August 2020 - CHILD AND CHEST HEALTH CARE

WHEN AND HOW TO START BABIES ON SOLID FOODS(WEANING),DR.DEV,M.D.,Pediatrician and Pediatric Pulmonologist,Sahibabad,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 28 Aug, 2020 - Child Health Guides,Medical Guide,Parents’ Guide,Professionals Guide, - 1 Comment

It is very common question and very common mistakes by parents,regarding when and how a solid food is introduced to baby.All babies should exclusively be breast fed right from birth ,preferably starting within 30-60 minutes of birth till the age of 6 months.Some mother says that since the child is born through caesarean section(OPERATION),I have started the baby to feed through bottle with formula milk.This is not the correct reason to start formula feeds.Milk production is very less during initial 3 days of child birth but it is sufficient for the baby and it is highly nutrItious and immunobooster to the child.Milk production begins only when the baby starts sucking.If the baby sucks more ,the milk production will be more,if the child sucks less,the milk production will be less and if the child does not suck,there will be no milk production.

Solid foods should be started at the completion of 6 months of age.It should be noted by parents that the child is able to hold his or her head before starting solid foods.

It can be started with any food available in the house but it should be in purees form.There is sufficient evidence from agriculture based families that they start with any grain available to them like corn,millets,rice,wheat.What they do it that,they make the grain in powder form and mix it with animal milk and feed the baby.We have sufficient evidence from hunter and gatherers family that they start giving meat that is made like purees.

So,it is safe to start with any food items like rice,millets,banana,apple,wheat but it should be in the form of purees.It is a good practice that mother should taste the food before feeding the baby.If mother can propel the food placed over tongue through the roof of mouth towards the back of tongue very easily,it can be given to baby safely.

It should be noted that ,it is the time, just to start the baby on solid foods,not to completely feed the baby with solid foods.The staple food for the baby is still breast milk.So,give the starting food 2-3 times daily and continue one item for 1 week then change to another item.

Some baby may reject the food .In such circumstances,try giving the food with spoon 3 times before stop giving for that session.It has been seen that on third attempt most babies accept the feed.If the baby tries to hold the spoon,let the baby do it,and you can feed them with another spoon.

NOTE:The baby should be seated upright as shown in picture at the outset, and food should not be sticky or lumpy to avoid the chance of chocking.

SPICY AND FLAVOURED FOOD:These food items can be given at this age of weaning the child.Since the child is already exposed to these spices and flavours in food through breast milk or even before birth in the uterus through the blood of mother,the child accepts it and there is no harm to the child.

ALLERGIC FOODS:Allergic food items can safely be started at this age and moreover,introducing allergic foods like egg,peanuts,fishes at this age may lessen the chance of developing allergy later in life.

NOTE:If the elder sibling is allergic to some food item,it is mandatory to get the baby tested for allergy before giving that food.

Food items should be changed every week and all kinds of foods should be introduced by the age of 9 months.It has been observed that by doing so,the child accepts all kinds of food items later in life.

Breast feed should be continued till the age of 2-3 years.It has been observed that the child who continue to breast feed till 2-3 years ,accepts all home made foods easily in comparision to those who continue breast feed for lesser period.

The quantity of solid foods should be increased gradually and by the age of 9 months, some lumpy foods which dissolves easily in mouth or mashed foods should be given to baby.Teeth are not erupted completely at this age but the child learns to manage food items with gums and propel towards back of tongue.By doing so ,the chewing muscles also gain strength.

NOTE;There should not be particles of food in mouth after getting broken in mouth by baby to avoid choking.

Honey should not be given before 1 year of age due to risk of BOTULISM

It is a common practice in India to start weaning with DAL WATER(Pulse water) It is a wrong practice.Start with whole DAL in the form of purees,(any dal)then give khichri after 1 week,then give rice and pulse after 1 week like that.

you can make powder of multiple grains and give one grain mixed with breast milk or animal milk at a time then add another after 1 week and gradually give multiple grains after 4-5 weeks . Fruits and vegetables should be given in the same manner.

REFERENCES:

Abrams EM and Becker AB. 2015. Food introduction and allergy prevention in infants. CMAJ. 187(17):1297-301.

American Academy of Pediatrics. 2017. Starting Solid Foods. Retrieved from https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx (12/28/2018).

