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Eczema

Eczema

By: Dr Ameneh Khatami

Eczema is a common condition that causes itching, dryness and inflammation of the skin. It is more common in childhood and often starts in the first few months of life. The underlying problem is dryness, which causes the skin to itch. Scratching leads to inflammation of the skin and if the skin is broken, it can also become infected.

Treatment

Moisturisers

The key to controlling eczema is to keep the skin moisturised. Emollients and creams should be used regularly (at least twice daily), particularly after baths when the skin is most prone to drying. Oils can be added to the bath water, or running the tap through oats will help to moisturise the skin while bathing. Soap can dry the skin, so soap substitutes should be used in the bath and to wash hair. Irritants should be avoided, in particular caustic cleaning products and perfumes/fragrances in moisturisers or soaps.

Dryness of the skin causes the skin to feel itchy, and scratching the skin causes it to become inflamed.

Topical Steroids

If the skin can be kept well moisturised at all times, further complications are less likely. If however the skin becomes inflamed at any point, then topical steroids may need to be used. Regular moisturisers should be continued on all dry areas of skin and topical steroids used only on the inflamed areas. The most common steroid used is hydrocortisone and mild versions of this can be used on the face. Stronger topical steroids should not be used on the face. These are used twice a day, and applied thinly to the inflamed areas of skin. All topical steroids should only be used as prescribed by a doctor, and should not be used continuously (ie should have some “steroid free days”).

Topical Antibiotics or Antifungals

Occasionally, areas of skin that have broken from scratching and dryness can become infected with bacteria or fungi. If the infection is mild, this can be treated with a topical antibiotic or antifungal which should be prescribed by a doctor. Mixtures of antibiotic plus topical steroid, or antifungal plus topical steroid can be used, but these should be reserved for when there is evidence of infection. If there is only inflammation, just the topical steroid should be used to prevent breeding antibiotic resistant organisms.

It is important to prevent infections because this can trigger more inflammation of the skin.

Oral or Intravenous Antibiotics

Very occasionally, infected eczema can cause a larger area of skin infection, or a deeper infection under the skin, or in younger children a bloodstream infection. In such cases, oral or intravenous antibiotics may need to be used in hospital, or under guidance of a doctor.

Other treatments

In very young children, to prevent scratching at times when there is very inflamed skin, gloves can be used to cover the hands. Anti-histamines that cause drowsiness can also be used and may help the itch, but generally just help the child to sleep if the skin is very irritated. It is also important to always keep nails trimmed short and clean to prevent infections being introduced to skin through scratching.

For a small number of people, certain foods that they eat can make their eczema worse. Usually this occurs several hours or days after eating the food (it is not an immediate “allergic” reaction), but if a pattern becomes clear, then avoiding those food items can help to prevent flare-ups of eczema.

Long-Term

For most people, eczema improves with age. For those with severe eczema, repeated episodes of skin inflammation causes the skin to become thickened and scarred. Regular moisturising and prompt treatment of inflammation and infections can help to prevent scarring.

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Healthy Diet

Healthy Diet

By: Dr Ameneh Khatami

A healthy diet is an important aspect of keeping healthy, and this starts from birth.

Newborn – 3 months

For a newborn infant, breastmilk is the ideal form of nutrition. If breastmilk is not available, or it is not sufficient, then infant formulas should be used. In the first 3 months of life, additional water, juice or other fluids should not normally be necessary and should not be given to the infant unless directed to by a doctor. As the infant grows, the best indication of adequate nutrition is weight gain and growth charts should be used to monitor this.

Infant (until 1 year of age)

As the infant grows, weaning needs to be considered. The usual time of weaning is around 6 months, however some babies may show signs of being ready for introduction of solids from around 5 months of age (for example new night waking for a feed can mean that the child needs more food for their evening feed). It is also important not to delay weaning to long after 6 months because the infant can become more difficult to wean and sensitive to the introduction of some solids. When weaning an infant, it is important to introduce a variety or tastes and textures to allow the child to become accustomed to these.

In the first year of life, breastfeeding should be continued if possible, or formula milk should be used. Cow’s milk should not be used because this is very low in iron and other nutrients that the infant needs. Sweet foods and drinks should be avoided and if juices are given, these should be diluted to 1/5th strength. Nuts and seafood should be avoided in the first year of life because there is a greater chance of allergic reactions.

