Comprehensive Child Care: Need of the Hour!

Dear Dr Vashishtha,

I HAVE NOT GIVEN UP ON THE OTHER ISSUE!

-RN Srivastava, N.Delhi

Editors’ Reply:

Probably, you got it wrong. The cover picture of happy, healthy rural/slum children does not reflect the real picture, which is indeed quite gloomy. But the agencies want us to believe that everything is fine. They try to run away from the reality, which is not so attractive but rather repulsive and ugly VMV.

Hypocritical attitude?

Dear Dr. Vashishtha,

This refers to your Commentary on ‘International Health Agencies: How sincere are they?’ published in June - Sept., 2005 issue of Pediascene. What you have stated as observations are ‘nothing but truth only’.

The incident that you had narrated occurred in first week of September 2004. You have stated: I quote verbatim. "Nowadays, a UNICEF representative is given a VVIP status at most of IAP conferences. Organizing secretaries are willing to bend backwards to show their allegiance. And these officials probably enjoy all the attention, all the praise and a bit of flattery without realizing whether their ultimate purpose is being served."

After reading the Commentary, I searched and retrieved the June 2005 issue of Bulletin of Polio Eradication Committee of Indian Academy of Pediatrics. There was a two-page spread ‘stutigaan’ or biodata of Ms. Ann M. Veneman, Executive Director, UNICEF and Mr. Cecilio Adorna. Both are good persons, good at management, but did they really deserve two pages of the bulletin? You are Co-convenor of Polio Eradication Committee, how would you justify publishing it in June 2005 issue following September 2004 incident?

-Yash Paul, A-D-7, Devi Marg, Bani Park, Jaipur-302016, India

Editors’ Reply:

At times, you are not in control of all the things happening around you. "Pediascene" is the only publication on which I have complete sway. For others, I am not in control. -VMV

How do I treat? -Few queries

Dear Dr. Vashishtha,

I regularly read "Pediascene" for the variety of information it has about the Academy and articles are useful in professional practices. In the issue 2 and 3 volume 8, June and Sept. 2005, I found two issues that need clarification-

A. Form the correspondence between Dr. Parang Mehta and Dr. Agarwal, it appears that there is inadequate information about the value of amoxicillin in pneumonia. This is not true .A multicentric study published from India in April 2004 in British Medical Journal has clearly demonstrated that 3 days as well 5 days oral amoxicillin was effective in non sever pneumonia. Studies presented by us at PEDICON 2004 and published in the abstract book, have clearly shown efficacy of Ampicillin + Gentamicin combination in very severe pneumonia and sequential injectable and oral amoxicillin-clavulanate therapy in severe pneumonia. We routinely use amoxicillin in non-severe and severe pneumonia, and as a switch over from injectable therapy to oral therapy in ‘very severe’ pneumonia.

References-

1-Agarwal G, Awasthi S, Kabra SK, Kaul A, Singhi S, Walter SD. ISCAP study group. British Medical Journal,2004:328:791-93.

2. Singhi S, Pallab Ray, Akash Deep. A Randomized Trial of Ampicillin plus Gentamicin versus Chloramphenicol in very severe community acquired pneumonia. Proceedings of Pedicon 2004; 106-107.

3. Bansal A, Singhi S, Jayashree M, Randomized evaluation in the treatment of severe or very severe community acquired pneumonia. Proceeding of Pedicon 2004; 120- 121.

B. The author of the article on "Bacterial Meningitis", Dr. Puneet Kumar mentions use of hyperventilation to maintain PaCO2 at 25 mm Hg to reduce raised ICP. These days hyperventilation is recommended for short period up to 1 hour and PaCO2 should be maintained in the range of 32- 35 mmHg. Lower PaCO2 can cause marked reduction in cerebral blood flow and poor cerebral perfusion; which is detrimental to neurological outcome.

Use of dexamethasone is debatable in children in developing countries in all the studies from developing countries namely Brazil, Pakistan, Malavi have shown poorer outcome in children who received dexamethasone. If one wishes to use it one must ensure that patient has not received antibiotic preceding the use of dexamethasone; first dose of antibiotic must be given after first dose of dexamethasone.

-Sunit C. Singhi, PGIMER, Chandigarh

Authors’ Reply:

I am grateful to Prof. S. Singhi for his keen interest in my article. His queries gave me the opportunity to clarify these controversies in treatment of bacterial meningitis.

Degree of hyperventilation/ hypocapnia

Hyperventilation is one of the fastest and most efficacious means to reduce raised ICP. However, main concern in using this modality is effect of hyperventilation on reduction of cerebral blood flow, as pointed out by Prof. Singhi. Nevertheless, the degree of hypocapnia which can strike a balance between the two continues to be controversial. While some recommend a lower level of PaCO2 (25-30 mm Hg) [1, 2], others recommend a higher range (>30 mm Hg) [3]. Latest edition of Nelson’s Textbook of Pediatrics also recommends a PaCO2 level of 25 mmHg for treatment of raised ICP [4].

Moreover, most recommendations [3, 5, 6]

permit a lower of PaCO2 for a short time under close monitoring for treatment of acute rise of ICP. This may be followed by maintaining a level in low 30s.

Dexamethasone in Meningitis

Use of corticosteroids is equally controversial. Some studies have shown benefit [7, 8] while others have demonstrated harmful effects of corticosteroids [9]. However, most consistent benefit has been shown in meningitis caused by H. influenzae type b [4]. The dose of corticosteroid must precede antibiotic by 1-2 hour. This has already been clarified in the article. One reason why studies done in developing countries have shown poorer outcome with use of corticosteroids may be that most patients here present late and have already received some antibiotic.