American Academy of Pediatrics Committee on Nutrition. 2000. Hypoallergenic infant formulas. Pediatrics. 106(2 Pt 1):346-9.

Cameron SL, Taylor RW, Heath AL. 2015. Development and pilot testing of Baby-Led Introduction to Solids–a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking. BMC Pediatr. 15:99.

Coulthard H, Harris G, Emmett P. 2009. Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age. Matern Child Nutr. 5(1):75-85.

Daniels L, Heath AL, Williams SM, Cameron SL, Fleming EA, Taylor BJ, Wheeler BJ, Gibson RS, Taylor RW. 2015. Baby-Led Introduction to SolidS (BLISS) study: a randomised controlled trial of a baby-led approach to complementary feeding. BMC Pediatr. 15:179.

de Lauzon-Guillain B, Jones L, Oliveira A, Moschonis G, Betoko A, Lopes C, Moreira P, Manios Y, Papadopoulos NG, Emmett P, Charles MA. 2013. The influence of early feeding practices on fruit and vegetable intake among preschool children in 4 European birth cohorts. Am J Clin Nutr. 98(3):804-12.

Dogan E, Yilmaz G, Caylan N, Turgut M, Gokcay G, Oguz MM. 2018. Baby-led complementary feeding: Randomized controlled study. Pediatr Int. 60(12):1073-1080.

Du Toit G, Foong RM, and Lack G. 2016. Prevention of food allergy – Early dietary interventions. Allergol Int. 65(4):370-377.

Forestell CA. 2017. Flavor Perception and Preference Development in Human Infants. Ann Nutr Metab. 70 Suppl 3:17-25.

Forestell CA and Mennella JA. 2007. Early determinants of fruit and vegetable acceptance. Pediatrics 120(6):1247-1254.

Forestell CA and Mennella JA. 2017. The Relationship between Infant Facial Expressions and Food Acceptance. Curr Nutr Rep. 6(2):141-147.

Harris G and Mason S. 2017. Are There Sensitive Periods for Food Acceptance in Infancy? Curr Nutr Rep. 6(2):190-196.

Howcroft R. 2013. Weaned Upon A Time: Studies of the infant diet in prehistory. Stockholm.

Ierodiakonou D, Garcia-Larsen V, Logan A, Groome A, Cunha S, Chivinge J, Robinson Z, Geoghegan N, Jarrold K, Reeves T, Tagiyeva-Milne N, Nurmatov U, Trivella M, Leonardi-Bee J, Boyle RJ. 2016. Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune Disease: A Systematic Review and Meta-analysis. JAMA. 316(11):1181-1192

Liem JJ, Huq S, Kozyrskyj AL, Becker AB. 2008. Should Younger Siblings of Peanut-Allergic Children Be Assessed by an Allergist before Being Fed Peanut? Allergy Asthma Clin Immunol. 4(4):144-9.

Mennella JA, Reiter AR, Daniels LM. 2016. Vegetable and Fruit Acceptance during Infancy: Impact of Ontogeny, Genetics, and Early Experiences. Adv Nutr. 7(1):211S-219S.

Mura Paroche M, Caton SJ, Vereijken CMJL, Weenen H, Houston-Price C. 2017. How Infants and Young Children Learn About Food: A Systematic Review. Front Psychol. 8:1046.

Okubo H, Miyake Y, Sasaki S, Tanaka K, Hirota Y. 2016. Feeding practices in early life and later intake of fruit and vegetables among Japanese toddlers: the Osaka Maternal and Child Health Study. Public Health Nutr. 19(4):650-7.

West C. 2017. Introduction of Complementary Foods to Infants. Ann Nutr Metab. 70 Suppl 2:47-54.

title image of baby touching hands in high chair by lmnop88a / flickr

imagine of baby foods by Frédérique Voisin-Demery / flickr

image of baby making funny face while eating by Fimb /flickr

image of baby turning away from food by Abigail Batchelder /flickr

image of baby grabbing spoon by César Rincón / flickr

Content last modified 1/2019

VACCINATION(IMMUNISATION),IN CHILDREN,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Sahibabad,Ghaziabad,Delhi NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 21 Aug, 2020 - Child Health Guides,Medical Guide,Parents’ Guide, - 0 Comment

Vaccination(Immunisation) is a process in which a modified part of disease producing organism is given into the body, either through mouth or through injections.This modified part is not capable of causing disease but capable of activating the body to produce a substance in the body which kills the disease producing organism which subsequently invades the body.This is called active immunisation.It is done before any organism attacks the body.

