DR VERMA PAEDIATRICS SITE: phobia in children

DR VERMA PAEDIATRICS SITE: phobia in children

"EFFECT OF FOSTER CARE ON THE BEHAVIOUR & DEVELOPMENT OF CHILDREN"

* S.P. Goel ** Mukesh Verma
Department of Paediatrics & Neonatology,
LLRM Medical College, Meerut.
ABSTRACT
Background & Objectives : In developing countries, caring for the large number of children in orphanages is a challenging task. Studies have repeatedly shown that children in such institutionalized settings suffer from severe behaviour and developmental deviations. The aim of this study was to assess the quantum of behaviour and developmental problems in children living in orphanages/Foster care institutions in our setting.
Design : Comparative cross-sectional.
Setting : Tertiary care hospital & orphanages/Foster care institutions.
Subjects & Method : A total number of 52 children aged 6 months to 6 years living in two orphanages/Foster care institutions were studied for their behaviour and developmental problems and were compared with their age and sex matched normal children attending immunization clinic at a tertiary care hospital. Pre-school Behaviour Check List (PBCL) devised by McGurie & Richman was used for assessing behaviour problems and development was assessed by using DENVER-II in four parameters i.e. – gross motor, fine motor & adaptive personal social & language.
Results : Nearly half (44.2%) children living in orphanages had behaviour problems compared to only 25% control group children. Prevalence of behaviour problems were higher in males and in older children. In orphanages 71% children had atleast one area of developmental delay compared to 34.6% in control group. Global developmental delay was seen in 30.7% children of orphanages as compared to 13.4% in the normal environment. Most common developmental delay seen in children under Foster care was in the area of language development (69.2%). Sustained language defects were most common finding.
Conclusion : Foster care institution in our setting lack proper infrastructure, administration and guidelines. It thus becomes necessary to evaluate whether these institutions are part of the problem or part of the solution. Interventional strategies should be planned with an aim to give these children beyond the survival basics of shelter, Food & clothing.
Key words : Foster care, Orphanages, behavioural problem, developmental delay.
* Asso. Professor (Deptt. of Paediatrics), ** J.R. (Paediat

Dr Mukesh Verma's Curriculum Vitae

Name
Dr. Mukesh Verma
Father s Name
Ram Swaroop Verma
Nationality
Indian
Date of Birth
25th may 1975
Permanent Address
2, Nathu Ram Park 

Tehsil Road 
Najafgarh , New Delhi -43

Mobile No.
+91-9868366406
E-mail
drmukeshv@gmail.com

Qualifications
MBBS, MD (Pediatrics)

Medical Licensure & Memberships
Delhi Medical Council Registration Number-DMC/24581
Rajasthan Medical Council Registration Number-RMC/20383
Medical Council Of India-201(34)/2004/IMR/3475
Life member – Indian Academy Of Paediatrics
(National Chapter)-L-2006/V-418
(Delhi Chapter)-DB/L/05/V-20
Unrestricted Licensure to practice Paediatrics anywhere in India

