Tuesday, December 19, 2006

So how do I lower my cholesterol levels?

"Ok Doc, so you tell me that LDL is BAD and HDL is GOOD. How do I lower my LDL levels and increase my HDL levels?"

Why do you have high cholesterol in the first place?

I had a 43 year old male patient this week who was sooooooo happy to find that his cholesterol levels are so good even though, he claims that he eats really unhealthy hawker food and never excercises! Then I had this 42 year old female patient who is very strict about her diet, eats rolled oats every morning, takes cholesterol lowering medications, excercises regularly and yet has a high cholesterol level.

What does this tell us? It tells us that having a cholesterol problem is not solely based on what you eat and whether you excercise. If you have a cholesterol problem, it is because your liver is not able to regulate the cholesterol levels well. Your liver actually makes cholesterol for the your body's needs. It is a neccessary ingredient for buiding and repairing body tissues. Now if your liver somehow does not get rid of the bad cholesterol quick enough then cholesterol levels in the blood rises leading to problems.

So, for those unlucky enough to have a high cholesterol problem, you need to help your liver regulate cholesterol by eating less cholesterol rich foods. About 60% of all the cholesterol circulating in your body is made by the liver and 40% comes from what you eat. So by controlling your intake of cholesterol rich food, you can significantly influence your cholesterol levels.

You are what you eat!!

There are actually two different classes of food. One you should avoid and one you should eat more of.

Ones you try to eat less

These are the food that are high in Saturated Fats. In general, cholesterol comes only from animal fats but it is also necessary to reduce Saturated fats from plant souces as well.
The list is very long, but I just give you some categories to remember:

  • Egg yolks (white is ok)
  • Milk products like soft cheeses, butter and cream
  • Meats - Any fatty meat is bad, Sio Bak, Lard, Sausages, Luncheon meat, chicken skin etc
  • Organs - Kway Chap, Foie Gras, Chicken livers etc
  • Deep fried Stuff - Chips, Fries, KFC etc
  • Nuts that have lots of oil, like macademia and cashews
  • Coconut cream!! All the yummy lemak stuff
  • Dressings- all the creamy ones like mayonnaise and thousand island
  • Seafoods - Cavier, fish roe, Crab roe (hairy crab), Prawns.
  • Snacks, Desserts, Pastries, Ice Cream

Ones you eat more because they help lower Cholesterol levels

  • Oatmeal contains soluble fibres which help lower LDL (Good old Quaker Oats)
  • Walnuts and Almonds
  • Omega 3 fatty acids: There are 2 main sources. Fish such as Mackeral, Tuna, Trout and Salmon and plant sources such as Flaxseed, Walnut, Soybean oil and Canola oil

Contrary to popular belief, soybeans have not been shown to actually lower cholesterol levels

More info can be found here

When do I need to take medications?

Different strokes (pardon the pun) for different folks!! It all depends on your risk factors and how high you cholesterol is. We usually advise patients to try dieting first and if that doesn't bring the cholesterol down to an acceptable level then medications are started.


In this blog, we discussed about how to lower your LDL cholesterol, which is essentially through diet control. In my next blog, we will talk about how to raise your HDL levels. Remember that the old adage is true, you are what you eat!

Monday, December 18, 2006

How to read that Cholesterol Report

One of our readers wrote:

Dr, I love food, but my last cholesterol report showed that my cholesterol level is 324. Should I be concerned?

Why bother about cholesterol levels?

Think of your arteries as the piping of your kitchen sink and cholesterol as the oils that you flush down the sink everyday. If you ever have the privilege of opening up the pipe, you will get a dark sticky layer of gunk coating the inside of the pipe. This is similar to what cholesterol does to your arteries. Prolonged elevation of cholesterol will lead to narrowing of the arteries. If the arteries to the heart are blocked, you get a heart attack. If the arteries to the brain are blocked, you get a stroke.

How to read that Cholesterol Report

This is what a typical Cholesterol Report looks like. Let me highlight to you what is important.


This is related to having too many calories in the diet. Calories from sugar and other carbohydrates like rice, cakes, pasta etc are converted to Triglycerides to be stored in the body.
While the link between Triglycerides and Heart Disease is not has strong as with Cholesterol, it should not be allowed to get too high as it may lead to other problems such as pancreatitis and diabetes mellitus.

What to do?

Lose weight, cut down on sweets, soft drinks and alcoholic drinks, esp Beer. Omega 3 fish oils may be of benefit. If your Triglyceride levels are very high, (>400) the Doctor may prescribe some medications to lower it.

Total Cholesterol

People always tend to look at this but usually we don't use this number to determine if you need to take medications. That is because the Total Cholesterol is made up of the LDL and the HDL, so if your LDL is low but HDL is high, you might have a high Total Cholesterol level, but it may not necessarily be bad since it is good for the HDL to be high.

HDL Cholesterol

This is what we call "Good Cholesterol". The higher the better. Less than 40 is no good. Excercise can help raise HDB Cholesterol levels.

LDL Cholesterol

This is the one that we look at to determine if you need medications. Your target LDL level depends on you and the number of risk factors you have for developing heart disease. So for example, a 60 year old man who is obese, smokes has high blood pressure and diabetes will require his LDL levels to be <100. style="font-weight: bold;">The bottomline is that the LDL levels need to be adjusted to individual needs.

The Total Cholesterol/HDL ratio

This one is useful for research purposes. But in essence if your Ratio is low is good because it shows that you have a high HDL level compared to the LDL.

Want to know what your chances of getting a heart attack is over the next 10 years?

If you have your cholesterol report and blood pressure readings, you can calculate your 10 year CardioVascular Risk by clicking here

For more information about your Cholesterol Levels, click here

Thursday, December 14, 2006

New Mothers: What is this 6 in 1 Vaccination for my Baby?