When an organism has already attacked the body and body is not capable of fighting it,antibody already available is injected into the body to kill that organism and it is called passive immunisation

Immunisation starts from birth, when no organism has yet attacked the body. When it is not done ,antibody which has come from mother to newborn acts as a killer to any attacking organism,provided it is already present in mother.

SCHEDULE OF VACCINATION:

AT BIRTH(1.);BCG-to protect against Tb(Tuberculosis) is given on left arm and a scar may form at the site after healing of the wound formed 4-6 weeks after the vaccination.Scar persists lifelong.

(2) Hepatitis B first dose is given to protect against hepatitis ,a liver disease.

(3)Oral polio vaccine is given through mouth to protect against polio disease.

AT 6 WEEKS OF AGE:a combination vaccine is given which contains DPT,IPV,Hepatitis B,Hemophilus influenzae b. DPT protects against Diphtheria,Tetanus and Pertussis.IPV is injectable polio vaccine to protect against polio,Hemophilus vaccine protects against a bacterial infections causing pneumonia and meningitis.

At this age Pneumococcal conjugate vaccine can be given to protect against severe form of pneumonia and Rotavirus vaccine can be given orally to protect against severe form of diarrhoea.

AT 10 WEEKS OF AGE: All vaccines given at the age of 6 weeks are repeated.

AT 14 WEEKS OF AGE:All vaccines given at the age of 10 weeks are repeated except Rotavirus if R1 has been used.If R5 has been used for Rota virus protection,then it is also repeated as third dose.

AT 6 MONTHS OF AGE;The first dose of influenza vaccine is given to protect against influenza virus causing severe form of pneumonia in children.

AT THE AGE OF 7 MONTHS;The second dose of influenza vaccine is given which is then repeated every year.

AT 9 MONTHS OF AGE;MMR vaccine is given to protect against viral diseases caused by measles,mumps,and rubella viruses.

At this age Typhoid conjugate vaccine can be given as a single dose to protect against Typhoid fever and Meningococcal conjugate vaccine can be given to protect against meningitis(brain fever) caused by Meningococcus.It is repeated after 3 months,.

AT 1 YEAR OF AGE;Hapatitis A vaccine is given to protect against hepatitis ,liver disease.At this age ,Encephalitis vaccine(JEEV) can be given to protect against Japanese encephalitis ,a lethal disease.This vaccine(JEEV) is repeated after 4 weeks.

AT THE AGE OF 15 MONTHS:MMR vaccine is repeated .At this age, Varicella vaccine is given to protect against chicken pox.The booster dose of Pneumococcal conjugate vaccine is given at this age.

AT THE AGE OF 18 MONTHS:BOOSTER doses of DPT,IPV and Hepatitis A is given.Booster dose of Hemophilus influenza type b is also given at this age.

AT THE AGE OF 2 YEARS; Vi Polysaccaride vaccine may be given to protect against Typhoid to those child who has not received Typhoid conjugate vaccine

AT THE AGE OF 4-6 YEARS;BOOSTER DOSES of DPT,MMR AND VARICELLA are given at this age.

AT THE AGE OF 10 YEARS;TdaP Vaccine is now recommended which acts as a booster for Diphtheria,Tetanus and Pertussis.For girl child ,HPV vaccine is given to protect against cervical cancer and it should be repeated after 1 -2 months and 6 months of first dose.

AT THE AGE 16 YEARS:TdaP vaccine is repeated.

POST EXPOSURE VACCINE;In case of dog bite or bite from any wild or unknown animal ,a vaccine is given to protect against a lethal disease,Rabies.It is 100% lethal disease for which no treatment is available.

Five doses are given on days 0,3,7,14,28.In third degree, bite immunoglobulin is also given as early as possible and not beyond 7 days.

NOTES;a minimum of 4 weeks interval is must between two doses of same vaccine.But, it can be given if one has missed the schedule date.It is safe to be given between 4-8 weeks.

If a child is completely vaccinated, there is no need of repeated Tetanus vaccine after minor injuries.

No vaccine gives 100% protection.

Adverse effects can happen to any vaccine ,most commonly within 30 minutes after vaccination but may occur later on.

