Saturday, August 17, 2019

Breast feeding in special cases

Hello Awesomites!

-HIV positive mother
-Active Pulmonary TB
-Working mothers



CONTRAINDICATION OF BREASTFEEDING :

  • HIV, HTLV-1 and 2
  • Inborn error of metabolism LIKE GALACTOSEMIA AND PHENYLKETONURIA
  • Untreated case of tuberculosis
  • Herpes lesion on mothers’ breast
  • Mother on certain medication like anti-cancer drug or radioactive isotope etc.
WITH INCREASED BURDEN OF HIV AND TB,INDIA CAN’T AFFORD TO  CONTRAINDICATE THE BREASTFEEDING.


  1. IS THERE ANY RELATION BETWEEN BREASTFEEDING AND RISK OF TRANSMISSION?
  2. DO ART HAS ANY ROLE TO DECREASE THE TRANSMISSION?


ARV INTERVENTION
RISK OF HIV TRANSMISSION FROM MOTHER TO CHILD
NO ARV                 BREASTFEEDING +
30-45%
NO ARV                 BREASTFEEDING -
20-25%
3ARVS(ART)         BREASTFEEDING +
2%
3ARVS(ART)         BREASTFEEDING -
1%

HOW TO KNOW THE HIV STATUS OF CHILDREN LESS THAN 18 MONTHS?

 
METHOD USED - DNA PCR on a DRIED BLOOD SAMPLES OF INFANT
TEST PERFORMED -

  • 6 WEEKS
  • 6 MONTHS
  • 6 WEEKS AFTER CESSATION OF BREAST FEEDING (if being EBF)
  • 18 MONTHS

PEDIATRIC COMPONENT IN PPTCT


  • DURATION OF NEVIRAPINE PROPHYLAXIS TO HIV EXPOSED INFANT SHOULD BE MINIMUM OF 6 WEEKS.


  • INITIATION OF BREAST FEEDING WITHIN AN HOUR OF DELIVERY AS THE PREFERED OPTION


  • CONTINUE BF ATLEAST FOR 1 YEAR FOR THOSE WITH HIV -VE STATUS  AND 2 YEARS FOR HIV +STATUS OF CHILDREN


  • ENSURE INITIATION OF CO TRIMOXAZOLE PROPHYLACTIC THERAPY AT 6 WEEK OF AGE



MATERNAL COMPONENT IN PPTCT
“ART TO ALL PREGNANT AND BREASTFEEDING WOMEN LIVING WITH HIV “

TARGET POPULATION
ART REGIMEN
PREGNANT AND BREAST FEEDING WOMEN WITH HIV 
BUT NOT ON ART
TDF+3TC+EFV
PREGNANT WOMEN AND BREAST FEEDING WOMEN WITH HIV AND RECIEVING ART
THE SAME ART REGIMEN MUST BE CONTINUED 
  
AFASS
 

AFASS CRIETRIA is used to decide whether a HIV positive mother can breast feed or not provided that she has not started top feed yet.
(Why? Once the mother started to top feed the child, this criteria is not used. HIV positive mother in such case should continue top feed. Because mixed kind of feed is more dangerous than top feed alone)

  • Acceptable: The mother perceives no problem in replacement feeding.
  • Feasible: The mother (or family) has adequate time, knowledge, skills, resources and support to correctly mix formula or milk and feed the infant up to 12 times in 24 hours.
  • Affordable: The mother and family, with community or health system support if necessary, can pay the cost of replacement feeding without harming the health or nutrition status of the family.
  • Sustainable: Availability of a continuous supply of all ingredients needed for safe replacement feeding for up to one year of age or longer.
  • Safe: Replacement foods are correctly and hygienically prepared and stored, and fed preferably by cup.