One of our readers enquired about the 6 in 1 Vaccination that is available for newborns. So I thought I will just let you know about it.

The Vaccination Schedule for Singapore can be found here

Based on this schedule, your child will receive:

Birth: BCG and Hepatitis (Done at the hospital)
1 mth: Hepatitis
3 mth: DTP + Polio (Diphtheria, Tetanus, Pertussis)
4 mth: DTP + Polio
5 mth: DTP + Polio
6 mth: Hepatitis

This completes the vaccinations for the first year.

What is this 5 in 1 vaccination?

The smart scientists came up with what is known as a 5 in 1 vaccine. The 5 in 1 basically combines DTaP + IPV + Hib (Haemophilus Influenzae type B) into one vaccination. You may notice that there is a slight difference in the annotations. The "a" in DTaP stands for acelluar as opposed to whole cell vaccine. Acellular means that only purified Bacterial Parts are used in the vaccine as opposed to using the whole Bacteria. Acellular vaccines have been shown to have less side effects than whole vaccines.

IPV stands for inactivated Polio Virus as opposed to the Oral Polio which is a live virus given by mouth. The inactivated Polio Virus is incorporated into the 5 in 1 vaccine.

Haemophilus Influenzae type B (Hib) is not included in the schedule but it is an important vaccine to give to baby. Before the introduction of Hib, 10 -15 babies died in Australia each year from this disease, and 20-40% of the survivors were left with permanent neurological damage. So it is good to protect baby against this.

So as you can see, the new 5 in 1 vaccine offers many advantages over the old vaccination scheme.

So what is the 6 in 1 vaccination?

The clever scientists again made life easier for parents and doctors by coming up with a 6 in 1 vaccine. The 6 in 1 is actually the 5 in 1 plus the Hepatitis vaccine.

So instead of the old schedule where the baby needs to be given 5 injections, now the baby only needs to be jabbed 3 times. With 6 in 1 the schedule becomes:

Birth: BCG and Hepatitis (Done at the Hospital)
2 mth: 6 in 1
4 mth: 6 in 1
6 mth: 6 in 1

Less in injections means less pain and less chances for side effects to occur.

Our clinic offers packages for the new 6 in 1 as well as for the 5 in 1 vaccine. Do write to leslie.tay@gmail.com or call 67850311 for more information.

More information about childhood vaccines can be found here

Wednesday, December 13, 2006

What you should know about Cardiovascular Disease

Today's big health news is that Singaporeans only have a vague idea about how to prevent heart disease. So I have decided to write a series of blogs on the factors that affect the health of your heart and what you should do. Let me first start by giving you a real life scenario:

Mr M was a 42 year old patient of mine who has a history of high blood pressure and cholesterol. When I first saw him about a year ago, he was perfectly well, aside from high blood pressure and high cholesterol. He suffered no symptoms at all. He told me that he previously had an excercise stress test that showed some minor irregularities but he has not followed up on it. My advice to him was that he should go for a repeat excercise stress test and referred him to a cardiologist for follow up.

The months went by, and Mr M delayed going to the cardiologist because he felt he had no symptoms and did not want to do another stress test. I don't blame him, because in an excercise stress test, you go on a thread mill and have to run for a period of time. (How many of us like to do that?)

I finally suggested an alternative which was to do a 3D CT scan of the heart to look at the blood vessels of the heart which he finally agreed to do. An example of the 3D CT scan is shown above.

The 3D CT showed that his main artery was critically blocked and that his other 2 arteries have also narrowed. This means that at any time, he might suffer a massive heart attack. Within a week he had open heart surgery and had a 6 vessel bypass! The 3D CT scan had saved his life.

How you get a Heart Attack and Stroke

Cardiovascular problems (Cardio - heart, Vascular - blood vessels) are one of the biggest killers in Singapore. They occur when because of certain factors the blood vessels to the heart and brain narrow and eventually blood supply to these vital organs are cut off. The result is a heart attack or a stroke.

What are the Risk Factors for Heart Disease?

Below are the risk factors for Heart Disease, I like to divide them into 3 groups.

Group 1: Those things you can't do much about.

1. Male - if you are a man your risk goes up
2. Age - Men above 45 and women above 55 have higher risk
3. Genetics - If your parents have heart disease, you are at higher risk

Group 2: Those things you can do for yourself

1. Smoking - Stop smoking! Smoking dramatically increases risk of cardiovascular diseases
2. Alcohol - Too much drinking will also increase risk.
3. Obesity - Diet and Excercise and keep your weight to below a BMI of 23!

Group 3: The things you should consult your Doctor:

1. Hypertension - The silent killer, you may not feel any symptoms and the damage is gradual
2. Diabetes
3. Cholesterol levels

The bottomline is this: Prevention is better than cure and you should visit your doctor to discuss with him about how to prevent heart disease!

In the meantime, if you know your cholesterol and blood pressure readings, you may wish to calculate your 10 year risk of getting a heart attack by clicking this.

More information about Cardiovascular Risk Factors are found here

My next Blog in the Cardiovascular Health Series will touch on Cholesterol and how to read your cholesterol report.

Monday, December 11, 2006

Hepatitis B Carriers: What you need to know!

One of my patients said this to me:

Dr, I was diagnosed as a Hepatitis B carrier 2 years ago. What do I need to do?

Please listen, if you are a Hep B carrier, it is IMPERATIVE that you are regularly checked by a Doctor at least twice a year and that your spouse/partner is protected against Hep B.

Importance of Hepatitis B in Singapore

1. 4% of Singaporeans are Hep B carriers, so there are quite a lot of people carrying the virus in their bodies!