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SISUNATOVIR,A PROMISING DRUG TO TREAT SEVERE RSV INFECTIONS INCLUDING BRONCHIOLITIS,Dr.D.K.JHA,M.D.,Pediatric Pulmonologist,Delhi,India

DR DEV KUMAR JHA - 13 Aug, 2020 - Respiratory, - 0 Comment

RSV(Respiratory syncytial virus) is the most common cause of bronchiolitis in children.

Bronchiolitis is usually mild but in infants between 3-6 months,it may become serious and sometimes life threatening.

It usually becomes serious in preterm infants and infants already having cardiac disease with significant shunt,infants having CLD(Chronic lung disease,previously known as BPD) and infants with primary immune deficiency.

There is no specific treatment other than Rivaverin which may or may not work.

So, the mainstay of treatment is only supportive and it has high morbidity and mortality.

In such situations,a new drug Sisunatovir may be life saving for many infants.

In a research ,66 adults were inoculated with RSV,then they were given treatment with this new drug Sisunatovir.It resulted in significant reduction in clinical symptoms with significant reduction in viral load,with no significant adverse effects.The new drug was well tolerated and there was no resistane to this new drug.It was Phase 2a study.

Sisunatovir binds to the surface protein F, of RSV and inhibits its replication.It is a fusion inhibitor which is administered orally.

REFERENCES:ReViral announces FDA Fast Track designation granted to sisunatovir for the treatment of serious respiratory syncytial virus infection. https://www.businesswire.com/news/home/20200804005065/en/ReViral-Announces-FDA-Fast-Track-Designation-Granted. Accessed August 4, 2020

Meaning of ground glass opacity on Chest CT,Dr.D.K.Jha,M.D.,Pediatric Pulmonologist,Delhi,India

DR DEV KUMAR JHA - 07 Aug, 2020 - Respiratory, - 0 Comment

Computed tomography of chest(Chest CT) has become an essential imaging modality to diagnose many chest conditions including some complicated Pneumonia.

As CT chest is time consuming,so children below 3 years should better be sedated for proper examination of chest by CT.

Ground glass opacity (GGO) may be seen in different chest conditions and its location may give some clue to the diagnosis.

In the time of widespread occurance of COVID 19 ,CT chest may be useful to point towards diagnosis when the serological tests are negative.

In COVID 19 Pneumonia typical findings on chest CT is bilateral ground glass opacity located peripherally in the subpleural regions and at lower lobes of lung.Later on there may be crazy pavy changes with architectural damage ,perilobular opacities superimposed upon ground glass lesions.

There may be consolidation in the lower lobes of the lung located in subpleural regions suggestive of COVID19 Pneumonia.

Atypical findings in COVID19Pneumonia may be ground glass opacity on the upper lobes of lung,peribronchovascular regions and,there may be cavitation,lymphadenopathy and pleural thickening.

Ground glass opacities are also seen in other viral pneumonia.It is seen in upto 75%cases of Adenovirus Pneumonia and more than 75%cases of cytomegalovirus(CMV) Pneumonia.It is also seen in approximately 25% cases of Herpes simplex Pneumonia.

It is also seen in Pneumonia due to Pneumocystis carini but in this case it is mainly located on the upper lobes.

GGO may be observed in interstitial lung diseases(ILD) but the pattern of distribution may differentiate it from infective origin.

GGO may be seen in lung injury caused by electronic cigarrette smokes,eosinophilic pneumonia,hypersensitivity Pneumonia,Pulmonary alveolar proteinosis,diffuse alveolar hemorrhage,and pulmonary edema.

Bacterial Pneumonia can be differentiated by the distribution of opacities in the focal ,segmental and lobar regions not predominantly in the lower lobes.Other findings also differentiate it from viral pneumonia, like cavitation,lymphadenopathy and lung abscess

REFERENCES;Cite this: Broad Differential Diagnosis of Chest CT Ground-Glass Opacities – Medscape – Jul 16, 2020.

Ground glass opacity in CT Chest,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Sahibabad,Ghaziabad,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 04 Aug, 2020 - Professionals Guide, - 0 Comment

The most common imaging technique to diagnose a chest contion is Chest X-Ray.

Chest X-Ray has low sensitivity to diagnose a lesion of chest ,particulalry parenchyma of lungs.

CT Chest ,although gives a high dose of radiation which is harmful particularly for a growing lung of child,is sometimes required to diagnose a chest condtion with more accuracy.

