Sustaining Breastfeeding together.

It was another breastfeeding  week  on 1st to 7th August, 2017. This year's theme challenged us to work together to make breastfeeding sustainable. It requested the support of every man, woman, manager, policy maker, NURSE, doctor, health attendant, Husband and everybody.
Breastfeeding is a BIG task, it drains energy, you may have witnessed or heard about women fainting after breastfeeding; such is the energy it consumes and this shows that the level of support needed by a breastfeeding woman is unquantifiable/ enormous.
If you did not talk to someone last week about breastfeeding , you didn't do too well, you still have the chance to do that before it is too late or better still forward this piece of information to them.
Can we have Breastfeeding celerebrated every week just to lay emphasis on the importance of breastfeeding?
I need not bore us on why breastfeeding or breast milk is important, its rich contents and the protections it offers are superior.
What I want us to pay attention to is helping the breastfeeding women around us do it well, any form of encouragement done properly will be appreciated; a thumbs up, a pat, money, food, space, breastfeeding leave with pay , a space in your establishment for brastfeeding mothers to breastfeed are just some of the supports that will make the breastfeeding mother do it well.
If you look around well enough this task is often left for the aged women in the community who themselves need support, they pass down traditional practices (big kudos to them), some of these practices are very helpful. That they are willing to help always is commendable. However, we are now in an era when we know better and our knowledge should set us free, set our community free also.
My major concern today are the challenges and myths of breastfeeding.
I have been in a nursery bay where HOT water was prescribed, to help uterus contracts and breast milk flows. Right in the hospital, even in labour wards you see people including healthcare practitioners prescribe bland PAP etc as a form of galactogogue. These are based on traditions and psychology; they have little scientific basis.
The challenges of breastfeeding are numerous, I will mention a few:

1. Milk not flowing: this is common in the first 3 days after birth, it is a normal finding in most mothers and will soon flow, as a mother, you need to relax, eat well and drink a lot fluids, be happy, ensure you are not in any form of pain as this can cause delay in milk flow.
Please my fellow doctors, DO NOT PRESCRIBE HOT WATER FOR THESE WOMEN, doing so has no established basis ,tell me how much hot water can a woman who should be well hydrated drink? The breastfeeding mother should take about 3litres of water daily, normal (water at room temperature) will do. If the lack of milk flow extends beyond the 3rd day with all the above mentioned stuffs clearly addressed pleas see your doctor (pregnant woman doctor (Obstetrician) or babies doctor (Paediatrician)).
Palm wine is not a special fluid, if you are not interested don't drink, don't blame your inability to produce enough milk on lack of palm wine, a lot of people get unneccessarily worried because of this temporary problem to the extent that such worry inhibit their milk flow.
Pregnant women and breastfeeding mothers need GOOD FOOD,simple well prepared meal, No mandatory Pap .
The list below is a well illustrated 10  steps to
SUCCESSFUL BREAST-FEEDING
  Every facility providing maternity services and care for newborn infants should accomplish the following:
  1   Have a written breast-feeding policy that is routinely communicated to all health care staff.
  ii Train all health care staff in the skills necessary to implement this policy.
  iii   Inform all pregnant women about the benefits and management of breast-feeding.
  iv    Help mothers initiate breast-feeding within a half hour of birth.
  v    Show mothers how to breast-feed and how to maintain lactation even if they should be separated from their infants.
  vi    Give newborn infants no food or drink other than breast milk unless medically indicated., please babies do not need water while breastfeeding exclusively, herbal concoction is not needed, brestmilk is all in all in the right proportions.
  vii   Practice rooming-in (allow mothers and infants to remain together) 24 hr a day.
  viii   Encourage breast-feeding on demand.
  ix   Give no artificial teats or pacifiers (also called dummies or soothers) to breast-feeding infants.
  x    Foster the establishment of breast-feeding support groups and refer mothers to them on discharge from the hospital or clinic.


