Dengue the killer disease

by Dr. Kolitha SELLAHEWA

Dengue is considered a killer disease and is sought with much fear by the lay public. But in reality the vast majority of patients recover completely. The onus of reducing the morbidity and mortality of dengue remains not only with the attending physician but also with the patient and relations.

I cannot overemphasise the importance of preventing dengue. In the absence of an effective vaccine the most effective preventive strategy would be to curtail disease transmission by eliminating the breeding sites of the carrier mosquito Aedes aegypti and Aedes albopictus.

Keeping one's home and environs free of mosquito breeding sites is the responsibility of every citizen in this country.

It simply boils down to being conscientious in the proper disposal of garbage and disposables all the time everyday and not confined to a dengue day or dengue week.

These are merely good habits to be taught, learnt cultivated and practised on a sustained basis anywhere and at any time. These good practices will not only impact in the reduction of dengue but also other vector borne diseases like malaria and filariasis as well as indirectly rabies by reducing the population of stray dogs who will not have garbage to feed, breed and thrive on.

The State has the responsibility of ensuring the proper collection and disposal of garbage as well as infrastructure development for the proper drainage of water.

The medical officers of health and public health inspectors have their own roles to play with utmost responsibility in the face of the current epidemic of dengue. Political infringements should not deter them from taking punitive action when the laws permit them to do so. On a matter of national importance politicians should not attempt to salvage offenders.

Infection with the dengue virus causes a broad spectrum of clinical disorders ranging from a completely asymptomatic patient to dengue fever, dengue haemorrhagic fever and the rare but more serious and often fatal Dengue Shock Syndrome (DSS). Being a viral infection and not having a specific antiviral drug the disease has to run its own course and heal itself by one's own defences and healing mechanisms. Towards this end the provision of proper nutrition, physical and mental rest, provided at home or in hospital, depending on the case, is of crucial importance. Patients and relations alike must understand that there is no magic overnight cure to send the patient back to work or school in double quick time.

They need to go through this phase patiently and diligently. Employers, teachers and sports coaches must also be fully cognisant of this concept and give adequate time off for those who are sick even if it amounts to missing important meetings, completing projects and presentations as well as attending tuition classes and sports practices.

The patient's life and wellbeing should take precedence over all these mundane issues. Blood tests such as ELISA and PCR are usually not required to manage dengue. It is a clinical diagnosis based on the presence of diffuse blanching erythema in a patient with features of a viral fever such as headache, retro-orbital pain, myalgia and arthralgia. Confirmatory blood tests are requested only when the diagnosis is not clear.

Once a dengue patient is admitted to hospital they should have confidence in the doctor caring for the patient who will do everything in the best interest of the patient.

They should not interfere with clinical management decisions and should also restrain from requesting for blood tests, commenting on reports and demanding saline infusions or comparing with what was done to another patient.

Each patient is unique and interventional decisions are based on an analysis of all the available information and clinical impressions, and not on isolated blood counts.

Such decisions are thus best left to the judgement of the attending physician who will know what is best for that particular patient. Any form of suggestions, interference, and undue anxiety from patients and relations can influence the physician's judgement and lead to unwarranted overtreatment with an attended adverse outcome.

A reduction in the platelet count referred to as thrombocytopaenia causes a lot of anxiety and concern among patients, relations, doctors and nurses alike. Thrombocytopaenia is exceedingly common in dengue and conceivably is associated with severe disease. But what is very important to remember is that it is only one of the markers of disease severity and the majority of patients with thrombocytopaenia do not progress to DSS and merely alerts one to manage such patients carefully over the critical period of 24 to 72 hours after which there is a spontaneous rise in the platelet count. It is exceptional and exceedingly rare for a patient with thrombocytopaenia to receive platelet transfusions even with counts as low as 10,000/ c.mm.

The judicious use of intravenous fluids for selected patients during the critical phase of plasma leakage forms the cornerstone of hospital based management and is designed to prevent progression to DSS.

It utilizes easily determinable bedside clinical parameters to base interventional decisions as well as the ending and optimization of fluid therapy.