2. Of these, 25% will develop complications which may lead to liver failure and liver cancer.

3. If you are a carrier, you may transmit Hep B to someone else!

In a nutshell, if you are a Hep B carrier, there is a chance that you may develop liver cancer and that you may also spread it to others.

How to prevent spreading Hep B to others

Hep B is transmitted through bodily fluids and are transmitted through sex, sharing of contaminated needles and sharing of other things that may cause bleeding like toothbrushes, nail clippers and shavers. Make sure you don't be a HERO and donate your blood or sperm!

What to do for your family members

It is important that your spouse be screened for Hep B and receive vaccination as soon as possible. It is advisable for others in the family to be screened as well. If you are pregnant, then the baby will need special treatment at birth.

What YOU need to do for yourself

1. Find a Family Doctor and make sure you visit him every 6 months

2. You will need blood tests to check for liver problems every 6 months

3. You will need at an Ultrasound of the Liver at least every year and for some high risk patients, twice a year

4. If you are not vaccinated against Hep A you should do so.

5. Avoid alcohol as this will cause more problems for your liver


Hepatitis B carriers have a chance of developing liver cancer and should be seen by a doctor every six months. Their family members and other sexual contacts are also at risk and should be screened. Hep B is a bigger problem than AIDS and kills more people every year than AIDS so you should be very careful.

Thursday, December 07, 2006

For Men: Dr, how come my b---s shrink when I go swimming?

One of my patients asked me this question today!

I told him that I wanted to blog the answer and asked for his permission to take a photo of the organ in question. He declined of course. I quipped that it was because he was afraid someone might recognize him just by looking at that part of the body which got his wife laughing uncontrollably AT him. Trust is such a important quality in a husband and wife relationship, don't you agree?

The function of the male testicles are to produce sperms. It so happens that they function best at a temperature just cooler then normal body temperature. So during a hot day, the scrotal muscles relax so that the testicles will dangle further away from the body and when it is cold, the scrotal muscles contract to keep the testicles warm.

Here are some things you should not do if you wish to father a child:

1. Avoid Spas!! Soaking a long time in Spas with water temperatures above 40 degrees Celsius might be really relaxing BUT it may lower your sperm count!

2. Avoid long bicycle rides while wearing tight bicycle shorts! The tight shorts and the bicycle seat keep the testicles closed to the body and may compromise sperm production.

3. Avoid long hours sitting on your chair or car! You should get up and let them dangle every now and again!

4. Avoid Smoking and Alcohol as they may affect the sperm count!

An Interesting Postulation

It is a fact that sperm production decreases in hotter climates. So could it be that our low fertility rates are due to the fact that Singapore is hot and most of our guys work long hours sitting in their offices?

While you are thinking about this, I think I will just get out of my chair and go for a quick stroll!

For more information on how to optimise your fertility rate (for men) please have a look at this interesting article from MayoClinic. Click here.

Wednesday, December 06, 2006

Can I get Hepatitis B from eating raw Seafood?

Doctor, I know that I can get Hepatitis B from eating raw Seafood right?

This is perhaps one of the commonest misconceptions in Family Practice. The problem is that most patients do not differentiate between Hepatitis A and Hepatitis B which are two very different diseases altogether. So here are a few points to you understand the difference.

1. Hepatitis just means inflammation of the liver. This inflammation can develop from a whole range of conditions. Hepatitis A and B refer to inflammation of the liver caused by 2 different viruses, the Hep A and the Hep B virus.

2. Hep A is the one that you get from eating contaminated food and water. (Not just seafood, any food can be contaminated with the virus). When you get Hep A, you might get jaundiced and develop fever and have flu like symptoms. Most people recover fully from Hep A but some do develop chronic hepatitis and liver damage.

3. Hep B is transmitted through contact with blood or semen. It is spread through contaminated needles (drug abusers) as well as sexual contact. Hep B has more severe consequences than Hep A. People who contract Hep B may go on to become carriers who can spread the disease to others. A person suffering from chronic Hep B may also develop liver failure and liver cancer.

4. You can vaccinate yourself against both Hep A and B. The vaccination for Hep A consists of 2 injections 6 months apart. The Hep B vaccination is 3 vaccinations at 0, 1 and 6 mths.

This is only a short article to help you differentiate between Hep A and B. For more information you may like to read this.

In my next article, I will be talking more about Hep B carriers and what screening tests are required by ALL Hep B carriers.

Treating people not diseases

Our motto "Treating people, not diseases" was an inspiration from the film, "Patch Adams" where he told his peers that when you treat a disease, you lose, but when you treat the person, you will win all the time. Most of you would have seen this film where Patch Adams (Portrayed by Robin Williams) was this eccentric Doctor who would put on a clown's nose to entertain kids who were dying.

Most Doctors shy away from incurable patients because sometimes we feel powerless in those situations and sometimes it is because we do not want to be reminded of our own mortality. But Patch was different. He focussed on the patient, not the disease, so he felt that he could still do something for the patient even though there is nothing that can be done for the disease.

"Treating people, not diseases" is an mindset we adopt to remind ourselves that we are treating not just a headache, runny nose or a cough. It helps us remember that patients are real people who work to earn a living and have families who care for them and have joys and struggles in life.

I heard it said somewhere before that people are like onions. When you peel off the superficial layers, the deeper more significant problems emerges. This happens everyday in Family Practice. Let me illustrate with a typical situation:

A 25 year old lady comes to the clinic complaining of a headache. "Treating the disease" would be to make an accurate diagnosis and then to prescribe painkillers after making sure that the headache is not an indication of some serious event. That is treating a disease called Tension Headache. There is absolutely nothing wrong with that because the doctor has done what is expected of him both legally and morally.