2. Pain while breastfeeding , this could be a normal finding initially but breast feeding  should soon be itch free, free flowing , if the pain is disturbing lasting more than few hours after delivery,  please prescribe pain killer for these women also encourage them to breastfeed more often during this period, yes the reasons for this pain may inlude
A) Breast engorgement.....  Breast is overfilled, overstretched and painful, mother will need to Breastfeed more often to prevent this very painful challenge, give pain killer if one develops , other treatment modalities include warm compress, warm shower etc
B) Breast abscess.... Please never allow it get to this level, if this develops see a doctor fast. The woman will have pains, fever and may have chills.

C) Sores on the  nipple(s)..this should not be, it is usually due to bad techniques of breastfeeding, the technique is about the most important thing , if the nipples have sores, the treatment is more breastfeeding to avoid engorgement and one can also express the milk and give through cup till the sores heal, the proper techniques must be emphasized. These techniques are usually taught during the antenatal vists and in the post natal ward after delivery (make it a point of duty to learn the proper technique, such that you can help yourself and people around you).
The technique is illustrated below properly.
Babies are designed to breastfeed and every mother is built to provide beast milk but the techniques must be right, everything must come together at the point baby attaches to the breast.
 Get in a comfortable chair with great back support to feed your baby. Using a stool to rest your feet on will help with good posture and prevent you from straining your neck and shoulders.
Use your breastfeeding support pillow if you have one. (And if you don’t, use whatever kind of pillows you can find to help support you and the baby). A good breastfeeding pillow can make a huge difference in getting the baby in a proper position to latch on well.
Make sure your baby is tummy-to-tummy with you at all times.
Make sure you bring your baby to you, and do not try to lean onto the baby. Not only will this cause severe strain on your neck and shoulders, but it can affect the baby’s position.
Remember to keep your baby’s ear, shoulder, and hip in alignment, which will make swallowing easier.
The baby’s nose should be opposite the nipple.
You might need to hold your breast to help guide the nipple to your baby’s mouth. Grasp the breast on the sides, using either a “C” hold or “U” hold. Make sure you keep your fingers far from the nipple so you don’t affect how baby latches on.
Aim the nipple toward the baby’s upper lip/nose, not the middle of the mouth.You might need to rub the nipple across the top lip to get your baby to open his/her mouth.
The baby’s head should be tilted slightly back. You do not want his chin to his chest.
When he opens his mouth wide with the chin dropped and tongue down, he should latch on to the nipple. If he does not open wide, do not try to shove the nipple in and wiggle the mouth open. It is best to move back, tickle the lip again with the nipple and wait for a wide open mouth.
Try to get as much of the lower portion of the areola (the area around the nipple) in the baby’s mouth.
The baby’s chin should indent the lower portion of your breast.
Look to see if the baby’s bottom and top lip are flanged out like fish lips. If they are not, you may use your finger to pull the bottom one down and open up the top one more.
Positioning your baby to feed

There are many different positions that can work while breastfeeding. It is important to find one that is comfortable for both you and your baby. Make sure to utilize the tips in the above list to help ensure your position is correct.
Cross-Cradle Hold:
This position is often the most helpful for moms right after birth and until they get more confident in getting their baby latched on correctly. It feels awkward for many moms at first, but once they see how it allows them to use both their hands more effectively, moms get more comfortable with it.
You will use the arm on the opposite side you will be feeding from to hold and support your baby, while you use the hand on the side you are feeding from to support your breast.
Lay your baby next to you, tummy-to-tummy, with your opposite hand supporting the back of his head. You want to make sure you are holding at the neck, so you are just guiding the head. You will use the other hand (on the same side the baby is feeding from) to hold and navigate your breast and nipple. Once the baby is securely latched on, you can move your arms to the cradle hold.
Numerous other methods exist, check and learn.

3.Lastly for today, is a 3rd challenge
 Breast leakage: innocuous, the milk overflows , stain wears and can be smelly, More hygiene needed, it resolves on its own.

The myth are numerous and challenges enormous the scope of today's blog can not exhaust them all. We shall revisit some other ones later .
 Here I rest my case for this week, help mothers breastfeed, give the needed support.




Leave your comments , questions and suggestions in the box below.

