Testing times again!!

Original post 19 Jan 2007

[Comments: Dejavu. May 2022]

To say that we are going through a rough patch would be an under statement. There was no smooth patch before…..and there is no sight of any of it in the near future either. It seems that in recent months all we did was manage one crisis after another.

One major illness on top of another has increased our patient population to an extent that is clearly well beyond the current capacity of public health care provision. As one of my colleagues suggested; we are indeed dealing with a “mass casualty”! And as with any mass casualty…..this current situation is taking its toll.

Post-Tsunami-Male’ is bursting at its sides. The congestion is virtually fueling the spread of one epidemic after another. Our public health care system is being tested way beyond its capabilities. It is evident that even at full capacity we would fall well short of the current health care needs.

These are testing times for all of us. The institution is struggling to manage its physical and service infrastructure in the crowded wards and waiting areas, the health care providers are being tested for their physical, mental and emotional endurance and the patients….well their patience, health and well being.

Where we are at now, we probably have never been before. And it is too painful to think of what would happen if things were to get worse than the current “things gone horribly wrong” situation.

Breath-holding spells in children.

Original post on 4 Oct 2007

What is a Breath holding spell?
A breath holding spell is a frightening experience for parents and on-lookers. During the episode the child becomes still, as if lifeless, with no breathing or movement. Traditionally breath holding spells have been divided into 2 main groups. One which is associated with cyanosis (bluish discolouration of the lips, tongue, face…..or even the whole body). These are called cyanotic breath holding spells. The second type is called the Pallid breath holding spell. In this type the child becomes pale and floppy.
In both of these types there is an inciting factor that triggers the event. This may be a painful experience (fall, injury….), a sudden startling or an upsetting event (like scolding in a bigger child).

How does the breath holding spell occur?
As previously said, there is an event that occurs which triggers the attack. In some very small infants this trigger may not be noticed. In most cases this provoking or triggering event causes the child to cry. This sometimes very strong crying is followed by forced exhalation (breathing out) and apnea (cessation of breathing). In Dhivehi language this can best be described with the phrase “romun romun gos hidhun”. There may be some differences to the events than is described here. For instance it is common for the crying to be very brief. There have also been instances where there wasn’t much or any crying.
In some of the cases of breath holding spells the period of cessation of respiration lasts long enough to cause seizure activity like stiffening of the body, jerky movements of limbs and opisthotonus (arching of the back – idhifushah dhemun).

What is the common age when these attacks occur?
Breath holding spells are rare before the age of 6 months. The attacks peak at around 2 years of age and usually disappear by about 5 years of age. It is common for the attacks to occur repeatedly and can sometimes occur several times within a few hours.

Is it something that the child does consciously?
Many experts on these events believe that in older kids the breath holding spell is brought on by the child in an attempt to change their environment and the response from the care-givers in much the same way as temper-tantrums (whether consciously or sub-consciously). With this view many experts believe that in these cases the best approach is behaviour modification by changes in parenting. Interventions such as placing the child safely in bed and refusing to cuddle or carry until recovery is complete has been used successfully.
This approach is not always accepted by parents who are concerned about the events and considers them to be life threatening events. Many parents initiate mouth to mouth breathing and other measures. This is not required in cases where the events are stereotypical and are clearly brought on by the will of the child.
There is some debate regarding the occurrence of the same events in infants less than 6 months. Although it has been documented to occur in this age group, it is much rare and the mechanisms are believed to be different. It is believed to be unlikely that the events are brought on by a conscious effort by the child. The most common observation in this age group is that the child cries very strongly followed by breath holding (which is associated with cyanosis and stiffening or jerky movements of the body). The child would spontaneously recover without any assistance.

Does the event cause damage to the brain?
Brain waves have been monitored in kids who have experienced these events. EEG is invariably normal. Statistically these has been no evidence that there is any increased incidence of epilepsy. There is however an association with behavioral changes in older kids, in whom it is believed that the breath holding spells are the result of behaviour changes and not vice versa.