When we try to treat the patient, the doctor takes the extra step to establish a relationship of trust whereby the outer layers of the onion can be peeled off to reveal the real underlying problem. I frequently have patients who present with seemingly innocent symptoms who are really suffering from depression or an inability to cope with the stresses of life. Some patients present with headache because they have not slept a wink, having to stay up the whole night looking after the newborn baby!

Many of our physical problems are a manifestation of psychiatric stressors. A condition like depression often masquarades as physical symptoms such as fatique, weight loss, menstrual changes, unusual sensations in the abdomen, chest or head, bodily aches and pain, dry mouth and difficulty breathing. The condition is common in stressed out Singaporeans but it is often not recognized by both the patient and her doctor. Unless the underlying depression is treated, the physical symptoms are likely to remain.

One of the most important roles of the Family Doctor is patient education, which is why I have started this blog. Many of the conditions are much better managed when the patient understands the rationale for treatment.

Asthma management is a very good example. Most parents who do not understand the rationale behind using Preventors often stop the medication prematurely. The parents who do understand the role of preventors are more compliant to give the medication for a longer period of time which result in the child being able to live without having to suffer the symptoms of asthma frequently. (For more info on Asthma, you may like to read the Asthma Series which have just been posted)

I will be the first to admit that "Treating people, not diseases" is sometimes difficult to do. I am far from perfect. (Some patients expect us to be superhuman and are surprised when a Doctor falls sick! If you prick us, do we not bleed?) Sometimes, after a long day, I get tired and it is much easier to just see the patient, prescribe some medication and send the patient home (Which is why it helps to close the clinic and take a nap in the afternoons) We can only say that we try our best.

If you have been our patient for a while, I hope this little article will help to explain our tagline to you and I hope you feel that we have tried to live up to the values that we espouse. If you have any thoughts or comments please feel free to express them by clicking the comments link at the end of the blog!

Monday, December 04, 2006

Asthma - What you need to know! Part 5

In Part 1, we discussed the issues facing the management of asthma in Singapore and we see that the most important thing is for parents to be empowered with the knowledge to manage their child's condition. In Part 2, we learnt about how to diagnose and stage the severity of Asthma. In Part 3, we discussed the different medications available and the difference between RELIEVERS and PREVENTERS. In Part 4, we looked at other ways of preventing Asthma by avoiding triggers.

In this last installment, we will bring it all together and discuss how to work with your Doctor to manage your child's Asthma.

The Asthma Action Plan

This is the Action Plan which I use in my clinic. It is the one produced by NUH under their I CAN! Asthma management program. I usually send children who need to have skin prick tests done to NUH as well.

The Action Plan helps parents to manage their child's asthma effectively by:

1. Clearly outlining the dosage of medications needed when the child is not having an Asthma Attack
2. Helping parents to recognize the onset of an Asthma Attack
3. Clearly outlining how medications should be increased based on the severity of the attack
4. Helping parents to know when they need to seek medical attention

So every child should have an Action Plan that is pasted on the fridge door so that parents can quickly refer to it when signs of Asthma start appearing.

The Peak Flow Meter

The Peak Flow Meter is used as a convenient way of assessing the severity of Asthma in the clinic or at home. By asking the child to blow into the device, you can gauge how severe the Asthma is by comparing it to the Peak Flow Reading when the Child is well.

If your child has Chronic Asthma, it may be useful to have one of these at home so that you can monitor the severity of Asthma your self. Sometimes in the very early stages of an Asthma attack, you don't get the wheeze or the shortness of breath. So, for example, when the haze situation returns and the PSI reading is high, the Peak Flow meter will help you gauge if your child is having Asthma even if he is not wheezing or coughing yet.

Wrapping it all up

I hope you found that the information contained in this 5 part series is useful in helping you better understand Asthma.

Knowledge means Empowerment. With the right knowledge, you, with your doctor's help can ensure that your child live a healthy and normal life!

Here are some more resources you can look at:

NUH's ICAN program
Asthma Patient Guide from Global Initiative for Astma
Asthma Patient Brochures from National Asthma Council Australia

Friday, December 01, 2006

Asthma - What you need to know! Part 4

In Part 3 we discussed the types of medications used in Asthma, in Part 4 we will look at other measures you can take to prevent an Asthma Attack

Avoidance of Triggers

Asthma is a form of allergic reaction. Being an allergy means that it is usually triggered by something. The commonest triggers are:

1. Cold and Flus
2. House Dust Mites
3. Animal furs like cats
4. Mould - I once had a patient who found that her asthma improved significantly when she thoroughly cleaned her aircon units!
5. The Haze or during the Seventh Month where there is a lot of burning papers
6. Smoking or 2nd hand smoke in the house

Knowing what triggers your child's Asthma will empower you to take some preemptive action to prevent the Asthma from occuring. The doctor will provide you with an ACTION PLAN which outlines what to do when the child is exposed to triggers. You should also take other steps to avoid the various triggers, for example, learning how to get rid of House Dust Mites around the home.

Food Allergies

Food is an uncommon trigger for Asthma. It only affects less than 5% of people with Asthma.

However, the common ones are:

1. Nuts
2. Fish and Shellfish
3. Milk
4. Eggs
5. Various Seeds
6. In the Singapore context, Bird's Nest is highly allergenic because of the impurities
7. Food additives


Some people get Asthma during excercise. This means the Asthma is poorly controlled. Children with excercise induced asthma should be managed by your Doctor. In general, Ventolin should be given half an hour before excercising and the child may need long term preventive medications.

A well managed child will be able to win an Olympic Gold Medal if the asthma is treated properly!

What else you can do.

Your doctor may arrange for a skin prick test in order to find out what exactly the child is allergic to. Then at least you KNOW what to avoid, rather then trying to be Kia Su and avoid everything!