QUESTIONS

  1. Where do you get your drinking water?
  2.  What kind of latrine/toilet do you have?
  3.  How much money could you afford for formula each month?
    Ps: calculate the amount based on the local costs
     
  4. Do you have a refrigerator with reliable power?
     
  5. Can you prepare each feed with boiled water and clean utensils?
     
  6. How would you arrange night feeds?
     
  7. Does your family know that you are HIV positive?
     
  8. Is your family supportive of milk feeding and are they willing to help

MANAGEMENT OF BABY BORN TO MOTHER WITH TUBERCULOSIS:-


  • Continue exclusive breastfeeding till 6 months of age & thereafter as in normal population.
  • Start ATT for mother immediately. Mother will be non infective within 2 months of regular ATT


  • Preventive Chemotherapy for baby (INH 5 mg/kg/day for 6 months)


  • Use face mask while around the baby, till 2 months after starting ATT.


  • BCG Vaccine at birth.Something is better than Nothing!


  • Re- immunized with BCG after stopping Preventive Chemotherapy. 
  • (Remember, it's not only mother, Anybody (with TB) around can infect the baby with Tuberculosis!)

Is ATT drug concentration in breast milk sufficient for the baby? NO

NAME OF THE GROUP
BREAST FEEDING
BARRIER METHOD
ISOLATION
BCG VACCINATION
IAP
TO CONTINUE
COUGH HYGIENE
1.IF MOTHER ON TREATMENT -NOT REQUIRED


2.IF MOTHER HOSPITALIZED, NON-ADHERENT TO THERAPY,MDR-TB - ISOLATION REQUIRED
AT BIRTH 
OR 


EVEN WITH INH PROPHYLAXIS
DOTS
ONLY IF MOTHER IS SPUTUM NEGATIVE
FACE MASK
IF MOTHER HAS ACTIVE DISEASE,NON-COMPLIANT AND HAS RECIEVED ATT PRIOR TO DDELIVERY 
POSTPONED
OR DONE
WITH INH RESISTANT OF BCG VACCINE 
AAP
ONLY IF MOTHER IS ON ATT
FACE MASK
MDR -TB AND NON COMPLIANT
GIVE BCG IN THESE MDR TB MOTHER
WHO
TO CONTINUE
FACE MASK
MDR -TB
INH THERAPY COMPLETED THEN AFTER 2 WEEK  OF COMPLETION BCG VACCINE GIVEN 
 THE DOUBT OF WORKING MOTHERS :-

For How long can expressed breast milk is stored? 


AT ROOM TEMPERATURE 
8-10 HOURS
IN A REFRIGERATOR
24 HOURS
IN A DEEP FREEZER (-20 degree)
3 MONTHS

HAPPY STUDYING ! 
-UPASANA Y.

Friday, August 16, 2019

Lamotrigine: A depression mood stabilizer

Lamotrigine is used primarily as an anticonvulsant for the treatment of generalized and partial seizures and is effective for treating focal epilepsies in the presence or absence of secondary generalization.

Friday, August 9, 2019

Photophobia vs blepharospasm

Both have the same presentation of tight lid closure.

In dark, blepharospasm won't be completely abolished while photophobia would.

Anaesthetisation(topical) reduces greatly the blepharospasm but not photophobia.

-Sushrut

Tuesday, August 6, 2019

Definition of generalized convulsive status epilepticus

Hi everyone,

Historically, the International League Against Epilepsy (ILAE) and others defined status epilepticus as a single epileptic seizure of >30 minutes duration or a series of epileptic seizures during which function is not regained between ictal events in a 30-minute period.

However, a 30-minute definition is neither practical nor appropriate in clinical practice.

Glucagon-like peptide-1 (GLP-1) receptor agonists

Hello everyone!

Let's talk about glucagon-like peptide-1 (GLP-1) receptor agonists today!

Sunday, August 4, 2019

Tetralogy of Fallot: The Basics

Hey guys, this post highlights the important points discussed in the accompanying video.