Toddler – Preschooler

In this age, the child can become picky and their diet can be determined on what they will eat rather than what they should eat! It is important to be firm but flexible when faced with a young child who refuses to eat certain foods. Basic principles are:

1)    Avoid processed foods as much as possible. Encourage a diet that consists mainly of foods prepared at home from basic ingredients.

2)    Encourage a range of foods with different tastes, smells and textures from a young age. This will help to prevent the child becoming very picky. If however, a child does not like a certain food, replace it with something similar (for example, if they don’t like cheese, offer yoghurt).

3)    Avoid food items that are harmful. These include caffeinated drinks (for example tea and coca cola), and very sweet foods. These should not be made available to the child. If they don’t see it, they can’t want it.

4)    Fat is not bad for a young child. For most children who are not overweight skim milk and low fat food options should not be used. However, foods that are high in fat should still only be given in moderation (for example chocolate, chips etc). 

5)    Allow flexible eating times. In this age, children will often eat small portions several times a day rather than large meals. Shared meal-times with the family should still be encouraged, but do not worry if a full meal is not eaten. Children will absorb a considerable portion of their calories in the day from smaller items that they eat as “snacks”. If you are worried about the volumes of food your child is consuming, keep a food diary for one week, noting down meal-time foods and snack foods eaten, as well as monitoring your child’s weight gain on a growth chart over several months.

6)    Avoid excessive fluid intake besides water. Excessive consumption of juice or milk will prevent intake of other foods. Cow’s milk can be introduced from 12 months of age; however a toddler milk formula can still be used until 2 years of age. Toddler formulas have more iron and nutrients; however they are usually quite expensive.

These principles can be maintained as children grow, teaching them to follow a healthy diet themselves. The key is to monitor development of milestones and growth on a standard growth chart. Speak to your family doctor if you are concerned about your child’s growth or development at any point.

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Passive Smoking (Second-Hand Smoke Exposure)

Passive Smoking (Second-Hand Smoke Exposure)

By: Dr. Ameneh Khatami

Environmental tobacco smoke, or second-hand smoke, can be a direct cause of lung disease in adults and children. It is responsible for significant mortality in adults (for example from lung cancer). It also causes significant damage to the lungs of adult non-smokers, including reduced lung function and exercise tolerance, increased sputum production and cough, and chest discomfort and shortness of breath.

In children, second-hand smoke exposure is associated with an increased risk of lower respiratory tract infections, such bronchiolitis and pneumonia, as well as upper respiratory tract infections (“colds”) and ear infections. Children of smoking parents are much more likely to be hospitalised with chest infections, and to experience recurrent episodes of wheeze. Recurrent ear infections also increase the risk of chronic middle ear fluid (“glue ear”) and hearing impairment. This can subsequently result in poor learning in school. Second-hand smoke exposure also results in reduced lung function and increased risk of developing asthma. In children with asthma, exposure to tobacco smoke increases the severity and frequency of asthma symptoms.

In addition to the effects on the respiratory tract, second-hand smoke exposure increases the risk of many other infections including meningococcal meningitis and gastro-enteritis (diarrheal illnesses). Long term effects of smoke exposure during childhood include ongoing lung disease (such as asthma), as well as an increased risk of taking up smoking in adolescence or adulthood.

It should also not be forgotten that smoke exposure can start prior to birth, and the negative effects are also evident prior to birth. The most common complications related to smoking during pregnancy are prematurity and poor growth. Infants that are born prematurely or small for their gestational age are at increased risk of infections and other complications in the neonatal period, as well as increased risk of asthma and lung disease in later childhood.

Risk Factors

The effects of childhood second-hand smoke exposure are generally more significant if it is the mother who smokes, presumably due to closer physical contact between mothers and children. The harmful effects are also more significant at a younger age, again possibly due to increased close contact with parents, which reduces over time, as well as the immaturity of the lungs and immune system in infancy and early childhood.

The severity of these effects is directly related to the degree of smoke exposure. For example, parents who smoke have a greater effect than grandparents or other distant relatives. Also, smoking within the house and car has a greater effect than smoking outside, especially in small, crowded homes. 

Management

Treatment of smoking related diseases in children (for example recurrent chest infections, ear infections, asthma and other wheezy illnesses) relies on eliminating the exposure to smoke. In the first instance, the exposure can be reduced by avoiding smoking in the house or car. This must be avoided at all times, not just when children are around, as the smoke lingers in carpets and upholstery.  For families with very young children who are in close frequent contact with smoking parents, it may also be useful to use a “smoking jacket”, to be worn when smoking outside, and removed before coming back into the house, to reduce the amount of smoke that attaches onto clothes.

