wants to be diaper-changed, wants to be held or
stimulated or is tired and wants to sleep.
Feeding techniques should also be instructed. Overfeeding should
be avoided. Frequent burping is suggested to minimize swallowing of
excess air. Positioning infant at semi-upright is better. Making sure
that nipple hole is just big enough to allow steady stream of milk is
likewise important.
Dietary manipulation may be considered. Shifting to an elemental
non-cow’s milk formula or a lactose-free formula may be tried. Consult
the pediatrician first before changing infant’s milk.
A drug therapy to facilitate burping has no proven beneficial effect in colic.
Most importantly, parents of colicky infants need support and
reassurance that the infant will outgrow the symptom by age 3 or 4
months. The parents do not cause the colic and the colic will not harm
the baby.
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September-October 2007
BREASTFEEDING
In conjunction to what the
milk formula commercial says that “Breastfeeding is best for babies up
to two years,”…Human breastmilk is indeed the ideal food for full-term
babies especially during the first six months of life and should be
continued even with the addition of solid foods at least through the
first two years of life.
The advantages of breast-feeding for infants are as follows:
1. Human breastmilk is nutritionally unique, complete and adequate in optimal proportions.
a) Protein content of whey/casein ratio is 70/30.
b) Lipid content provides 50% of calories in breastmilk.It has lipase,
essential fatty acids and LC-PUFAs like arachidonic acid and DHA.
c) Carbohydrate content provides less than 50% of calories, main source
of which is lactose with complex carbohydrates and some
oligosaccharides.
d) Mineral content is low but bioavailable like calcium, phosphorus and iron.
e) Vitamins are present depending on the nutritional status of the
mother.The water-soluble vitamins like vitamins B and C, being the most
predominant. Vitamin K and D should be supplemented from outside
sources.
2. It contains “bioactive factors” which are the immunoglobulins
providing protection from infections. These are not found in milk
formulas.
3. It is practical, convenient, always fresh at proper temperature and free of contamination and adulteration
4. Maternal-infant bonding is enhanced during breastfeeding. With
prolonged breastfeeding, there will be improved cognitive and motor
abilities in term infants.
5. Feeding problems are minimized like constipation, diarrhea and infant colic.
6. It is beneficial to the mother as follows:
a) Promotes better postpartum recovery
b) Protects against breast cancer
c) Provides emotional satisfaction through bonding
d) Savings
Successful management of
breastfeeding starts during prenatal visits. The breasts are examined
to identify problems that will hinder breastfeeding like inverted
nipples. During postpartum, nursing mothers are taught on the
importance of the let-down reflex to initiate breastfeeding. Likewise,
they are counseled on breastfeeding problems because establishing a
good milk supply is critical. An adequate milk supply is assessed if
8-12 feedings are being fed to the infant.
Common breastfeeding problems are as follows:
1. Breast engorgement is common on the second to the fifth day postpartum. It is prevented by on-demand feeding by the infant.
2. Sore nipples are caused by improper positioning of the infant.
Therefore, a good position like a cradle hold or football hold and a
good latch are suggested.
3. Mastitis comprises breast pain and fever. Consult your doctor, he
will prescribe you a good anti-penicillinase antibiotic for this.
4. Nipple confusion is prevented this exclusive breastfeeding is encouraged.
Absolute contraindication to
breastfeeding is a mother who is HIV positive. A relative
contraindication to breastfeeding is a mother with active pulmonary
tuberculosis. Since any drugs taken by the mother is excreted in
breastmilk, she should consult her doctor for possible discontinuation
of breastfeeding.
July-August 2007
Migraine Headache
Headache is a common problem in pediatrics. Parents
usually seek medical attention for a child with headache to seek
assurance that the headache is not a sign of a severe underlying
disorder like a brain tumor.
Infants and children respond to a headache in an unpredictable
fashion. Most toddlers cannot communicate the characteristics of
a headache, but rather, they may become irritable and cranky.
Then they vomit and prefer a darkened room because of photophobia or
repeatedly rub their eyes and head. Children are poor historians
when describing a headache and its associated symptoms.
One of the most important causes of headache in children is migraine
headache which accounts for 75% of headache in young children.