For more information, you can click here

In Part 5, we will be discussing how to work with your Doctor to monitor and manage your Asthma

Thursday, November 30, 2006

Asthma - What you need to know! Part 3

In Part 2 we discussed how to recognize Asthma and how to grade the severity of Asthma. In Part 3 we will look at the different medications used in Asthma

What happens to the Airways in Asthma?

In Asthma, there is narrowing of the airways which result in difficulty in breathing. There are 2 mechanisms involved. First, the airways are inflammed ie swollen and red, and secondly, the muscles around the airways contract, making the airways narrower.

So we have 2 types of medications which treat each problem, viz RELIEVERS and PREVENTERS


These medications help to relax the muscles and thereby offers quick relief when the asthma strikes. They offer only temporary relief but DOES NOT treat the inflammation.

So if you have a persistent form of asthma where there is a moderate level of inflammation in the airways, these only provide quick relief but does not treat the underlying problem.


These medications are steroids which act to reduce the inflammation in the airways. They don't give immediate relief but when used over a period of time, they help the airways revert back to normal. They should be taken on a long term basis and not only when the child has an asthma attack. Always follow the doctors advise when using inhaled steroids.

New Anti-Inflammatory Agents

These are a new class of drugs used in Asthma. The one most commonly used is montelukast which you might have come across. These medications are taken orally and they also serve to control the inflammation. They are non-steroids and because they are taken orally they also work to prevent other forms of allergy at the same time, like allergic rhinitis (sensitive nose).

Combination Therapy

There are some inhalers which combine both a RELIEVER and a PREVENTER. They are used for more severe forms of asthma. The most commonly used ones are Seretide and Symbicort.

How the medication is delivered

Both Preventors and Relievers are best given via inhalation. For younger children, usually a spacer is used. Older children, usually by 6 years of age, can inhale directly. Another way of delivering the medication is by nebuliser. Both nebulisers are spacers are equally effective in delivering the medication.

Really important points to remember

1. Always follow the doctor's instructions on how to use the medications. The commonest problem I face is that parents use PREVENTERS for a few days then stop and use it again when the child has another asthma attack. This is not the right way to use PREVENTERS and may mean that your child's illness become protracted!

2. Another common misconception is that patients tend to use only 2 puffs of Ventolin and feel that is all they can use. If your child is having a severe Asthma attack, you can give 4-6 puffs for those above 6 years of age and, if necessary, repeat in 20 minutes, while you make your way to the clinic.

3. RELIEVERS should only be used to relieve symptoms and for the prevention of excercise induced asthma. If you find that you have to use it regularly, then it may indicate that the child needs to use PREVENTERS instead.

4. Moderate to high doses of steroids can cause some problems like some growth retardation, but so can poorly controlled asthma. Used within safe limits, the benefits of using steroids outweigh the risk. The amount of growth suppression is likely to be only less then 1 cm IF high doses of steroids are used.

In Part 4, we will be looking at other ways of preventing asthma attacks

Wednesday, November 29, 2006

Asthma - What you need to know! Part 2

In Part 1 we discussed the issues concerning Asthma. In Part 2, we will try to understand what Asthma is and how to gauge whether the Asthma is mild or severe.

What is Asthma?

First you need to understand the nature of asthma. It is a chronic disease like hypertension and diabetes. When you have asthma, the airways in your lungs are always sensitive and inflammed! If your child has eczema, you will understand what I mean. Just as the skin is sensitive, itchy and red in eczema, the airways are also inflammed and sensitive in asthma. So asthma is a disease that requires long term treatment rather then just a one off treatment like a cold.

What happens to the airways?

The airways become thicken and inflammed inside so the passsage where air can travel through narrows. This causes the wheeze which is very much the same way you whistle. The airways take awhile to become inflammed and will also take awhile to get back to normal. If you do not treat the airways, the long term inflammation will result in airways which are permenantly narrowed!

How do you recognize asthma?

Not all children who wheeze have asthma. Of the kids who have asthma, at least half will only have mild asthma. Here are some of the common signs that your child may have asthma:
  1. Wheezing, which can be brought on by triggers such as the haze, cold weather, dust and respiratory illnesses
  2. A cough that never seems to go away
  3. Coughing at night incessantly
  4. Shortness of breath
  5. Unable to run or do PE without getting tired and short of breath or wheezing
And at the same time there is a history of:
  1. Childhood eczema
  2. Parents have asthma
  3. Hospitalization during infancy for respiratory problems
Asthma is divided into 4 levels of severity

Step 1: Intermittent
Wheezes less than once per week and night coughs happen less then twice a month.

Step 2: Mild Persistent
Wheezes more than once a week but less than once a day and night coughs more than twice a month

Step 3: Moderate Persistent
Wheezes daily has night coughs more than once per week

Step 4: Severe Persistent
Limited Physical activity and frequent night coughs

As a parent what you need to know is this:
  1. Does your child have asthma? If so, he needs to be treated
  2. Does your child have Step 2 Mild Persistent form of Asthma? If so, he needs to have long term preventive medication (we are talking 3 to 6 months of continuous medication)
In Part 3 we will discuss the types of medications available for treating Asthma.

In the meantime, if you think your child may have asthma, you can take the asthma test by clicking here

Tuesday, November 28, 2006

I am Breast Feeding, Is this Medication Safe?

"Doctor, I am breastfeeding, so is this Medication Safe for the baby?"

This is one of the commonest question that I get from Breast Feeding Moms. So what I want to do is to give you some pointers:

Some pointers on Medications while Breastfeeding

1. Some of the drugs will invariably be found in the Breast Milk, so you have to be careful especially when the baby is very young and especially if he is preterm.