Febrile convulsion : Prevention and care

Scary as it goes, convulsion or fits (seizure) is the commonest scary experience for mother to witness a child have, they chant all sorts of names. Jesus, Jehovah, doctor, Yepa, Oh! Ha! Just to mention a few.

I have witnessed them pee themselves but that is fine. What bothers me and affect these children more than the convulsion are the wrong interventions  and the insults we inflict on them during this process.

This brings us to today's blog tittle.

"Care and Prevention of Febrile Convulsion in Children"

What is Febrile convulsion?

It is a convulsion (fit) or seizure in children when they are having fever, occurs usually in children between the age 6 months  and  60 months (5yrs).

Convulsion may be characterized (but not restricted to) by abnormal movement of any part of the body usually jerking, pedaling, abnormal blinking of the eyes, upward rolling of the eyes, stiffening of the body, etc.
It is quite a common place in children.

Fever is defined as elevated body temperature, subjectively and rather unreliably checked by placing the back of the palm on the forehead in this part of the world.

The reliable method is by using a thermometer, a specimen is shown below.

Off mode

Default value when switched on.

Reading after measurement

Temperature greater than  37.5 Celsius measured from the armpit (there are other places one can check) is referred to as fever.


What are the causes?

The causes are mostly from infections, that may affect any part of the body except the brain. These include but not limited to :

Malaria
Catarrh and cough (flu, pneumonia)
Infection in the throat (tonsillitis and pharyngitis)
Infection in the passage for urine (urinary tract infections)
Infection in the ear (Otitis)
Like I said, infection anywhere in the body except the brain may be a cause . If the infection is in the brain, the outcome is worse and the associated fit is not called febrile convulsion.

What to do during a febrile illness to avoid febrile convulsion?

1. Have a thermometer to measure your children temperature. This can be done by anybody and everybody.A digital thermometer displays the temperature of the body on its screen.

Switch on the thermometer and simply put in the ampit for 2 minutes or till it alarms, Check the number displayed thereafter,If lesser than 37.5 Celcius, no problem, Values greater than 38 Celsius are particularly disturbing and requires care that may include

a) Complete exposure of the child
b) Fanning
c) Bathing with lukewarm water
d) Toweling with wet napkins (wet with warm water)
e) Administration of Paracetamol (only if the above methods fail and temperature is greater than 38 Celsius).
   Paracetamol should not be used routinely in any child to prevent fever (it damages the liver and the kidney if used excessively).
Such child should at least be reviewed by a family physician or a paediatrician(babies doctor)

What to do during convulsion

Convulsion for one minute is like eternity to an helpless mother, so any form of intervention will do. Anything done to stop the convulsion is usually welcomed and appreciated though most of these interventions are needless and harmful as we shall soon see , the following are recommended steps of interventions

1. Remove all clothing and allow proper ventilation

2. Put to lie on the left side

3.Follow steps a to e of prevention written above

4. If available, insert a rectal diazepam. This is a gel that can be placed in the body through the anus and hastens abating the seizure

4. It is also Paramount to see a doctor (babies doctor)

May I quickly add that febrile convulsion usually does not leave a child damaged, There is no long term outcome. It is our wrong interventions during this period that damage these children.

What not to do.

1. Do not pee on the child. This is rather a common practice. Please, do not do it. The  danger is the child run a greater risk of aspirating the urine(breathing in urine) and suffer lung infections and may even die from choking.

2. Do not give COW Urine,sounds funny or you say barbaric, people do it, and it is a very common practise.
The first problem here is cow urine, the second is that it is used alongside onion and garlic making a concoction that potentially lowers the blood sugar making the child to have more convulsions and subsequently suffer permanent brain damage.

3. Do not put their leg(s) in fire, Yes, people do it,in the last one month, I have seen a couple of cases.

The fact here is that fire can only worsen convulsion, It does not stop it,the child is then left with a damaged foot, prolonged hospital stay, more psychological effect the extent of which can not be quantified.

4. Do not insert spoon, or anything in their mouth while convulsing,  you may remove their teeth , injure the mouth structures and the child may choke.