Migraine is defined as a recurrent headache with symptom-free intervals
and at least with three of the following symptoms are present:
1.) unilateral location of a throbbing headache 2.) associated with an
aura 3.) Nausea, vomiting and abdominal pain 4.) Relief following sleep
and 5.) a positive family history.
The cause of migraine headache is unknown but an inherited
predisposition to vasomotor instability appears to be an important
underlying factor. 90% of children has a parent with history of
migraine.
A variety of factors may precipitate migraine. The most common
are dietary and pharmacologic agents. Red wine, chocolates, nuts,
cheeses, preserved foods and some seafood may precipitate
migraine. Hormonal changes like menstruation, allergies to food
and drugs, personality traits characterized with high achievement such
as type A personality, stress, excessive loud sound and bright flashing
lights as in places like disco bars or concerts, are all implicated in
precipitating migraine headaches.
There are two common types of Migraine headache:
1.) Classic Migraine
It is a biphasic event and consists of two phases: In the
initial phase called an AURA, symptoms of visual disturbances are noted
such as blurred vision blind spot, flashing sparkling lights, and even
transitory blindness. The second phase consists of a dull,
throbbing, pulsating or pounding headache. It is unilateral in most
cases and intense in region of eye, forehead and temple.
2.) Common Migraine
This differs from classic migraine in that the symptoms of a
biphasic mode of aura and headache do not occur. The more typical
symptoms are personality changes, body malaise, dizziness and nausea,
besides the visual disturbances.
Recurrent vomiting may be the only manifestation of common migraine in preschool children.
Most migraine headaches are not severe and are readily managed by
conservative measures without requiring medical attention. The
family must be taught on “how to live with migraine:”
1. Avoid activities and foods that are known to trigger migraine attacks when possible.
2. When attacks occur, give in and go to bed.
3. In most cases, acute migraine attacks can be treated conservatively
by placing the child in a quiet room, offering analgesics like
Paracetamol or Ibuprofen and letting the child sleep. Usually
vomiting heralds the end of the attack. Then the child falls into
sleep. Then the headache is resolved upon awakening.
4. Use as little pain medication as possible because repeated dosages may only lead to further gastrointestinal upset.
5. Do not use narcotics and other addictive drugs to treat severe
attacks. Any medication that put the child to sleep will abort
the attack.
Consult your physician if the following occurs:
1. If migraine is not relieved with analgesics, an ergotamine is needed for the acute attack.
2. If migraine occurs more than twice a month, and disturbs the normal
flow of the patient’s daily activities, a prophylaxis is needed.
3. Headache that wakes up the child at sleep or occurs first thing in
the morning, may be a sign of increased intracranial pressure.
4. Headaches due to paranasal infections like sinusitis wherein antibiotics are warranted.
5. Migraine headaches associated with neurological symptoms like
numbness and weakness and seizure may be categorized as complicated.
6. If a previously simple focal headache progressed to a multifocal or
persistent headache with increasing intensity may be a sign of
increasing intracranial pressure, an MRI or CT scan is warranted.
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The common cold otherwise known as acute rhinitis or acute
nasopharyngitis is the most common infectious disease in humans.
On the average, children acquire 6-10 colds in a year whereas adults
experience about 2-4 colds in a year. The reason for this may be
related to the child’s relative lack of resistance to infection and to
the child’s increase contacts with other children in school.
Among 200 different viruses identified to cause the common cold, the
most common is the rhinovirus followed by para-influenza virus and the
respiratory syncytial virus (RSV). The mode of transmission is
mainly through inhalation of droplets from a cough or sneeze and from
direct physical contact with secretions.
Clinical Features:
1. Initial symptoms are nasal irritation and scratchy throat.
Within hours, a thin nasal watery discharge and sneezing are noted.
2. Post-nasal drip and mouth-breathing and nasal stuffiness may be present and may lead to sore throat.
3. Nasal discharge may be initially watery and later becoming purulent on the 2nd-3rd day.
4. Other symptoms include fever, headache, body malaise, cough and watery eyes.
5. Symptoms subside within 5-7 days therefore the disease is
self-limiting. However, a few viruses may cause symptoms that
persist until 10-14 days, although this is rare.