2. You should try to feed the infant just before taking your next dose or as late as possible after you have taken your medication.

3. If you smoke, you should know that nicotine increases the risk of respiratory distress in your child.

4. Always think, how this drug will affect you will also affect the child. So things that can make you drowsy, like sleeping pills, anxiety pills, even some antihistamines (for runny nose) can make your child drowsy and may have adverse effects.

5. Please don't assume that all medications are unsafe and so avoid taking medications altogether. You may be putting yourself at risk!! If you are unwell, seek medical advise!!

The list of medications is very long, so I am providing a link to a very good website that you can visit which lists all the medications and gives a rating as to whether it is safe.

Please click here and bookmark it!

Monday, November 27, 2006

Asthma - What you need to know! Part 1

Part I: Issues involved in the management of Asthma

sthma is one of those diseases in which many people have preconceived ideas. Just me just give you some examples of the things which the person on the street believe in which are either not true or only half correct:

  1. I don't want to use steriods for my child because it is bad for him
  2. If I start using the puffer, my child will get addicted to it
  3. Aiya, he will eventually grow out of it anyway
  4. Ventolin syrup is the way to treat asthma
  5. My child will never be like a normal child because he has asthma, there is a lot of things he cannot do
  6. Olympic atheletes cannot possibly have asthma
  7. Asthma is a disease that is just a bit of wheeze so it is not life threatening
  8. He does not have a wheeze, therefore he does not have asthma
In Singapore, 1 in 5 children have asthma. But somehow asthma is still underdiagnosed, meaning that many people with asthma are not being treated properly. For a developed country, Singapore has a very high incidence of Asthma related deaths.

The central issue, in my opinion, in properly managing asthma in children is Parent Education.

First the parent needs to be convinced that the child has asthma and accept that he does. This is not so easy and from a parent's point of view I can understand why. Once you accept that the child has asthma then there are a lot of implications. He'll need to be on puffers, steroids and the rest. Some parents prefer NOT to believe their child has asthma. So they go on taking cough mixtures and resist giving puffers. They will seek alternative forms of medicines like herbal remedies.

In children, the diagnosis of asthma is most often made on clinical grounds based on the history and symptoms of the child. So if the child's parents have asthma, the child wheezes twice a month for the last 3 months and also coughs incessantly at night, then we are highly suspicious that she has asthma.

The Bottomline in Asthma
  1. Asthma kills
  2. An asthmatic child without proper treatment may suffer growth retardation
  3. If asthma goes untreated, the child has a higher probability of developing more severe and persistent forms of the disease
  4. Proper treatment of Asthma, by giving inhalers with or without steroids can mean your child will live a "normal" life without wheeze, night coughs and be able to play sport without getting short of breath
  5. Asthma is a chronic disease that needs regular visits to the doctor for at least 6 months
  6. The only way to treat Asthma is when parents are empowered with the right knowledge to manage the disease with the help of their doctor
In Part 2, I will talk more about the diagnosis of Asthma and how to stage the severity of Asthma.

Friday, November 24, 2006

My child is not speaking yet!

Chatty little 3 year old

"Doctor, my son is already 2 years old and he doesn't speak much, just a few words. Should I be worried?"

One of the frequently encountered problems in family practice is the question of whether there is any speech delay in the child.

Being a parent of 2 kids myself, I can understand how distressing it is when your child is still struggling with a few words, but your best friends child of the same age is already reciting Shakespeare in Queen's English!

Speech delay may mean that the child has an underlying problem like hearing difficulties or some other neurological problem. These should be assessed by your doctor. But it may also just mean that the child may be just slow to start speaking. So the question is when do you need to bring him to the doctor for an assessment.

In a nutshell, you should bring him to the doctor if he is:
  1. Not turning his head to sounds by 6 months
  2. Saying only 6 single words by 21 months
  3. Unable to speak in 2 word phrases by 2 years
  4. Speaking unintelligibly to the family at 2 1/2 years
  5. Not speaking in short sentences by 3 years
Please do not use your friends child as a comparison. Kids develop at their own pace. I remember that last year's top scorer for PSLE was this boy who did not start talking until quite late! On the other hand, do be cautious if he fails to meet the milestones as highlighted above.

For a detailed look at the milestones, please click here

Thursday, November 23, 2006

Ode to my Stethoscope

Doctor's Eye View of the Stethoscope
There's no doubt about it! The Sthethoscope is the ultimate icon of the Doctor. Get a model, put a stethoscope around his neck and suddenly everybody thinks he is a Doctor.

Today, I just want to pay tribute to the instrument that is closest to my heart (literally). I hope you learn something about this indispensible instrument along the way.

When I was still a young medical student last century, I remember as a first year student looking up at the fourth year student with a sense of envy. One day, I shall have that stethoscope around MY neck! How wonderful that would be! Well, after 3 torturous years of physiology, anatomy, biochemistry and other stuff that I only vaguely remember now, I made it to fourth year! My first day at the hospital was special. I got to wear my white lab coat (which nobody wears nowadays except for medical students) and I put that stethoscope around my neck. My my, I instantly felt that I could save the world!

The first stethoscope I had was a Littman's Classic. It was one of those Toyota Corolla stethoscopes. Cheap and functional. My more well heeled classmates, ie those Hong Kong Dudes who drove into Uni in their red sportscar with the number plate Doc 888 (in Sydney, you could get these) got the Littman's Cardiology, which was like the BMW of stethoscopes. But hey, never mind, it is WHO uses the stethoscope and the skill involved that counts doesn't it?