All these are feasible in a high dependency area in the ward in any hospital anywhere in this country and not necessarily in intensive care units. Dengue patients presenting early before the stage of DSS need not be admitted to intensive care units for management.

While conceding the importance of sustained efforts in preventing dengue, once infected the patients and relations must learn to cooperate with the attending physician and remember the important role they too have to play to reduce morbidity and mortality due to dengue.

Thumb-sucking:

Don't taste the finger

by Dr. Jyotinder Kaur

Most children suck their thumb or fingers at one time or another. Some even suck their toes, wrists or forearms. But don't worry, young parents - here's help

Many babies have been known to do thumb-sucking while still in utero (in the uterus) which has been seen in antenatal ultrasonography.

Blisters can be seen on the wrists and fingers of newborn babies as a result of intrauterine sucking. Thumb sucking comes naturally to a baby and is not related to any single factor like hunger, emotional insecurity or exploring the body. It is a habit largely observed in the newborn period and at the time of teething. It peaks between 18 and 21 months. Most children gradually give up this habit by the time they reach the age of six, before their permanent teeth appear. The act is also often associated with ear pulling, hair pulling or rubbing the nose with a doll or soft fabric or with sucking the blanket. The thing to remember is that children give up this habit on their own accord.

Breast Feeding

Breast-fed babies have been found not to thumb suck! This is because their need to suck is already met.

The baby suckles as long as it wants - it is the baby that decides when to let go of the nipple. If your baby sucks the thumb, despite your nursing her, maybe you are not giving her enough time.

Allow her to suckle for a longer period of time. Usually a baby gets all the milk she needs by suckling at each breast within five to six minutes, but you may allow this to go on till she herself lets go.

This may satisfy her and make her give up the thumb-sucking habit.

Bottle Feeding

Thumb sucking develops in the average bottle-fed baby when she does not suck at the bottle for more than 10 minutes. If your baby is bottle-fed and is sucking her thumb, check the bottle to see whether the nipple-hole is too big, making her finish the bottle too fast.

Slow down the pace of bottle-feeding; let her take her own sweet time.

And yes, do ensure that the hole is not too small to make it difficult for her to get milk at all. Very often when a baby starts teething, she may suck her thumb, only to relieve the itchy feeling in the gums that is so common during this period. It is easy to tell the difference between this casual sucking and the habit. If it is just casual, you may notice her chewing on it too. Giving her a teething ring may also help. Mothers are obsessed by the idea that if their child continues to suck her thumb, she will have protruding teeth. Although it is a fact that thumb sucking can make the baby's front upper teeth come forward and the lower teeth to retreat, this depends very much on how she sucks her thumb and in which position she holds it. This displacement of teeth may also not be permanent. So as long as she gives up the habit before she is six, there is usually no permanent damage to the teeth.

Hunger Pangs

If the baby is hungry, very often she may suck her thumb. Do not get worried if she does it only for a few minutes before meals. But if she does it even after that and also during meals then it is a sure sign that you need to distract her. This habit may arise because of insecurity or boredom or sleepiness.

You might see it subsiding for a while and returning at the slightest sign of need for some additional comfort, making you feel guilty. Do not worry - if she is occasionally sucking her thumb but is otherwise happy, it is just a habit she will definitely give up.

10 Tips to Help Stop Thumb Sucking

Keep your cool. Getting hassled about it will only transfer your worries on to your baby making her feel even more insecure.

•Do not pull your baby's thumb out of her mouth every time she puts it in. You might just end up making her more obstinate.

•Do not tie bandages, put bitter pastes, paint bad tasting substances or any of these things - these normally backfire.

•Try to distract her attention by offering her a toy, which she has to probably take with both her hands. If not, you just might see the other thumb going in!

•Distract your child when the thumb goes in, by engaging her in an activity that requires using both hands. Clapping works well.

•Try rewarding her if she does not suck.

•Encourage her to give up the habit in a friendly way.

•Use peer pressure as a powerful motivator: invite your child's friends over who don't suck their thumbs.