5. Don't give anything by mouth while a patient is convulsing or sleeping after convulsion, It is dangerous.

Most of the above interventions are instituted by Neighbours, grandparent, friends etc but not by the mother who is at the time of event practically " brain dead".
This is a case where doing nothing ( if u do not know what to do )is far better than doing useless stuff.

Please share this information , it will definitely help some poor children somewhere.

Leave your comments , suggestions , additions and questions in the comment box below.

MCQ2/8/17

1 . A 5yr old girl  referred to you on account of Vaginal bleeding noticed following development of breast about 4month prior, she deny use of oestrogen containing creams, she has genus vagum and an irregular sharp edged rash on the the trunk , her pulse rate is fast and bounding.
The following conclusions are likely to be true of this condition

A). The average age of affectation in girls is 3yrs
B). In patients with associated cushing syndrome the      ACTH level is low
C). Clinical hyperthyroidism is uncommon in this condition
D). Phosphaturia is the commonest extra glandular manifestation
E). A missense mutation occured in this patient.

2.Growth hormone is indicated in the following conditions
A) Turner syndrome
B)Prader Willis syndrome
C)End stage renal disease
D)Growth hormone deficiency
E) intra uterine growth restriction

3. The mother of a new born(1hr old) has called your attention to teeth in her baby's mouth , she knows this is unusual and wants an explanation, some of the valid points  you told her include

A) This is an abnormal condition and the teeth as a rule must be extracted.
B) her child's condition is called neonatal teeth
C) cleft palate must be ruled out
D). Usually occur on the mandible
E) attachment of the teeth is deep rooted

4. A 6mo old boy seen at the out patient department with nasal discharge of few days to which the care giver procured decongestant from OTC, the attending resident noticed the heart rate to be 210bpm despite normal Temperature and respiratory rate , child is otherwise normal , you are invited to review and corroborate the above findings

A) This condition is likely not to need treatment.
B). This condition may rapidly progressed to heart failure
C) The over the counter decongestant may have a role in development of this condition
D)deep intranasal suctioning may reduce the heart rate
E) Digitization may be needed.

5.The result below was obtained from a 4yr old boy with Loss of consciousness.
Sodium ion:152mmol/l
Potassium ion : 3.8mmol/l
Random blood sugar,: 162mg%
BUN: 6mmol/l
Bicarbonate : 17mmol/l
Chloride ion :118mmol/l
The following conclusion is/are true

A) he has metabolic acidosis
B)plasma osmolality is 425Mosmol/l
C.) The anion gap is normal
D) Has renal tubular acidosis
E).May have diabetes insipidus

MCQ: 31/7/17

Use 7.5min for the questions.
Answer true for correct statement and false for incorrect statement
Incorrect answer attract 0.5 mark deduction.
Pass mark is 13/and above.

1.  A 2 -day old girl noticed to have bled per rectum, the following may hold true of this patient

A). He may have vitamin k dependent bleeding.
B). He may have swallowed her mother's blood during delivery.
C.)bet-ke test may be important in making diagnosis
D).haemophilia is not a possible diagnosis since the baby is a girl
E). She has necrotizing enterocolitis

2. The following investigation result were obtained for the above child
      i prothrobin time ( 20s)
     ii plasma thromboplastin time (80s)
     iii platelet counts (250000/ul)
     iv cloting factors 5 and8 (normal)
Which of the following is /are true statement(s)

A).protein induced in vitamin K absence is a sensitive marker in this condition
B). The level of cloting factors 2,7,9, and 10 may be normal in this condition
C). The patient may have hemophilia A
D. There is impaired post translational decarboxylation of vitamin k dependent clothing factors.
E.Oral vitamin K may be used for prevention of this condition

3.  A 4-week old boy has being vomiting, failing to thrive and he is severely dehydrated, the following are some of the differentials to consider
A.) Cystic fibrosis
B.) Galactosemia
(C).Neonatal diabetes
D). pyloric Stenosis
E). Sepsis

4. The above patient (3) was noticed to have cataract and jaundice on examination, blood culture done for the patient yielded Klebsiella sp.
The following are some of your conclusions

A).The boy most likely has Cystic fibrosis
B). Exclusion of glucose from the diet of this boy  should be considered
C).The deficient enzyme may be Galactose-1-phosphate uridyl transferase.
D).Symptoms are due to accumulation of galactose in the blood
E.)This boy may suffer mental retardation.