When should a parent be concerned about apnea?
During a breath holding spell the main concern of the parent is that the cessation of respiration could caused the brain to be damaged because of lack of oxygen. The breath holding episode are usually of a short duration, a few seconds to less than about 1 minute. This may seem a lot longer to a parent or an on-looker witnessing the event. It may be difficult for that person to remain calm and do nothing. However, it has been shown that there is no need to do any thing during this short spell. The best thing that one can do is to place the child safely away from harms way and observe.

Many parents want to know, how long they should wait before doing something to help. If the episode lasts longer than described above, assistance in breathing is usually initiated. There is no convincing evidence whether this is needed or not.

What can be done to help?
Although easier said than done, staying calm is perhaps the best thing one can do. This will enable the person to be more objective. I must emphasize here that there is usually no need to do anything! There will be complete recovery with no long term effects. It helps greatly if one is trained in first aid and basic life support skills.

If there is concern about choking, placing the child over the lap face down and giving a couple of gentle but firm blows to the back between the shoulder blades can help to expel the object causing choking. This maneuver is only helpful if there is choking.

If an object is clearly seen within the mouth it may be removed. However, it is no longer recommended to do a blind finger sweep of the mouth. It could cause more damage.
Gentle physical stimulation may initiate breathing in the child. This can be achieved by flicking the sole of the feet or rubbing the back.

Rescue breaths may be required if the apnea lasts longer. This can be done by placing the helpers mouth over the child’s mouth and nose (if mouth only- then the nose would need to be pinched to close it). It is best if the helper takes a fresh breath just before placing his mouth over the child’s. The helper then blows gently to inflate the Childs’ lungs. this has to be done gently to prevent damage. A couple of breaths may be all that is needed.

When resuscitation is required, the diagnosis of breath holding spells should be questioned. Other causes should be looked for.

More detailed resuscitation should only be attempted if one is trained in life support skills.

What should not be done?
The child should not be shaken! Shaking can cause damage to the brain and the spinal cord. Some people have given chest compressions believing that it helps in re-establishing breathing. Chest compressions (as seen on TV) is used only when the heart beat is slowed or absent. It does not help in breathing. Chest compressions should only be attempted by someone skilled in life support.Water (whether cold or not) should not be splashed on the child.

Consulting the health care provider.
Especially in those cases where the breath holding spell is the first episode, the child is younger than 6 months or when there are other associated problems or events it is important to have the child seen by a health care provider.

What should we expect to see at the end of the event?
With a breath holding spell the child would return to his or her normal self a few minutes after the event passes. There would be no lasting effects on the child. If there is any concern about any physical signs after the event has passed, the child should be taken to the health care provider.

Constipation in Children

Original Post on 5 Oct 2007 (Edited)

Constipation is the passage of stools with a frequency much less than usual or passage of hard and difficult to pass stools. Different children may have different “normal” frequency of passing stools and may range from soft stools passed every 3-5 days to passage of soft formed stools a couple of times a day.

Is constipation an illness?
Constipation is not an illness per-se. It is rather a symptom of an illness or condition.

What are the common causes of constipation in children?
By far the most common cause of constipation is the lack of dietary fiber. Consumption of highly refined and processed food leads to formation of compact and hard stools because of lack of fiber. Fiber when present leads to formation of softer and less compact stools.
Poor toilet training habits are also increasingly responsible for cases of constipation in children. Inadequate toilet training causes infrequent emptying of the bowels which in turn leads to desiccation of the fecal mass in the rectum to form hard stools. On the other hand, overly vigorous toilet training practices may also lead to constipation. Children may resent having to go to the toilet and may forcibly hold their bowels leading to inadequate and infrequent emptying and formation of hard stools.
Less frequently, constipation may be a symptom of an abnormal intestine or hormonal imbalance. These need to be specifically ruled out in very young children with very severe constipation.

Strategies and concepts in the management of constipation:
Softening stools: There are several ways of ensuring softer stools. In mild cases of constipation simple stool softening measures may be highly effective by themselves.

  • Natural stool softeners: Dietary fiber from vegetables and fruits are very useful. The fiber in vegetables gives shape and less compactness to the formed stools which prevents constipation. Certain fruits and fruit juices contain non-absorbable osmotic sugars like Sorbitol. These sugars cause the stool to retain larger volumes of fluids making them softer and easier to pass. Juice of Pears, Prunes and Apple contain significant amounts of Sorbitol and are very helpful while managing constipation.
  • Medical stool softeners: There are several agents available as stool softener and many practitioners have their favorites. Lactulose is one such agent commonly used in Maldives. It is a safe and effective compound.