The years went by, and me and my Littman's Classic made it through Med School and I became an Intern. It was then that I realised that the Stethoscope was my 2nd most important instrument. Horror of horrors!!! The most important instrument the doctor has is not the iconic stethoscope, no, no, no. The instrument that doctors need, more than anything else, the instrument that if he does not have, he ceases to be useful to the hospital system is NOT the stethoscope......... its his pen. Without the pen, you cannot write in the patient's notes and prescribe for the patient. In other words, without the pen you are as impotent as a Eunuch on a cold winter's day.

I remember doing my ward rounds while in Concord Hospital, Sydney. The hospital was spread out so that each ward was like a standalone ground level dormitory linked by sheltered walkways. While walking from one dorm to the next, I would often swing my stethoscope round and round. (The walk was long and I was bored) I remembered thinking to myself that should some crazed patient from the psyche ward suddenly ran out to attack me, how my stethoscope can be transformed into a Nanchacku type weapon. A hit on the head with a swinging stethoscope wielded by a Bruce Lee lookalike (we chinese all look the same to Aussies so they tell me) could inflict some serious damage. And after the patient has been knocked unconscious, the stethoscope could then be used as a restraint. Thankfully, my fantasy never materialised!

Oh yes, I was going to tell you how the thing works!

Basically the stethoscope transmits sounds. So instead of me putting my ear to your chest, I can put the bell of the stethoscope (that's the round bit) on your chest instead and still hear your heart beating. (This is good because some chests are pretty hairy). We really only use the stethoscope to listen to sounds coming from the heart, lungs, abdomen and for taking blood pressure. With practise, the stethoscope can be used to tell if there are any heart problems, like valve diseases, enlargement of the heart, lung infections, asthma.

Of course if you watch a TV show like ER, the stethoscope is often used to diagnose critical conditions such as a spontaneous pneumothorax (when air is trapped in the chest cavity outside the lung, thereby collapsing the lung itself) after which the really handsome doctor (never happens in real life right?) would stab a large bore needle into the chest wall to release the air pressure built up in the chest cavity. Another day, another life saved!. Hooray for the handsome doctor. (BTW, if you look closely, the stethoscopes are all even cheaper than a Littman's classic, they use BATA (Buy and Throw away) stethoscopes or the Lada equivalent of stethoscopes! (Now you know!)

One of the commonest mistakes the parents make when I pass them a stethoscope to listen to their own kids' lungs, is that invariably they will put it one upside down. No, the stethoscope should be worn this way -->

It's quite uncanny as almost every parent will make the same mistake. Almost like a four year old who always puts their shoes on the wrong way!

Just in case you are wondering why Doctors hang the stethoscopes around our necks, I will admit that when I was a medical student, it was a matter of pride. But after a while you realise just how convenient and practical it really is! If you don't believe me, I can give you a stethoscope and you spend a day doing ward rounds. I guarantee that by the end of the day, the stethoscope will unconsciously be hanging around your neck!

Today, I sit in my comfy leather chair with my relatively brand new Littman's CARDIOLOGY II with dual diaphragms. One side for adults, turn the other side for kids! Technology keeps moving ahead with 3D CT scans now able to reconstruct the blood vessels of the heart in 3 Dimensions, BUT it will never replace my trusty stethoscope. After all, you can't possibly hang a CT scanner around your neck and still try to look good at the same time!

I hope you have enjoyed my little story and learnt something along the way. If you are a medical student reading this, let me give you a word of advise. Always choose a black stethoscope because it matches most shirt/blouse colours. If you are a layperson reading this and want to try using a stethoscope, may I suggest that you always check to see if there is anything in the earpiece first. Don't say I never warned you!

Tuesday, November 21, 2006

Do you Grind your Teeth?

I was asked by a parent today concerning her son's habit of grinding his teeth during sleep.

Teeth grinding or Bruxism is a common problem in both Adults and children. Usually it is a sign of tension but it can be because the teeth are not aligned properly. It is aggravated by stress.

In children it can occur during the daytime, but more commonly occurs in both adults and children during sleep.

Some things you can try

  1. Try to relax before bed. Listen to soft music, practise meditation etc
  2. Slowly munch on something like an apple to loosen the muscles of the jaw
  3. Take a warm bath before bed
  4. Use a hot towel applied to the sides of the face. This will relax the muscles of the jaw
  5. If you grind during the day, be aware and try to stop grinding
  6. You should visit the dentist who may fit a plastic device to protect the teeth at night
  7. The doctor may prescribe some medication for relaxation although this is best avoided
For more info click here

Monday, November 20, 2006

Help Doctor, my child is CONSTIPATED!

Constipation is one of the most common problems in Children. But, another common problem is Parent's expectation of how often the child should have a bowel movement.

I have many anxious parents who come into the clinic and tell me that their child is constipated. The child had soft stools the day before but no stools today. Before we get carried away with treating constipation, let's understand when we call constipation constipation.

When is constipation, CONSTIPATION?

  1. Less then 3 bowel movement a week, or not having bowel movement for 3 - 4 days
  2. If the stools are very hard and the child has difficulty passing the stools
What you can do

  1. Give lots of fluids. Water and naturally sweetened fruit juices are best. Avoid soft drinks and fruit juices which are artificially sweetened
  2. Give the child lots of fibre in the form of cereals and bran. Fruits such as papaya and even dried fruits like prunes and raisins are excellent for promoting bowel motion. Make sure they get their vegetables which are a good source of fibre
  3. Getting the child to be active and excercising. Bring the child to the playground and let them run around and jump up and down!
  4. Always make sure that the constipation is not due to other causes. The Doctor will help you determine that
  5. Use a bit of lubrication like wiping a bit of petroleum jelly on the anus
  6. Make sure the formula is prepared according to instructions. Some overenthusiastic parents and grandparents put more powder or compact the milk powder to help the child grow fat fat faster!
Don't let the child be Constipated too long!!