However, optimal management is complete smoking cessation of all adults in contact with children. There are many different smoking cessation programmes, some of which can utilise nicotine replacement therapy (for example nicotine patches, gum or inhalation devices). Other counselling and behavioural programmes also exist and advice can be sought from family doctors on the most appropriate programme for each individual. Ideally, smoking cessation should be initiated prior to pregnancy, as smoking in pregnancy can lead to several risks for the mother and child.

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Diarrhea (Gastro-enteritis)

Diarrhea (Gastro-enteritis)

By: Dr. Ameneh Khatami

Rotavirus

The great majority of diarrheal illnesses (gastro-enteritis) are due to viral infections (>80%). Some of the most common viruses include Rotavirus, Adenovirus and Norovirus. Rotavirus is the most common cause of diarrhea in children and by the age of 5 years, almost all children will experience at least one episode of rotavirus infection.

Occasionally bacterial infections can occur, but in developed countries these are rare and generally occur in relation to in-adequate hygiene during food preparation. Common bacterial pathogens associated with food-borne outbreaks of diarrhea include Salmonella, Clostridium, Campylobacter and E. Coli. Other sources of bacterial and parasitic infections (for example Giardia) are exposure to animals (including domestic farm animals) and untreated water (including swimming in rivers and lakes).

Clinical Features

Diarrheal illnesses vary in severity and symptoms depending on the infecting organism, age of the patient and several other host and environmental factors. The most common symptoms reported during diarrheal illnesses are nausea and vomiting, anorexia (lack of desire to eat), fever and abdominal pain. Many other symptoms are possible and can include rash, lethargy, rectal bleeding, headache and swollen joints. Symptoms such as vomiting and fever often resolve much more rapidly than the diarrhea itself, which can continue for 1-2 weeks. Although repeat infections are possible with the same infecting agent (for example rotavirus), the illness is usually most severe during the first episode.

Younger children, infants and the elderly are more likely to experience severe disease, as are those with other underlying medical conditions. In these groups there is an increased risk of dehydration, and other complications. Increased loss of water in stool and reduced intake due to vomiting and anorexia can result in rapid dehydration, particularly in young infants. In these vulnerable groups, severe disease can also occur with the patient becoming unwell with a high fever and rapid spread of the infecting organism via the bloodstream to multiple organs outside of the gastro-intestinal system. However, for the great majority of diarrheal episodes, the illness is mild and self-limiting and no specific treatment is required.

Management

For most diarrheal illnesses no specific treatment is required. Antibiotics are rarely used as most of the pathogens involved are viruses. Even in proven cases of bacterial or parasitic infections anti-microbial treatment is often not indicated. Cases that may require treatment are those that are very severe, or occasionally in cases of prolonged illness.

The most important therapy during diarrheal illness is fluid management. If there is dehydration, this needs to be corrected, as well as maintenance of ongoing hydration needs in the context of increased fluid loss. This means that enough fluid should be taken in, to make up for losses in diarrhea and vomits. This can be particularly challenging in young children and infants. In most people, including young children, frequent small volumes of fluid will optimise intake and reduce the risk of vomiting.

If an infant is breastfed, breastfeeding should continue. For formula fed infants and older children and adults, any fluid that is tolerated should be encouraged. Plain water should be not be the sole form of fluid intake as this will not include all of the salts that are lost in the stool. Oral rehydration solutions/sachets can be purchased with or without a prescription that are the optimal form of fluid intake (with the exception of infants that can be breastfed). The taste of these can be mildly unpleasant and may require flavouring with fruit drinks, however, very sweet drinks (including fizzy drinks, fruit juices and cordials) should be avoided because the sugar in these will increase diarrhea by drawing more fluid into the gut. If sweet drinks are being consumed, these should be diluted.

The great majority of cases can be managed at home with close attention to fluid intake. The best indicator of hydration is urine output, although this can be difficult to judge in young infants with watery diarrhea. If urine output falls to less than half of usual, this may be a sign of dehydration and the child should be assessed by a doctor. Weight loss is common during the illness and is not worrying if hydration is maintained because in the setting of most developed countries, the majority of children are not malnourished and therefore have adequate reserves to deal with a short period of reduced nutritional intake.

If there is any concern about maintaining hydration (for example frequent vomiting or very profuse watery diarrhea) or any sign of dehydration (reduced urine output, dry lips, reduced tears, sleepiness/tiredness), then advice from a doctor should be sought urgently.