Professional Medical Education

MBBS-From Dr S N Medical college Jodhpur

MD Pediatrics-From LLRM Medical college Meerut U P, India. (2001-2004).
Post Graduate Training/ Internship
INTERN (01/99-12/99)
Dr S N Medical College And Associated
Mahatama Gandhi hospital, Mathura Das Mathur Hospital and
Umaid Hospital, Jodhpur Rajasthan , India
· 12 months of clinical rotations in Departments of Medicine, Surgery, Obstetrics & Gynaecology, Paediatrics, Ophthalmology, Anaesthesiology, Community Medicine, Orthopaedics and EN
POST GRADUATE RESIDENT,
DEPARTMENT OF PEDIATRICS
(05/2001-06/2004)
L L R M Medical College and associated Sardar vallabh Bhai Patel Hospital, Meerut U P, India.
Was responsible for running OPD, well baby clinic, immunization clinic, adolescent counseling & developmental screening. Competent in procedure like IV canulation Endotracheal intubations, bone marrow aspiration, exchange transfusion, lumbar puncture, ascitic tap, intraosseous canulation suprapubic tap arterial & venous sampling.
Research & Papers
Thesis (2000-2002) titled Effect of nutritional status, social and home micro environment on the development of children. The paper on the thesis was presented at 42nd National Conference of Indian Academy of Pediatrics at Kolkata in Jan 2005
Presented paper titled IVH/GMH in premature & LBW and its co-relation with maternal factors at 40th National Conference of Indian Academy of Pediatrics in Mumbai in Jan 2003
Presented paper titled Effect of foster care on the behavior and development of children at 41st National Conference of Indian Academy of Pediatrics at Chennai in Jan 2004.
Presented paper titled IVH/ GMH in premature and LBW babies at 41st National Conference of Indian Academy of Pediatrics at Chennai in Jan 2004.
Presented paper titled Clinico-radiological correlation of children with seizure Disorder at 42nd National Conference of Indian Academy of Pediatrics at Kolkata in Jan 2005.

Academic Honours & Awards
Awarded First Prize in Post Graduate Pediatric Quiz Held at 2nd Pediatric Multi-specialty update at SGPGI , Lucknow in Nov.2003
Best Paper Award at 41st National Conference of Indian Academy Of Paediatrics at Chennai in Jan 2004
Awarded First Prize in Dermatology Quiz at state level at SP Medical College, Bikaner.

Trainings & Workshops attended
· Attended Pediatric intensive care workshop at PGI Chandigarh in Oct 2003.
· Completed course in Practical Pediatric nutrition organized by CRNSS and Apollo Hospital in March 2003.
· Successfully completed Provider course in Pediatric Advanced Life Support (PALS) in accordance with American Heart Association and IAP in Oct 2005.
· Successfully completed Neonatal Advanced Life Support (NALS) in accordance with American Heart Association, American Academy of Pediatrics and IAP in Jan 2006.
· Attended 2nd Single theme workshop In Neonatology on Birth asphyxia At PGI Chandigarh in Sep 2003.
· Completed workshop on Neonatal resuscitation at AIIMS in accordance with WHO collaborating center of IAP and AAP in Apr 2002 and again repeated the same with newer guidelines in 2003.
· CME & Conferences attended



















· Update on Pediatric Neurology by Indian Academy of Pediatrics Meerut Oct 2003.
· Update on Practical Pediatrics by Indian Academy of Pediatrics Meerut Apr 2003.
· Technical cum POD Training on leprosy organized by DHS, Govt of NCT Delhi in July 2006.
· CME on RNTCP (DOTS) organized by RNTCP, Government of Delhi.
· Attended 2nd Single Theme Workshop in Neonatology on Birth Asphyxia at PGI Chandigarh in Sep 2003.
· CME on Neonatal Hematology organized by IAP-Delhi, NNF and IAP PHO Chapter in FEB2003.
· CME on Common Emergencies in Pediatric Practice by IAP Meerut in Dec 2003.
· Training on AIDS organized by Delhi AIDS Control Society in June 2006
· CME on common Emergencies in Pediatric practice by IAP Meerut in Dec 2003
· Update on Neonatal & Pediatric cardiology at PGIMER & associated RML Hospital , New Delhi on 22nd September 2007.

NEURO-IMAGING IN HYPOXIC ISCHAEMIC ENCEPHALOPATHY

Hypoxic ischaemic encephalopathy refers to collection of abnormal neurological signs like decreased activity, poor suck, respiratory difficulty due to antenatal or perinatal hypoxia and associated postnatal morbidity like cerebral palsy, mental retardation, epilepsy etc. This condition is associated with considerable long term morbidity and therefore an early diagnosis can obviate serious neurological damage.

Etiology
The causation of HIE is multifactorial, however the common causes for this are
1. Maternal diabetes.
2. Pregnancy induced hypertension.
3. Intrauterine growth retardation.
4. Severe bleeding.
5. Placental insufficiency.
6. Prolonged labour.
7. Dystocia.



