A 28 day-old baby with jaundice

A mother exclusively breastfeeds her baby. Her baby has persistent jaundice but otherwise well. The parents are very concerned.The doctor writes the following letter to the baby. The baby name is BB, and the parents are Mr & Mrs AA, for the sake of their privacy.

Dear Ms BB,

Hi, good day!

First and foremost, I would like to tell you that Mr & Mrs AA are very loving and caring parents. You must be the luckiest girl on earth to be their little girl. I believe your 2 year-old elder sister must be totally agree with me.

Just to recapitulate, your highest serum bilirubin level was only 238 umol/L when you are 10 days old. This was normal physiological jaundice. When I saw you this morning, you have grown into a 28 day-old cute little girl. You looked slightly jaundice but otherwise active, well and healthy. For your information, your father had just arrived home from his US business trip that morning. He must be tired after the long travel but for your sake, he brought you to my clinic immediately.

Please be reassured that you are a very healthy baby girl. Your problem of prolonged jaundice is just part of a normal body process. I can confidently say this because you are well, pass normal colour stool and the blood investigation is normal. Your liver function test shows you have unconjugated hyperbilirubinemia. Total bilirubin 197 umol/L, direct 7, indirect 190.

Your mother, Ms A gives you the b(r)e(a)st feed, the most nutritious food on earth. Although this may contribute to your prolonged jaundice but her decision to continue breastfeeding is the best decision.

I can see your parents are very concerned with your prolonged jaundice. Mr A had googled online for information on neonatal jaundice. Nevertheless, not all the online information is reliable. I have attached an articles for your parents to read so as to alleviate their anxiety. I hope this helps.

BREASTFEEDING A NEWBORN WITH JAUNDICE

I am privileged to be your paediatrician.

Thank you.

Yours truly,

Allergy - Where does it start & Where does it end?

I chaired an allergy workshop in G Hotel, Penang on 26 September 2010.

Assoc Prof Dr Amir Hamzah Abdul Latiff from Monash University Malaysia gave a very interesting lecture on "Allergy - Where Does It Start & Where Does It End?".

I found this is a very interesting topic, a question I have never give a deep thought.

Does allergy start before pregnancy, during pregnancy or after delivery?
Does allergy end as a result of prevention, treatment or sadly, death?
Is it true the answer is "from womb to tomb", as shown below?

I will spend more time on this topic -- Allergy.

MMR vaccine and Fever

All babies need to receive MMR vaccine at 12 months old. This is a combination vaccine for Measles, Mumps and Rubella. Normally, the post vaccination fever occurs on the first 2 days after vaccination. However, this particulat vaccine cause fever from day 7 to day 12 after vaccination. Although this only occurs in 5-15% of cases, the parents need to know this statistic so as not to get worry should the fever does occur.

Dengue Outbreak Areas in Penang -- update on 20 September 2010

I attended a dengue seminar organised by Penang State Health Department on last Sunday. There are lectures from public health (vector unit) and infectious disease consultants (adult and children medicine). The participants are doctors from private practice.

I benefited from the lectures and impressed on the heated discussion during the Q & A session. The doctors are really concerned with the dengue outbreak in Penang.

• There are already 4 dengue deaths this year, compared to only 1 last year.
• The dengue vaccine is coming soon (I have heard it from the medical student days!!!)
• The WHO has made the classification easier and more practical to doctors.

Below is the list of dengue outbreak areas in Penang, copy and paste from an email from Penang Sate Health Department:
Dear All
Enclosed is the current dengue outbreak areas

update on dengue outbreak areas, 15 localities

Flat Hamna, Sungai Dua, Timur Laut
Taman Pelangi, Bukit Mertajam, SPT
Kampung Pisang, Air Itam, Timur Laut
Flat Seri Delima, Sungai Ara, Barat Daya
Taman Bukit Jambul, Timur Laut
Taman Utara, Batu Uban, Timur Laut
Tingkat Teluk Kumbar, Bayan Lepas, Barat Daya
Lorong Nipah, Sungai Dua, Timur Laut
Jalan Molek, Taman Brown, Timur Laut
Lengkok Sungai Gelugor, Gelugor, Timur Laut
Desa Airmas, Sungai Dua, Timur Laut
Desa Permai Indah, Sungai Dua, Timur Laut
Lorong Semarak Api, Air Itam, Timur Laut
Sunny Ville, Batu Uban, Timur Laut
Lorong Mahsuri, Bayan Lepas, Barat Daya