Fuch's s in Ophthalmology

Following this are ascribed to Fuch

1. Fuch's heterochromic iridocyclitis
2. Fuch's corneal endothelial dystrophy
3. Gyrate atrophy of the choroid
4. Ciliary body adenoma

-Sushrut

Leptospirosis

Rats, rains, ricefields?
Ringing any bells?
Sewer workers coming in with jaundice and fever?
Still no?
Assam/Odisha/Kerala floods?
This spirochete called Leptospira is the culprit.
Most common species is L. interrogans and L. biflexa.
It is epidemologically important as high case fatality rate (CFR) between 5-20%
It affects 1.03 million people anually.
Endemic in states of Kerala, Tamil Nadu, Karnataka, Gujrat, Odisha and Andaman Islands.
Males suffer more than females.
More common post monsoon, natural disasters like floods and cyclones.
Transmission- water or soil contaminated by the urine of infected animals or by direct contact with infected animals such as cattle, buffalo, goat, sheep and pigs carriers of infection.
Rodents harbour leptospira in their renal tubules LIFELONG!!! and are considered reservoir hosts.
Leptospira forms biofilms for survival in renal tubules of reservoir and carrier animals.

Vascular endothelial damage is the primary lesion in leptospirosis ,after entry in the host.

CLINICAL  PRESENTATION
1. Anicteric phase- symptoms unnoticed. Sudden onset of remittent fever, chills, severe myalgia, intense headache and B/L conjunctival suffusion.
Mild proteinuria with few casts and cells in urine, cough and chest pain.
2. Icteric phase-  severe form of disease, where lepto from blood vessels trasfered to organs.
C/F- fever, myalgia, headache, conjunctival suffusion, acute renal failure-oliguria, anuria, nausea, vomiting, diarrhoea, abdominal pain, hypotension.
Elevated transaminases, leucocytes, erythrocytes in  urine, albuminuria, increases in blood urea and creatinine.

LIVER+ KIDNEY= WEIL'S DISEASE
HEPATIC- mild to severe jaundice, tender hepatomegaly, hepatic encephalopathy
RENAL-  acute tubular necrosis(ATN) , interstitial necrosis, renal failure.
RBC casts are common in urine microscopy.
PULMONARY- cough, respiratory distress, basal and mid zone opacities, hemorrhagic pneumonitis, interstitial and intra alveolar hemorrhages
CVS- shock, arrythmias
CNS-meningitis, irritability and restlessness, seizures, encephlitis, focal neurological deficits macular, maculopapular erythmatous skin irruptions
Pregnancy with leptospirosis BAD PROGNOSIS.
LAB- elevated WBC, Neutophilia, high ESR, thrombocytopenia, increased BUN and increased creatinine phosphokinase
D/D- falciparum malaria, dengue, scrub typhus, typhoid, viral hepatitis, acute encephlitis syndromes and pyelonephritis.

Diagnosis-
Dark ground microscopy, immunofluorescence, culture, histopathological staining assay.PCR
microscopic agglutination test (MAT) ELISA, IHA

Treatment and prevention:start treatment clinically
susceptible to penicillin, doxycycline, cephalosporine, tertracycline, macrolides, fluroquinolones.
DOC OPD pts. T. Doxycycline 100mg BD for 7 days, IPD severely ill- Crystalline penicilline 20Lakhs unit,6hrly. pregnant and lactating- ampicilin 500mg 6hrly
corticosteroids in gradual doses in severe hemorrhagic is considered.

prevention- rodent control, health education,personal protection, animal vaccination

Thats all folks!

Stay awesome:)

Dr. ShilPill

Thursday, August 1, 2019

No Vitamin A in Stargardt's disease

In lipofuscinoses like Stargardt's, fundus flavimaculatus, and Best's disease spectrum, Vitamin A and related compounds are avoided as the metabolites of those is what causes the disease in the first place. Usually, Vitamin A is prescribed empirically by general ophthalmologists for degenerative diseases of the retina.

-Sushrut