Anatomical and physiological factors as related to imaging-
Fetal brain is different from adults with regards to cerebral blood supply. In adults the watershed region is the superomedial aspect of cerebral hemispheres, the region between the vascular territories of anterior, middle and posterior cerebral arteries. However in preterm infants this region is in the periventricular white matter. On one side is the germinal matrix with its rich blood supply and on the other side are branches from leptomeningial vessels. The intervening area is most susceptible to the hypoxic changes. With the maturation of the fetal brain this watershed region shifts to the sub cortical white matter.
Physiologically too, the fetal brain responds differently than the adults to hypoxia. The cerebral circulation lacks auto regulation and is in the ‘Pressure-passive’ state i.e. the cerebral perfusion changes as the intravascular pressure changes. This auto regulation is further impaired by hypoxemia and hypercarbia.
So, on one hand hypotension can lead to an ischaemic insult to the brain, increase in vascular pressure can cause hemorrhage.Since the fetal life arterial partial pressure of oxygen is quite low, hypoxic ischaemic disturbances are primarily a consequence of hypoperfusion.Certain evidences also indicate that certain excitatory neurotransmitters (i.e. amino acids esp. glutamate) are released excessively at the synaptic clefts during conditions of hypoxic- ischaemia. These may play a role in neuronal damage.

Imaging in HIE
Close coordination between a pediatrician and neuroradiologist is essential for correct interpretation of imaging features of HIE.
Sonography is the most frequent and widely used modality. As the anterior fontanels is open in the neonatal period it allows quick, bedside examination of the neonatal brain without the hazards of ionizing radiation and at a fraction of a cost of the NCCT or MRI. However the major drawback is the intra. and interobserver variation in the interpretation of the findings as this modality is highly operator dependent. NCCT is more objective modality for the imaging especially in the presence of acute hemorrhages.
MRI has now emerged as more sensitive and specific modality for the evaluation of HIE. Not only it can detect early ischaemic and hemorrhages changes, it can also better characterize the findings picked on initial sonography. It in turn helps in predicting the prognosis of the infants with HIE. Now, the reports of detection of ischaemic changes in first few hours of life with MR diffusion and MR spectroscopy has shifted the focus from merely detecting the abnormalities to the early detection when medical interventions might still be helpful.

Major patterns of HIE on imaging
1. Periventricular hemorrhage
2. Periventricular leukomalacia
3. Cerebral edema.
4. Subcortical/ parasaggital leukomalacia.
5. Focal cerebral ischaemias.
6. Cerebral atrophy.

Periventricular Hemmorhage
Occurs mainly in the preterm infants and refers to germinal matrix hemorrhage with or without associated intraventricular or parenchymal hemorrhages. Caudo-thalamic groove is the most common site. On sonography and NCCT acute hemorrhage appear as bright hyperechoic areas in the periventricular region. In few weeks time they either resolve completely or change into subependymal or porencephalic cysts. These cystic changes are better picked on NCCT.
Grading of IVH (Papile et al)

Grade-1 Hemorrhage confined to the germinal matrix.
Grade-2 IVH without ventricular dilatation
Grade-3 IVH with ventricular dilatation.
Grade-4 Associated parenchymal hemorrhage.

Periventricular Leukomalacia-
It is the term given to the ischaemic changes occurring in the periventricular region in the preterm infants. Classically the lesions of PVL are bilateral, symmetrical and located in peritrigonal white matter or in the areas around the frontal horns.
On ultrasound in the acute stage it appear as periventricular hyperechoic areas or PV flare with echogenecity similar or more than that of the adjacent choroids plexus. They have to be differentiated from the periventricular blush seen in normal infants.
On NCCT they are seen as hypodense areas in the above mentioned location. Here it is difficult to differentiate them from normal unmyelinated white matter seen in immature brain.
Conventional MRI depicts these lesions as the areas of abnormal signal intensity both on T1WI andT2WI. MRI is more sensitive in detecting the areas of hemorrhage occurring in PVL, which on sonography may be completely missed or seen merely as areas of inhomogenecity in periventricular flares.
Chronic PVL
There is change in the periventricular region with in 3-4 weeks and may completely resolve(within months). The periventricular changes are not appreciated on USG or NCCT or result in ventriculomegaly. However, MRI is a sensitive modality to detect the chronic changes, which are seen as-
1. B/L symmetrical, hyperintense foci in periventricular white matter on PD and T2WI.
2. Reduction in periventricular white matter leading to abutting of deep cortical sulci to the ventricular wall.
3. Irregular ventriculomegaly.