Prevention

Diarrheal illnesses are highly contagious and will often spread through family members, or through classrooms and hospitals. Strict attention to hand hygiene is very important and is the key method of preventing spread. Other preventive measures include avoiding drinking untreated water, and maintaining good hand hygiene after exposure to animals.

In many developing countries, diarrheal illnesses are endemic, and more often caused by bacterial pathogens. Travellers to developing countries can develop “traveller’s diarrhea”, and although most cases are mild and self-limiting and do not require treatment, prevention is possible. When travelling through such countries, it is a good idea to avoid street food and to only drink bottled water, or water that has been boiled. Specific advice can also be sought prior to travel from a travel health advisor or family doctor.

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Iron Deficiency

Iron Deficiency

Dr. Ameneh Khatami

Iron deficiency is the most common nutritional deficiency in the world. It has widespread effects on the individual and the community as a whole due to reduced growth and learning in children, as well as fatigue and reduced physical ability in adults.

Causes

The most common cause of iron deficiency is reduced iron intake in the diet. This is particularly common in vegetarian individuals and in young children. Iron deficiency can also occur due to blood loss, in the form of sudden haemorrhage (very uncommon) or slow chronic loss, for example in the stool. In women, heavy periods (menorrhagia), particularly in young girls, can also result in iron deficiency.

In breastfed infants, iron deficiency in the mother can result in iron deficiency in the infant due to reduced iron supply in the breastmilk. Furthermore, prolonged exclusive breastfeeding (beyond 6 months of age) can result in iron deficiency because there is insufficient iron in breastmilk to sustain the growing infant beyond this time. In toddlers who have started cow’s milk, excessive milk drinking (and thus, reduced consumption of other foods) can result in iron deficiency because there is very little iron in cow’s milk.

Chronic diseases (such as cancer, arthritis, inflammatory bowel disease etc) can reduce the body’s ability to bind iron. Rarely, problems with the bowel can cause an inability to absorb iron from food.

Whenever iron deficiency is discovered, the cause should be determined. As most cases are due to inadequate dietary intake, the treatment is relatively easy; however, other causes that may require different treatments should be excluded. Furthermore, if iron deficiency is noted, other nutritional deficiencies should also be excluded (for example folate deficiency).

Diagnosis

Iron deficiency can be tested for on a blood test. This can determine the degree of iron deficiency, but not the cause of it.

Complications

The most obvious effect of iron deficiency is anaemia. This occurs when there is insufficient iron for haemoglobin production. Haemoglobin is required to carry oxygen in red blood cells, thus iron deficiency anaemia results in reduced exercise tolerance, shortness of breath and tiredness. Severe iron deficiency anaemia can reduce the oxygen supplied to the heart, and in individuals with pre-existing heart disease this can cause angina or even a heart attack.

In children, iron deficiency can result in poor growth and impaired learning ability. There is also an increased risk of common childhood infections due to negative effects of iron deficiency on the immune system.

Other symptoms of iron deficiency include leg cramps and ice-chewing.

Prevention

Iron deficiency can be prevented through adequate dietary iron intake. The best source of iron is red meat. Leafy green vegetables contain a form of iron which is not readily absorbed by humans, thus cannot be relied upon to avoid iron deficiency.

To encourage iron absorption, fresh fruit or fruit juices can be consumed at the same time as red meat, as vitamin C increases iron absorption. In addition, milk (or dairy products) should be consumed at a different time to red meat as calcium reduces iron absorption.

Iron deficiency in breastfed infants can be prevented by ensure that the mother is not iron deficient, and treating her if she is found to be iron deficient. Furthermore, exclusive breastfeeding beyond 6 months of age should be avoided, and cow’s milk should not be used in children younger than 12 months of age.

Infants who are born very prematurely, are at increased risk of iron deficiency and as such, a small dose of iron supplement may be used as prophylaxis for the first few months of life. 

Treatment

If iron deficiency is diagnosed, treatment is usually by supplementation. In cases of mild deficiency, dietary changes (eating more red meat) may be sufficient. However, if there is significant anaemia, iron capsules or syrups may be used. These are very effective, however they can cause the stool to look black, and can also result in constipation.

If the cause of iron deficiency is blood loss, this will also need to be addressed. Blood loss in the stool requires several specific investigations and treatment depending on the exact cause of bleeding. For women with heavy periods, these can be managed by hormone treatments that can reduce the severity of blood loss.

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Copyright © Fatima Zahra Charitable Association. All rights reserved.