Cathartics: These are agents that cause forced bowel movements and evacuation. These are generally not recommended in children and may be counter-productive. These should be use only under medical guidance.

Enemas and rectal stools softeners: stool softening and lubricating agents may be given per rectally in cases of severe constipation or when stools are very hard and painful to pass or when there is pre-existing rectal or anal injury from constipation. These are sometimes very helpful but are not recommended for routine use because of their invasive nature. These too must be used only under medical guidance.

Improving toilet habits: regular bowel emptying to prevent retention and desiccation is a helpful strategy in children who have severe constipation. These will however only be successful along with stool softening strategies. One concept involves aggressive stool softening measures for a few weeks followed by gradual toilet training routine. The success depends on the child accepting use of toilet bowls as a safe and pain free way of emptying bowels.

Strategies I commonly use:
Mild constipation: If the problem is of acute onset and very mild I usually prescribe a short (about a week) course of oral stool softener (mostly Lactulose) followed by changes to diet to include fiber-rich vegetables (like green leafy vegetables) and packed fruit juices (mostly apple, pear and prune juice). This is usually very effective and the feedback I have received from parents has been very positive.

Acute severe constipation (Especially when a child has not made a stool for several days and has hard and difficult to pass stools): I mainly concentrate on minimizing discomfort and preventing the acute constipation changing to a chronic one. My strategy involves aggressive stool softening measures for about a week. They mainly include use of multiple daily doses of an oral stool softener (like Lactulose) along with rectal stool softeners (like glycerine suppositories) for the first few days of treatment. I tell parents to insert the suppositories and to leave the child be, not making him go to the toilet. The reason for this is that I want to give time for the glycering to lubricate and also soften the stools before the child is made to pass stools. I do this because I believe that the child should have minimum discomfort when passing the long delayed stool. Once stools are being passed regularly I would cut down on the number of times oral stool softener is used to about once a day (mainly just before bed time) for another week. During this second week of treatment I would ask the parents to concentrate on introducing fiber-rich food and stool softening fruit juices and to ensure toilet training measures are in place.

Chronic severe constipation: In addition to the management discussed for acute severe constipation, I would usually investigate these children for other less common causes of constipation such as intestinal anomalies and hormonal imbalances. The management strategies would also concentrate on effective toilet training practices. It is absolutely essential that toilet training be initiated after stool softening strategies are in place and working effectively. I believe in a slow, gradual introduction of toilet training. I would sometimes begin by asking the parents to get the child to simply sit on the toilet seat while fully clothed. They don’t have to pass stools. This is done to remove “potty-fear”. Once this is achieved I would ask the parents to get the kids to sit on the potty just wearing their nappies or under garments. They don’t have to pass stools. One this is achieved, over the next few days I would ask the parents to get the child to sit on the potty undressed and ready to pass stool. Allow them to pass stool if they would like to, it is not compulsory. However, whether they pass a stool or not I would ask the parents to wash their bottoms before allowing them to leave the toilet. At this point many of the kids would have realized that they need not fear passing stools. Passing the softened stools does not hurt at all. That alleviates their fear of the potty and passing stools.

One very common misconception among parents and some medical personnel is that constipation can be resolved just by getting the child to drink more water. While it may be true that drinking very little water could lead to some hardening of stools drinking extra amounts of water has not been found by research to be an effective strategy in managing constipation. The extra water is absorbed from the gut and passed out in the urine and has little or no effect on stools.

Drug abuse of a different kind!

Original Post on 23 Nov 2007 (Edited)

I have spoken on this issue a few times with my professional friends and colleagues. It is something that causes concern to me and colleagues.

The issue is Drug Abuse! Not the type that we most commonly hear about. This is different but nonetheless deeply worrying and potentially dangerous and in extreme cases potentially life threatening.

I am referring to abuse of non-narcotic prescription drugs. No, not by the person who is using it, but rather by the person who is prescribing it!