Grading of PVL
Grading of PVL has been proposed by many authors however one given by De Vries et al is most followed.
Grade-1 periventricular echodense areas persisting for seven days or more
Grade-2 periventricular echodense areas evolving into small fronto-parietal cysts.
Grade-3 periventricular echodense areas evolving into multiple cysts in the parieto-occipital white matter.

Grade-4 echodense areas in the deep white matter evolving into multiple subcortical cysts.

Subcortical Leukomalacia And Cerebral Edema
The subcortical region is the watershed area in the term infants, thus the ischaemic changes are noted in this area. When the hypoperfusion in profound and for a long period, whole brain is affected and features of diffuse cerebral edema are seen. On sonography the edematous brain appears as diffuse increase in the echotexture of cerebral hemispheres. NCCT the findings of diffuse low attenuation involving both hemispheres are noted.

Prognosis
The prognosis is predicted mainly by the clinical scoring systems which use clinical signs as well as EEG findings to stage the disease. However certain imaging features are associated with poor prognosis. In general the prognosis is in direct relation to the grade of injury. Higher the grade poorer the prognosis. In a study by V. Pierrat et al. 29 out of 30 patients with grade2/3 PVL developed cerebral palsy. Diffuse decrease density on CT in term infants is also associated with poor prognosis. Resistive index of less than 60 in cerebral arteries on Doppler scanning is associated with poor outcome. On MRS decrease in ATP is associated with death in the neonatal period.

Conclusion
Hypoxic ischaemic encephalopathy is a frequent problem in preterm and at term infants and the early diagnosis of this entity can help in management and can alter the long-term prognosis. Various radiological modalities are available like USG, CT and MRI. No single modality is sufficient for complete diagnosis and follow-up. Close coordination between the pediatrician and radiologist is required to adequately manage this entity.