Complications occur if symptoms persist more than 7 days without
improvement with supportive treatment. If this is the case,
consult your physician. The following complications are
considered:
1. Otitis Media- there is an associated earache
2. Sinusitis- there is an associated facial pain with very foul-smelling nasal discharge
3. Tonsillitis- patient complains of difficulty in swallowing
4. & 5. Bronchitis and Pneumonia- associated with productive cough and prolonged fever
6. Asthma- on the other hand, may be triggered because of the colds but it is not a complication
Treatment:
1. Treatment is mainly supportive like bed rest, plenty of fluids and regular balanced diet
2. Nasal drops in children may be given to treat nasal obstruction
3. Aspiration of nasal secretions may be helpful in children
4. Humidification of mucus thru nebulization may promote mucus expulsion
5. Decongestants may relieve symptoms of nasal congestion but
should be used only for a few days to avoid drying the nasal mucosa.
6. Antihistamines may relieve inflammation such as runny nose and watery eyes.
7. Antibiotics have no effect on the virus and is indicated only for the bacterial complications previously mentioned.
Prevention:
1. Frequent hand washing
2. Cover mouth when coughing or sneezing
3. Avoid exposure to persons with cold
4. Avoid going to congested areas or places with many people
5. Avoid psychological and physical stress
6. Maintain a balanced diet and a healthy lifestyle
There is no conclusive data that Vitamin C can prevent colds.
The
prospects for a cold vaccine are remote because of the numerous viruses
causing the common
cold.
THE FEBRILE CHILD
One of the most
common presenting symptoms of children in the outpatient clinic is
fever. It accounts for 10-20% of patients seen at the outpatient clinic.
Normal body
temperature is 37 C orally. A body temperature above 37.8 C measured by
mouth and greater than 38.4 C per rectum and axillary temperature more
than 37.3 C is labelled as fever.
Fever is the
body’s normal response to infections. It occurs when various infectious
and non-infectious processes as well interact with the body’s defense
system. In children, this may be due to bacteria, viruses, fungi, etc.
Most fevers associated with viral illnesses range between 38.3-40 C and
last for 2-3 days.
There are three (3) pathophysiologic causes of fever:
1. The hypothalamic set point is raised due to infection, collagen diseases and
malignancies
2. Heat production is exceeded by heat loss as exemplified by fever in excessive
environmental temperature and in hyperthyroidism
3. There is defective heat loss as seen in heatstroke
Infectious agents contain toxins which are composed of proteins. When these
proteins called pyrogens breakdown, they cause the body temperature to rise, hence
fever. Pyrogens are due to the release of prostaglandins in the
hypothalamus. Hence, elevating temperature setting resulting to heat
generation and conservation.
The following
are important concerns and frequently asked questions on fever in
children:
1. Do all fever need treatment?
Fever causes undue anxiety and concern on parents
and may cause uncomfortable feeling on the child. Therefore, treatment
maybe instituted as follows:
a) Tepid water sponging is preferred over ice water as the latter may cause chilling.
Increase oral fluid intake and avoid overdressing. Alcohol in the sponging water has no advantage and its fumes may be toxic.
b) Use of antipyretics: aspirin or acetaminophen every 4 hours or Ibuprofen every 8 hrs.
Fever causes no harm such as brain damage unless it reaches 41 C and
above. Therefore, avoid temperature reaching greater than 40 C because
damage to brain may result to convulsions or seizures.
2. Is the cause of fever bacterial and therefore warrants antibiotic
treatment? Or is it viral in which case there is no need for specific
treatment?
Some diseases are clearly bacterial and some diseases clearly viral. However, the
dilemma is when there is no clear cut evidence whether the disease is viral or
bacterial. Example is acute tonsillopharyngitis where it is very
important to note because it causes complications such as rheumatic
fever and glomerulonephritis if untreated. Hence, consulting the
physician is very crucial.
3. Is there a way to identify febrile patients who are at high-risk for life-threatening
infections?
When patient is below 3 years old and with high-grade fever and without any focus of
infection, consult physician because these are high-risk patients.
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