5. The following conditions are commoner in females
A).Patent ductus arteriosus
B). Atrial septal defect
C).Ventricular Septal defect
D). Coaractation of aorta
(E).Pulmonary stenosis

Newborn Cord Care

I have chosen to speak out to the public through this medium having kept quiet for so long .
The last straw of events happened this weekend, another baby lost to a very preventable death, through needless hot formentation of  the remnant of the baby's cord a means through which, though rare, an infection, a kind that sort of eat up the flesh around the cord occurs , This I must agree is rare occurrence but usually a fatal one.
Before I continue with my rant, may I be permitted to educate us on the universally acceptable means of caring for a newborn umbilical cord remnant.

What is an umbilical cord?
It is a thin rope of fleshy white gelatin that attach a baby to the placenta. It serves as a means of communication between the baby and the placenta (the mother).
It is a passage through which digested food from the mother, oxygen and other essentials of life are passed to the baby. Some of  the baby's wastes are also passed through it to the mother for removal.
A baby is delivered of the mother only when the cord is severed after expulsion of the baby through whatever means Vaginal or abdomen (in case of caesarian cut).
The remnant of the severed cord is clamped (tied) as it contained blood vessels and will bleed out all the baby's blood if left unclamped (not tied). This remnant will naturally degenerate and drop off the baby, usually between day 4 and 7 though may rarely remain intact for longer time (maximum 28days), after which it is considered prolonged (Seek medical attention if it has not dropped after 2 weeks).
It usually will drop without leaving any appreciable wound, but may rarely leave an innocous fleshy outgrowth (Seek medical care if you see this).

Picture of a newborn showing the cord immediately after severance

Why is the need for special care of the cord?

The process that leads to eventual dropping of the cord produces dead tissue that is slightly foul smelling and must be cleansed off.
The dead tissue is a good medium for bacteria infection and other disease causing agents to grow and multiply so we must clean to prevent this.


What are the ways by which we can care for the cord?
1. Normal baby bath twice daily (where necessary) with warm water containing one to two drops of savlon , towel dry after.
2. The remnant of the cord should not be tucked in to the diaper as it may be readily contaminated with baby's urine and stool.
3. The cord can be swabbed with methylated spirit (alcohol swab) 3 to 6 times daily at regular interval, triple dye or bacitracin, if available, may be applied daily.
4. WHO ( World Health Organisation ) recommends application of chlorhexidine  gel (Available in health centres and some pharmacy shops) or savlon cleaning)
5. After the umbilical cord has dropped off, cleaning with methylated spirit should continue for one or two days after which no special care is needed.
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What is fobbiden?

1. Application of cow dung, yes I said cow poo, it is rather a common practice (though has reduced drastically) to see people apply this mess on their baby's cord. This is a dangerous practice as many of such children die of infection and/or tetanus.

2. Hot formentation... This is the cause of my early rant , it is a rampant practise in this part of the world and rather unfortunate  as both the very educated and the uneducated are involved.
What is more disheartening is that this is like a tradition passing from one generation to the other.
We have to stand right and stop this right away( Say no to Cord formentation)
It is cruel as many of these children cry ceaselessly and helplessly while going through this torture
The baby is  a well formed human , no internal wound of any sort that will be healed with your hot formentation, so stop it.

Picture of one of the scores of affected children

Another victim of our gruesome traditional practice

4.Application of mentholatum, Robb or Dustin powder is also very dangerous.

 Anything other than the above mentioned methods of care can be potentially dangerous , ask from babies doctor before you do them.


Yes that you did it for your baby and you got away with it does not make it right.
I may have been hot formented but I (we) am(are) here to stop these barbaric practises .

 We care , God heals.



Leave your comments or questions in the box below

Oral Question 28/7/17.