How To Stop Breastfeeding

So you've decided to stop breastfeeding? But how best to stop? Especially as many children refuse to stop and demand that you continue nursing. There are many techniques, one of which Ask for advice as to how to go about weaning and you'll receive a variety of answers. Some responses range from just plain silly to potentially dangerous. Some people will recommend that you just change to bottle feeding whilst others will even recommend taking some form of 'drying-up' meditation; please avoid medication and there are better ways than switching to bottle feeding.
One school of thought - one that was quite common in our grandparents' day and is still common in some cultures - is for mother to take a vacation away from her child. The idea being that mother is far enough away not to hear her baby's cries and that when the mother returns after a week, the baby will no longer want to be nursed. There are some serious drawbacks to this method. The first being, that many children will not have forgotten about breastfeeding and will demand it upon mother's return. Secondly, and most importantly, is the emotional impact on the child when separated from mother. Adults may refer to the time spent away as 'separation', but the child will see it as desertion. There is nothing an adult can do to explain a mother's absence from a child less than 3 years of age. Each child has a threshold when it can endure a mother's absence; after this time a child will begin to mourn for the loss of its mother. The emotionally and psychological damage on a child shouldn't be underestimated. The damage can be life long. Many institutions and organisations now realise the harm done when a mother and child are separated; one only has to look at how many hospitals provide bedding for a child should the mother spend time in hospital. Weaning by separation is a risky strategy: avoid it.
Another 'quick and easy' method is to sabotage the sweat tasting breast milk. Mothers can purchase a foul-tasting liquid which is painted on thumb or nipple. In other cultures, mothers use various herbs and spices to bring about weaning. Igorot mothers in the Philippines have used ginger or chilli-pepper sauce. In the Eighteenth century is was quite common for mothers in European countries to apply mixtures containing alum, mustard or wormwood. Applying this type of quick-and-easy method of weaning is risky. For one thing, applying such mixtures must be painful for mother as well as child. Breastfeeding is as much about giving your child comfort as it is about giving nutrition. Breastfeeding is teaching your child to trust you, its mother. By suddenly, offering a bitter, foul-tasting liquid instead of the usual sweet, delicious milk will seem like a betrayal to some children. Nearly 2,000 years ago, the Greek physician Soranus expressed disapproval of the practice, citing the injurious effect of the sudden change, and that the bitter or evil-smelling substance could injure the child's stomach. Of interest is that the taste of breast milk changes when the mother becomes pregnant; many older children who were breastfeeding at the time have told how the once delicious milk changed to something less tasty. Although we don't know for sure, it may be Nature's way of weaning one child in preparation for the next. Anyhow, it doesn't always work as many children continue to happily suckle during pregnancy.
Ignoring a child's crying is hard for a mother. Nature has programmed children to cry when in discomfort or in need of something, and for parents to respond when their children cry. But ignoring a child's crying can be a good thing. This isn't to say we completely ignore our child's tears, rather, by occasionally not giving in, we are teaching our children a valuable lesson: we don't always get everything we want in life. We teach this lesson often to our children; by refusing to buy candy and the supermarket checkout, or by not letting them watch television past their bedtime. The secret is patience. You make the call; when to ignore a child's crying and when to respond. At first you can ignore the crying for a set time before soothing your child by nursing. Eventually you can allow your child to cry itself out, but to offer your breast the next time he cries. Given time, your child will come to terms with the diminishing amount of nursing she receives, and if you provide other stimuli and rewards the needs for mother's breast will fade out completely.

phobia in children

What is a phobia?
A phobia is an identifiable and persistent fear that is excessive or unreasonable and is triggered by the presence or anticipation of a specific object or situation. Children and adolescents with one or more phobias consistently experience anxiety when exposed to the specific object or situation.
Common phobias include fear of animals, blood, heights, closed spaces, or flying. In children and adolescents, the identified fear must last at least six months to be considered a phobia rather than a transient fear. Types of phobias seen in children and adolescents include the following:
§ Specific phobia - anxiety is associated with a specific object or situation. The phobic object or situation is avoided, anticipated with fear, or endured with extreme anxiety to the extent that it interferes with normal routines and activities.
§ panic disorder with or without agoraphobia - an unpredictable, unexpected period of intense fear or discomfort compounded by shortness of breath, dizziness, lightheadedness, shaking, fear of losing control, and an increased, racing heart beat (called a panic attack). Symptoms can last several hours, but usually peak after 10 minutes. Agoraphobia is defined as a fear of open spaces such as being outside or leaving home alone related to one or more phobias or the fear of having a panic attack.
§ Social phobia - fear of one or more social or performance situations in an age appropriate setting with others within the same age group (i.e., school play, recital, giving a speech or book report in front of the class).
§ Selective mutism - the inability to speak in specific social situations in a child or adolescent who can and does speak in other situations.
What causes phobias?
Both genetic and environmental factors contribute to the onset of phobias. Specific phobias have been associated with a fearful first encounter with the phobic object or situation. Sometimes children develop phobias by observing fearful reactions of others. Children’s fears are often natural and arise at specific times in their development. Children may develop fears from a traumatic experience (e.g. traumatic dog attack), but for some children, there is no clear event that causes the fear to arise. Some children become fearful simply by watching another child acting scared. Some children may refuse to sleep alone due to fears of creatures in their closet, while other children report feeling afraid of the dark. Children's fears are often associated with avoidance, discomfort, and physical complaints, such as rapid heart beat, stomach distress, sweaty palms, or trembling. Researchers have found certain fears arise at specific ages in all children, and these fears tend to disappear naturally with time, as the child grows older. When children’s fears persist beyond the age when they are appropriate, and begin to interfere with their daily functioning, they are called phobias. Typically, children who are experiencing a phobia should be referred for treatment by a psychologist.
Child’s fears may be normal Most children are able to report having several fears at any given age. About 90% of children between the ages of 2-14 have at least one specific fear. If child’s fear is not interfering with his routine daily life (e.g., sleep, school performance, social activities), or your family’s life, then most likely you will not need to bring your child to a psychologist for help. Following are some common phobias found at different ages:
Ages 0-2 years- loud noises, strangers, separation from parents, large objects Ages3-6 years- imaginary figures (e.g., ghosts, monsters, supernatural beings, the dark, noises, sleeping alone, thunder, floods) Ages 7-16 years- more realistic fears (e.g., physical injury, health, school performance, death, thunderstorms, earthquakes, floods.