Let me take Antibiotics, the group of drugs used to fight off bacterial infections, for the sake of demonstrating my case.

The amount of Antibiotic prescriptions and its use has not been studied in the Maldives, EVER! However, speak to any pharmacist and you’ll hear from them that they sell plenty more of this group of drugs than they would expect. Talk to medical practitioners and you will hear from them that antibiotics are many a time prescribed unnecessarily and irrationally; a situation that amounts to “drug abuse”!

Antibiotics are the most important weapons in modern medicine in fighting off infection when an infection is established. Its use and abuse dictates over a period of time, how effective and useful it would remain in the future in fighting deadly infectious diseases. Antibiotics have no effect on Viruses, hence it has no role in the treatment of exclusive viral infections.

Antibiotics work by inhibiting the replication of bacteria, causing dysfunction in their life cycle and incurring fatal damage to its structure and functioning. These effects result in the death of the bacteria and assist an infected patient in overcoming the illness. Different antibiotics work by different mechanisms, targeting different events in the life cycle of the bug or damaging different structures of the bug that are essential for its own survival. This means that, although classified into a single group, antibiotics among themselves are very different, sometimes even uniquely so. These differences in the way different antibiotics work causes some to be effective against some bugs and virtually useless against some other bugs. The bugs themselves can over time acquire characteristics that make them “immune” to the effect of an antibiotic that previously was able to kill them: development of resistance to antibiotic.

Over years of testing and clinical use, data has been gathered and analysed to get a better understanding of which antibiotics are effective against which kinds of bugs. Armed with this collective knowledge, medical practitioners can prescribe appropriate empirical antibiotics for bacterial infections. With antibiotic resistance increasing, the collective knowledge on BUG vs ANTIBIOTICS, continues to change. Some bugs have over years acquired such effective capabilities of overcoming antibiotic assault that new SUPER BUGS, resistant to a multitude of antibiotics, have now emerged. MRSA: Methicillin Resistant Staphylococcal Aureus has been making headlines all over the world.

The drug abuse in relation to inappropriate and irrational antibiotic prescription is one that worries infectious disease specialists and international authorities and regulatory bodies.

My personal experience is that several patients are prescribed antibiotics for no justifiable medical reason and against collective good practice guidelines based on evidence based medicine. For instance, use of antibiotics – sometimes multiple antibiotics, for treating clinically and laboratory diagnosed viral diarrhea is unjustified and potentially dangerous. This is however a common practice even among some senior doctors.

Reputable and internationally acclaimed journals, organisations and medical associations have come up with guidelines on management of diarrhoealdiseases in children. All of them unanimously agree that routine use of antibiotics for diarrhoea is irrational and potentially harmful. Those who do use antibiotics in ALL cases of diarrhoea claim that they are doing so to ensure that all potential causes of diarrhoea are addressed in treatment; a technique called SHOT GUN THERAPY. {A shot gun fires multiple pellet projectiles in a “spray” ensuring a “hit” even when the gun is not exactly aimed at the target}. Shot gun therapy is irrational, is against good medical practice and reflects poorly on the grasp of medical knowledge by the one who uses it.

Increasing number of antibiotics are heading towards becoming utterly useless and obsolete because of their abuse. In our small community, bacterial resistance to antibiotics is already a huge concern. Microbiology culture reports (blood culture reports, urine culture reports and swab culture reports) are increasingly demonstrating the emergence of multi-resistant potential SUPER BUGS.

Allowing irrational antibiotic use, one that I would call as “drug abuse”, to continue will almost certainly make treatment of life-threatening infections more difficult than they already are. We, like the rest of the world, are heading toward an inevitable SUPER BUG crisis unless we rationalise antibiotic use and stamp out the abuse.

It is my plea to medical practitioners in Maldives, both local and expatriates, to give this some thought, keep themselves up-to-date on medical knowledge and make an effort to minimise their contribution to this growing problem. Let the collective experience of the larger international medical and scientific community ( evidence based medicine: derived from systemic reviews and other high level evidence) guide you, rather than sticking to personal observations and experiences (anecdotal evidence) when they differ. That would be the right choice for you, your patient and the future of medical success.