Protruded belly button -- Umbilical hernia

You may notice some babies with the following condition, especially in a premature baby or young infant:

picture source

This is called umbilical hernia. It occurs because the two sides of the abdomimal wall muscles are still not adhered completely, thus leaving a space for part of the tummy contents to protrude out (image).

Generally, it does not cause problems and resolved by one year old. Should the condition persisted until school going age, then we hae to do something to avoid teasing in school. This involves a very minor surgey as illustrated below.

There are some myths about this condition, among them are described below:

• This create an entry point for the "wind" to enter -- this is not true as the covered skin is intact, thus leaving no door/ window to enter =)
• This can be resolved by occluding the bellybutton with a 50 cents coin -- this is not necessary as the condition resolved when the underlying muscle layers adhered completely. As the condition usually resolves spontaneously, making this grandmother's ritual appears to work.

Influenza Vaccine -- does my baby need it?

The Influenza A (H1N1) pandemic in 2009 caused great concerns among the caring parents. As the saying goes "prevention is better than cure", we are fortunate to have influenza vaccine to combat this common, and potentially dreadful infection.

The American Academy of Pediatrics (AAP), in response to this development, has updated its recommendation for influenza vaccine.
Recommendations for Prevention and Control of Influenza in Children, 2010-2011

• Children younger than 6 months are too young to receive influenza vaccine.
• Only 1 dose is needed for children at least 9 years old.
• Children younger than 9 years require at least 2 doses of 2009 pandemic H1N1 vaccine. They will need 2 doses of seasonal influenza vaccine this year if they did not receive the H1N1 vaccine during last year's influenza season.
• Children younger than 9 years who have never before received the seasonal influenza vaccine will require 2 doses.
• Children younger than 9 years who received seasonal influenza vaccine before the 2009-2010 influenza season need only 1 dose this year if they received at least 1 dose of the H1N1 vaccine last year, but they need 2 doses this year if they did not receive at least 1 dose of the H1N1 vaccine last year.  
• Children younger than 9 years who received seasonal influenza vaccine for the first time last year, but who only received 1 dose, require 2 doses this year.
• For children younger than 9 years who received influenza vaccine last year, but for whom it cannot be determined whether it was a seasonal influenza vaccine or the H1N1 influenza vaccine, 2 doses are recommended this year.
• For all children who require 2 doses, the second dose should be administered at least 4 weeks after the first dose.

Sounds confusing ? Never mind, bring your baby to the paediatrician and ask further.

 

A 2 year old girl had blood in the stool

A close friend sent me this picture (no consent given by the owner as she is only 2 years old!):

A 2 year-old girl had blood in the stool for the past one day. She passed motion five times already. She had low grade fever of 37.8 degree Celsius. She was otherwise well, active and not in pain.

I told the father if she was less than one year old, I would definitely start antibiotic. This is because there is higher risk of severe disease in this group of small infants. As she is two years old and appeared well, I offered 2 choices:

• Wait and see -- as there is possibility of spontaneous resolution of symptoms
• Antibiotic therapy -- as this can kill the causative bacteria, reduce duration of illness and reduce transmission risks. The following article may be helpful:

"The antibiotics recommended by the WHO—ciprofloxacin, ceftriaxone and pivmecillinam—are effective in reducing the clinical and bacteriological signs and symptoms of dysentery and thus can be expected to decrease diarrhoea mortality attributable to dysentery." (Beatrix S Traa et al. Antibiotics for the treatment of dysentery in children. Int. J. Epidemiol. 39 (1) Pp. i70-i74)

The father preferred to wait and see. I agreed.
P/S I enjoy discussion with the care-takers regarding treatment to the baby. They understand the baby condition, agree on the treatment plan and thus unload their unnecessary anxiety.