-Puneet Kumar, N. Delhi

References

1.Eliahu S. Feen, Jose I. Suarez. Raised Intracranial Pressure. Current Treatment Options in Neurology 2005 7: 109-117. Available at:

www.treatment-options.com/article.cfm?PubID=NE07-2-1-03&Type=Article&KeyWords=. Accessed on 31st August, 2006.

2. Frank JI. Management of intracranial hypertension. Med Clin North Am 1993, 77:61-76.

3. Nino Stocchetti, Andrew I.R. Maas, Arturo Chieregato, Anton A. van der Plas. Hyperventilation in head injury. Chest. 2005; 127:1812-1827.)

4. Charles G. Prober. Central Nervous System Infections. In: Behrman RE, Kliegman RM, Jenson HB (Eds). Nelson Textbook of Pediatrics, 17th edition 2004: 2043.

5. Suchitra Ranjit. Emergency and Intensive care management of a comatose patient with intracranial hypertension. Indian Pediatrics 2006; 43:409-415.

6. Hodgkinson V, Mahajan RP. Management of raised intracranial Pressure. Available at: www.rcoa.ac.uk/docs/B1_CME_CoreTopic.pdf#search=%22 Hyperventilation%20 Raised%20ICP%22. Accessed on 31st August, 2006.

7. Lebel M, Freij B, et al. Dexamethasone therapy for bacterial meningitis: results of two double-blind, placebo-controlled trials. N Eng J Med,1988; 319: 964-971.

8. Odio C, Faiingezicht I, Paris M, et al. The beneficial effects of early Dexamethasone administration in infants and children with bacterial meningitis. N Eng J Med 1991; 324: 1525-1531.

9. Lebel M, McCracken G, Friedland I. Delayed cerebrospinal fluid sterilization and adverse outcome of bacterial meningitis in infants and children. Pediatrics 1999; 83: 161-167.

Bird flu: Money generating gimmick?

Dear Dr Vashishtha,

I am forwarding a mail from my friend Dr Bhagia, now mostly in USA.  The world is usually guided by WHO in such matters.  Chickens are obviously affected in several countries but the risk to humans seems very small at the moment.  Our own experts seem to be quiet.  - RN Srivastava, New Delhi.

Hello fellow Indians,

First of all, I would like to tell every one that bird flu is nothing but money generating gimmick of certain companies/politicians. So far only 55 people have died of so-called bird flu (7000 died by lighting last year alone) so are we having a lighting epidemic, rubbish? These deaths were due to Respiratory syndrome, but not confirmed for H5N1.
How many people handling birds have died because of diarrhea? Must be more
than 55 in the last few years then we can say we are in a Salmonella epidemic?

Next, who stands to gain by all this? Roche by selling —Tamiflu. Who has the patent for Tamiflu : lesser known company Gilead. Who is the major shareholder of this company? Can any one guess?

Donald H. Rumsfeld was chairman of the Board of Gilead Sciences, where he remained until early 2001 when he became defense secretary in Bush’s Cabinet. The model suggests the parallel to the brazen corruption of Halliburton Corporation who’s former CEO is Vice President Dick Cheney. Cheney’s company has so far gotten billions worth of US construction contracts in Iraq and elsewhere.

Who else stands to benefit? Bush campaign funders, Bilderberger spokesman Etienne F. Davignon and Reagan-Bush former secretary of state George P. Shultz, both of who are also on the board of directors of Gilead.

Another member of the Bush circle is Lodewijk J.R. de Vink, who sits on the board of Hoffman-La Roche, Gilead’s partner.

In other words, bird flu will generate outrageous profits for insiders like Shultz, Rumsfled, Davignon and de Vink.

By the way what is Tamiflu (Generic name: oseltamivir phosphate)?

It’s an extract from "star aniseed" (our very own Garam masala – curry powder)
and each dose is $ 100 so even if 15% of the world has one dose then the total sale will be just $100 billion. Since last year media started this "Tamasha" by highlighting the news from other countries. Our poultry Industry suffered losses due to those rumors during that year and now millions of farmers will loose their jobs and be bankrupt but only a few people will make money. I know it is going to be late and millions are going to loose their livelihood in India. Chicken is being sold at Rs 4/kg in some places. Think of the state of the Farmer and unlike other countries he is not going to be compensated (only farmers in Navapur, Nandurbar are being compensated). So, it is my sincere request to all of you that spread this information to everyone, buy, cook and eat poultry products (chicken and egg) without hesitation and try to save the livelihood of millions of poultry farmers in India. Remember that anything cooked over 70 degrees is safe.- Dr Bhagia, USA

Useful website

Dear Dr. Vashishtha,

The website, Pediascene.com, seems wonderful and very useful. The polls, debates, discussions and the articles are interesting and quite useful. The links also come quite handy.

-Huseyin Caksen, M.D., Editor-in-Chief, Journal of Pediatric Infectious Diseases
Yuzuncu Yil University, Department of Pediatrics, Van, Turkiye

Informative bulletin

Dear Dr Vashishtha,

I am in receipt of Pediascene and I found the journal quite informative. The format is quite readable and overall the journal is indeed excellent. I am particularly impressed with the article of Dr Yash Paul on polio eradication. Keep it up!

-Sanjay Agarwal, Editor-in-Chief, International Journal of Medical Today.

RI should be strengthened

Dear Dr. Vashishtha,

It is really a cause of concern to see that there is emergence of cases of P3 Polio in Moradabad. In fact, all 5 cases of P3 have occurred in Moradabad. This shows that there is lack of routine immunization. So in my opinion routine immunization should be strengthened in that area and pulse polio campaign should include multivalent dose immunization in that area because general public only counts the doses of polio drops; they are not concerned about  the strain of Polio virus.

- Sanjiv Kumar, Aligarh.