Who is affected by phobias?
Anxiety disorders are common in all ages. The occurrence of specific phobias in children and adolescents is estimated to range from 1 percent to as high as 9.2 percent. While specific phobias often begin in childhood, they must be differentiated from normal developmental fears. Social phobias are only estimated to occur in up to 1.4 percent of children and adolescents. Panic disorders can develop at any age, but most often begin in adolescence or young adulthood. The study of panic disorders in children (before puberty) has only recently begun.
What are symptoms observed child with a phobia?
The most common symptoms that may occur when a child is exposed to or anticipates exposure to, a specific object or situation that produces intense fear or anxiety are
increased heart rate
sweating
trembling or shaking
breathlessness
feeling of choking
chest pain or discomfort
feeling dizzy or faint
fear of dying
numbness
· chills or hot flashes
The symptoms of a phobia may resemble other medical conditions or psychiatric problems. Always consult your child's physician for a diagnosis.
How are phobias diagnosed?
A child psychiatrist, psychologist or pediatrician usually diagnoses anxiety disorders in children or adolescents following a comprehensive medical and psychiatric evaluation. Parents who note signs of severe anxiety in their child or teen can help by seeking an evaluation and treatment early. Early treatment can prevent future problems.
Panic disorder, however, may be difficult to diagnose in children and adolescents and may require multiple evaluations and tests in a variety of settings.
How to prevent Phobias
Preventive measures to reduce the incidence of phobias in children are not known at this time. However, early detection and intervention can reduce the severity of symptoms, enhance the child's normal growth and development, and improve the quality of life experienced by children or adolescents with anxiety disorders. Helping children overcome fears
Communicate with children
Give children information about their fears. Answer their questions about things like wars, death, hospitals, disease, etc. Knowing about things helps to make children less fearful (but not too much detail for young children).
Understand your child
· Do not making fun of your child's fears.
Reassure children that they are safe and cuddle or love them until they calm down.
However, while you show your child that you understand that her fears are real, it is important not to let her think that you are also afraid (unless it is genuine) because it will make her more fearful.
Encourage them
· Praise and reward the child when he makes a step towards fighting or confronting his fear, e.g. getting closer to a dog if he is frightened of dogs.
Don't force your child to fully confront his fear, but take it a small step at a time and let him know you are proud of him when he does.
Control his fears
Having some control of the situation often helps with fears.
· Make sure your child has his own comforters, e.g. Dummy, blanket, night light, Toys etc.
· If your child is old enough, ask him what he thinks would help him, or make some suggestions and let him choose.
· For example, if the child is afraid of burglars, he could check that the room or house is safe, with windows locked, etc.
Give them a chance
Provide opportunities for your child to develop skills and gain confidence in his own ability. Confidence can't be developed on praise alone. It is success and being able to do things that build up a child's confidence.
· Let your child try things that he can do, and then give him lots of support and approval.
· Read children's stories that deal with fearful events those children overcome.
· Provide times for fantasy play where children can express their fears and take control of them.
Be their Hero
You are a role model for your children
· Show that you are calm and confident in the situation which is frightening to your child.
· Remember that children can learn fears from parents, and if you show anxiety in a situation your child may pick it up.