There are so many defined opacities seen on CECT or HRCT chest which gives diagnostic clues.

Ground glass opacities are one of them.

In the time of many cases of Pneumonia due to Corona Virus Disease 2019,it has been observed that the typical findings seen on CECT/HRCT Chest is ground glass opacities(GGO) seen in the periphery of lungs at subpleural locations and in the lower lobes of lungs bilaterally. Later on there may be crazy-pavy pattern,architectural distortion and perilobular opacities superimposed on GGO.There may be bilateral subpleural and lower lobe consolidation. .Atypically, a patient of COVID 19 pneumonia may have upper lobe and peribronchovascular distribution of GGO,cavitations ,pleural thickening, and lymphadenopathy.

It is very dificult to differentiate these lesions typical of COVID19,from other viral pneumonia as approximately 75% of Adenovirus pneumonia and more than 75% of cytomegalovirus and Herpes simplex virus Pneumonia have GGO on chest CT.Approximately 25% of Pneumonia due to Human Metapneumovirus has GGO on chest CT.

ILD(Interstitial lung disease) also shows GGO on chest CT.GGO is commonly seen in Pneumocystis carini Pneumonia but in such cases it is predominantly seen on upper lobes.

GGO is commonly seen in eosinophilic pneumonia,pulmonary edema,alveolar hemorrhage,hypersesitivity pneumonitis ,pulmanary alveolar proteinisis and lung injury due to vaping and use of electronic cigarettes.

These may be differentiated by clinical pictures.

Bacterial pneumonia may be differentiated from viral Pneumonia as the opacity has focal lobar,segmental,and sunsegmental distribution usually not predominantly in the lower lobes..It may be further differentiated by the presence of cavity.lung abscess and lymphadenopathy

REFERENCES:https://bit.ly/3exnOFJ Radiology, online July 7, 2020.

Mavrilimubab,may save patients with severe COVID 19 Pneumonia,Dr.Dev,M.D.,Pediatrician and Pediatric Pulmonologist,Sahibabad,Ghaziabad,Delhi-NCR

Pediatrician and Pediatric Pulmonologist Dr.Dev Kumar Jha,Formerly at AIIMS,New Delhi - 03 Aug, 2020 - Professionals Guide, - 0 Comment

It has been observed that the death due to COVID 19 infections is secondary to severe Pneumonia and systemic hyperinflammation.

Severe Pneumonia is a condition of Pneumonia, when support to the respiratory system is needed for its proper functioning.

Respiratory support may be in the form of oxygen inhalation or mechanical ventilation,invasive or non-invasive.

Systemic hyperinflammation is a state in which there is secretion of cytokines in huge amount,called cytokine storm.

These both conditions,severe Pneumonia and hyperinflammatory state carry highn mortality.

MAVRILIMUBAB is Granulocyte-monocyte colony stimulatinfg factor -receptor alpha ,monoclonal antibody with ability to check cytokine storm.

In a study at Italy,which is published in Lancet,authors studied on 39 patients who were non mechanically ventilated.They gave mavrilimubab intravenously to 13 patients in the dose of 6 mg/kg(single dose),in addition to standard care for Pneumonia. 24 patients received standard care for pneumonia and they acted as control.

8% patients in study group, progressed to mechanical ventilation as compared to 35% in control group(p=0.14)

During the follow up period of 28 days,non of the patients died in study group ,whereas 27% patients died in control group(p=0.086).

All patients (100%) showed clinical improvement in study group as compared to 65% in control group(p=0.03).Improvement was earlier in study group as compared to control group(p=0.0001).Fever control was faster in study group as compared to control group(p=0.0093).

Mavrilimubab was well tolerated with no infusion reaction,whereas 12% of control group developed infectious complications.

Study was done between March 15 and April 17,2020

SO,Mavrilimubab may be life saving in severe Pneumonia due to COVID19 and syudy on large sample is needed before its recommendation

REFERENCES;

De Luca G, Cavalli G, Campochiaro C, et al. GM-CSF blockade with mavrilimumab in severe COVID-19 pneumonia and systemic hyperinflammation: a single-centre, prospective cohort study [published online June 16, 2020]. Lancet Rheumatol. doi:10.1016/S2665-9913(20)30170-3

TOPICS: COVID19 LUNG INFECTIONS PNEUMONIA
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