•Make the child aware of this habit (without shaming or ridiculing), by having her look in the mirror when she is at it.

•Provide a substitute comfort activity and very importantly, refrain from lecturing or shaming.

Courtesy: B positive

Could acupuncture be used to treat 'lazy eye'?

Sticking acupuncture needles into points on the body classically associated with vision in Chinese medicine could prove to be an alternative to bothersome patches or drops for older children with a "lazy eye," suggests new research.

Children who received needling from a certified acupuncturist saw similar improvement in their affected eyes as those who underwent the standard treatment of wearing a patch over the strong eye for a couple hours a day in order to strengthen the weak eye: Most participants in both groups advanced two lines or more on an eye chart over the course of the study.

Experts don't recommend that parents swap out patches for acupuncture treatments just yet, however. Further research is needed to confirm the findings and to better understand just how the therapy works.

"Acupuncture has been used for a lot of things in Chinese medicine," senior researcher of the New York Eye and Ear Infirmary, Dr. Robert Ritch told Reuters. "And it's being used more and more in the West. But evidence-based medicine to see what it actually does is relatively lacking." Up to 5 percent of people around the world suffer from amblyopia, a condition characterized by poor vision in one eye and colloquially called lazy eye. It is the most common cause of vision problems in children.

Between 30 and 50 percent of amblyopia cases are caused by differences in the degree of nearsightedness or farsightedness between the two eyes, termed anisometropic amblyopia.

The problem can be corrected with glasses or contact lenses if caught at an early age. But both are less effective for children beyond about the age of 7, who have traditionally been treated with patches.

"Patching can be annoying for kids," Dr. Matthew Gearinger of the University of Rochester, New York, who was not involved in the study, told Reuters. "It may be socially tough to wear a patch at school, and wearing a patch at home can interfere with homework." Specially medicated eye drops, another common treatment, blur sight in the good eye and can also make homework difficult, added Gearinger.

In the new study, Ritch and Chinese colleagues looked at 88 children in China between the ages of 7 and 12 who suffered from lazy eye and had already been wearing glasses for at least 16 weeks. They randomly assigned about half the children to wear a patch over the good eye for two hours every day, and the other half to attend five acupuncture sessions weekly; both groups underwent their respective treatments for up to 25 weeks.

All the children were also given new glasses to wear and asked to perform an hour of daily near-vision activities.

By the end of the 25 weeks, the researchers found that at least 7 out of 10 children in each group saw their lazy eye's sight improve by at least two lines on an eye chart - from 20/40 to 20/25, for example.

More than twice as many children who received acupuncture overcame the condition compared to those who wore an eye patch: 42 percent versus 17 percent.

While Gearinger suggests that the concept is interesting and the potential for an alternate treatment for lazy eye encouraging, he cautions that the number of children studied was small. He also noted that the treatment option may be impractical in the U.S., where there are few acupuncturists with experience treating lazy eye.

Even if they were available, "it is a lot to ask parents to drive to a local acupuncturist 5 days a week, rather than just using drops or a patch at home," he said.

Dr. Peter Lipson, of the University of Michigan, also pointed to some limitations of the study, including the fact that "everyone knew who was patched and who got acupuncture," which could have biased the outcomes.

Lipson, who was not involved in the work, further suggested that without an untreated group the study can't rule out the possibility that not doing anything, or simply using corrective glasses and performing daily exercises, would work just as well.

"This is not, in my opinion, evidence toward acupuncture being as good as standard care, only that in this particular study children did about the same if they received standard care or non-standard care," Lipson told Reuters. "It says nothing at all about acupuncture." The researchers speculate in the Archives of Ophthalmology that acupuncture needles placed at vision-related points on the body might work by increasing the blood flow to both the eye and brain. But they acknowledge that what lies behind acupuncture's apparent success remains unclear.

Ritch and his team are following up with more studies to improve the understanding of how acupuncture may be helpful for lazy eye. "Don't knock Chinese medicine," said Ritch. "It's been around for more than 3,000 years and there's a lot we don't understand yet."

- Reuters