A 12 year old boy presented in a peripheral hospital with history of abdominal pain, several episodes of vomiting and Loss of consciousness.
He was managed as a case of typhoid sepsis to no avail necessitating referral to you.
You obtained an history of recent weight loss and secondary enuresis that begins about a month prior presentation, he is also dyspnoic with fast deep breathing.

(a) What is Your  likely assessment ?

b) Mention two bedside investigations that will help you clinch the diagnosis and your likely findings.

c) Mention 5 risk factors for this type of presentation.

c)  Outline 5 principles of managent.

d)What 4 complications can occur acutely in this pateint and explain  briefly the pathophysiology of any two.

A 15yr old girl  presented in accident and emergency unit with two weeks history of fatigue, headache , joint and chest pain and great discomfort whenever she is expose to sunlight. You noticed that she also has macular rash on the face , pale and has pedal edema.

a) .what is the most likely diagnosis ?

b)  Mention two differentials.

c)  State 5 of the criteria needed for making diagnosis.

d) Mention five relevant investigations. 

e)  mention Four drugs that can induce the above condition.

f)  mention three medications that may help in treatment of this condition.


A 3 week old boy is brought to your clinic for evaluation , he has
an episode of gross hematuria. , severe respiratory distress, mother volunteer  an history of small volume liqour in pregnancy, he appears to have an abnormal facie,
 abdominal examination shows a mass palpable to both flanks.
Amongst other abnormal result of investigations is a markedly deranged liver function test


A) What is the most likely diagnosis?
B) list two differential diagnosis
C) Mention four other investigations  that may be relevant
D) what two  prominent associations are expected
E.mention 5 complications that may arise
F.what will be your treatment plan?

 A 10yr old girl present in out patient department with history of pain in the ankles , and the wrists, the joints appear stiff on awakening in the morning.The involved joints are swollen , warm and tender.,

a. What is your diagnosis?
b. Give two differential diagnosis
C.list four investigations you will like to do.
D.Give five classes of this condition according to the international league
E. Mention three complications that may arise
F. Mention four drugs that may be beneficial

What is Macrophages activation syndrome(MAS)?
b. How is the diagnosis of MAS confirmed?

MCQ: 28/07/17

1. A 4yr old BOY with  severe infectious mononucleosis was investigated for immune deficiency , the result shows deficiency in certain adhesive proteins  on b and t lymphocytes.
The following is true of this patient immune deficiency.

a).  It is an X linked reccesive condition
b).  Affected patient may develop acquired                     hypogamaglobinaemia
c.)  This is Duncan disease
d.) Stem cell transplant offers no benefit
e.)  Prognosis is very poor.

2. A 5yr old boy rushed into CEW with history of repeated episodes  of convulsion  of an hour duration, he has had red urine that has being progressively reduce in quantity in the last  12hrs
Examinations reveal an unconscious child , with periorbital fullness and severely elevated blood pressure.
The following are true of this patient

a). C3 hypo complementemia is an expected         finding
b)  ricketsial is a known cause
c)   group B hemolytic streptococcus serotype 12 is a known cause
d.). congestive heart failure is a feature
e)   lumpy bumpy deposit of immune complex is seen on light microscopy

3. The serology result of a 7yr old boy is as shown below : 
              Anti HbC IgG positive 
             Anti HbS positive

The following are true of this patient
a. He has an acute infection
b. He is a chronic carrier of the infection
C. He is highly infective at this stage
d. He is safe throgh immunization against hepatitis b
e. He is previously infected but has recovered.

4. Molluscum contagiosum

a. A self limited condition
b. Caused by Pox virus
c. Curettage is the treatment of choice
d. Infection is life long
e. Coccidiomycosis is a differential

5. A 2 yr old boy was found with the container of red pills that belongs to his pregnant mother, he has swallowed some of the pills, if the toxic dose is exceeded the following will be True

a)  hematemesis within 6hrs of ingestion is expected
b.  This patient will benefits from administration of activated charcoal
c.  The boy will benefit from whole bowel irrigation
d. penicillamine is the antidote for the ingested pill
e)  the antidote is preferably given subcutaneously.

 7.5min time allowed
0.5 mark deducted as penalty for wrong options
Score above 20 is excellent
15 to 20 good
10 to 15 is average