A real life example

I saw a 5 year old child who had been having chronic constipation for almost a year. The passage of stools is very hard and she usually goes to the toilet only twice a week. It all started with simple constipation, but after a while, the stools were so hard that the skin of the anus was stretched so much that it started to tear, resulting in an anal fissure. Because it was now more painful to pass motion, the child controls the motion to avoid the pain. This results in the stools getting harder and drier and more difficult to pass. And the cycle goes around and around...

A word on toilet training

It is important that you do not let the child start to develop this problem. So in addition to the measures outlined above, you should also:
  1. Put the Toddler on the Toilet Bowl at the same time daily, usually after a meal and leave him there for 10 minutes. Make sure that the feet are rested on the floor or a stool. Encourage him to Pang Sai (Pass Motion), but if there is no motion, don't worry too much about it. Just do the same routine everyday.
  2. See your doctor once the constipation is more than 2 weeks. The doctor may prescribe some medication to help soften the stools. He will also check for other problems that may cause the constipation
That's it from me.

If you have a question, please click on comments and leave your questions there.

For more information on constipation, click here

Many cases of Diarrhoea and Vomiting recently

Just a quick note to everyone that we have been having a lot of Diarrhoea and Vomiting cases recently.

For Parents, please refer to my earlier Article on Diarrhoea

Please observe the usual precautions ie

  • Avoid sharing food
  • Washing of hands frequently
  • Be careful what you eat, make sure the food is cooked
  • Drink boiled or bottled water
Please see the doctor especially if the vomiting does not stop!

There was an outbreak last month which slowed down. But we may be seeing another outbreak at least here in the Tampines area.

Sunday, November 19, 2006

When is a Migraine not a Migraine

It is very common for patients to come into the clinic complaining of a "Migraine". People use the word Migraine to mean any form of headache.

Now, when Doctors use the word Migraine, we mean a specific form of headache. In fact, the word Migraine was derive from the Greek and it means "pain involving one side of the head.

When is a migraine a real Migraine?

These are some characteristics of a real Migraine headache:
  • One sided
  • Throbbing in nature
  • Usually very severe
  • Usually lasts several hours but can be up to several days
  • May be preceded by altered vision (Like flashes of light)
  • May be followed by nausea and vomiting
  • Tends to run in families
Few quick points on Migraine Headaches
  • They are sometimes triggered by certain foods, stress, weather changes etc
  • There are now very good (but expensive) drugs available which can stop the migraine quickly (You need a prescription)
  • When you are suffering an attack, shutting yourself in a dark room with soft music helps.

Now you know!!

For more information on Migraine click here

Help Doctor, my child is having a COUGH!


When my kids start to cough, my wife, my mom, my mother-in-law start to panic and push me to do something about it. Aiya, it's only a cough, why panic? But that's just because I have the necessary knowledge to discern between a dangerous cough and a benign (non dangerous) cough. So in this blog, I will share with you some points on how to handle your child who is coughing.

Why do kids cough?

Cough is important because it is the body’s way of clearing foreign objects and secretions from the respiratory tract. The cough itself is a symptom of an underlying disease and not the disease itself. Now, don't fall into the trap of assuming that treating a cough means giving cough syrups! If only life were so simple! The most important thing about treating a cough is to know the cause. Some coughs need to be treated with antibiotics, others may need to be treated with puffers (medication that is inhaled).

What are the common causes of cough in children?

A useful way to think about coughs is to divide them into into long term (more than 3 weeks) and short term coughs (less than 3 weeks)

Short term coughs

These are usually caused by infections or allergies. The infection may be isolated to the upper airways (ie the throat) or lower airways (the lungs). If the child is coughing and has a fever, it is advisable to bring her to the doctor to exclude pneumonia (lung infection). A child with a sore throat and a fever will need to be seen by a doctor.

Long term coughs

Some of the common conditions that can cause a long term cough are Asthma, Post Nasal Drip (this is when the mucous from the nose drips down to the throat and the child coughs to get rid of it) and Gastro-oesophageal reflux disease (When the stomach contents goes back up the food pipe.

When is a cough harmful?

The cough itself is not harmful. The important thing is to find out the cause of the cough. Conditions such as pneumonia and asthma which may have harmful complications if not treated early.

What tests should be done.

For any cough lasting more than 3 weeks, a Chest X-ray is advised to rule out important or uncommon causes for the cough like pneumonia, TB, developmental problems, inhaled foreign bodies and other diseases. Once the chest X-ray is shown to be normal, the most likely remaining causes of a long term cough are post-nasal drip syndrome, asthma and reflux disease.

Allergic Rhinitis/Post nasal drip syndrome

These children typically wake up coughing in the morning to clear the throat. They may frequently be having a runny nose but without a fever. You should approach your doctor who may assess the child and prescribe preventive medications.


These children may have an audible wheeze and be very short of breath after exercising. They may also wake up coughing in the middle of the night with an incessant cough. Asthma affects one in five children in Singapore so it is quite a common condition. When properly treated, the child should be able to function like any normal child.

You should be suspicious of Asthma if
  1. There is a family history of Asthma

  2. The child has eczema (sensitive skin) or allergic rhinitis (sensitive nose)

  3. Cough incessantly in the middle of the night

  4. Wheezes

  5. Gets very short of breath when excercising
Asthma needs to be properly managed by your doctor. Children who wake up more then 2 nights per month coughing or has a wheeze one or more times every week need to be treated with preventive medications.

Gastro-esophageal Reflux Disease

The child may complain of abdominal discomfort and may have reflux of milk after feeds. A trial of anti reflux medication for 2 weeks may alleviate the symptoms of cough.

The 100 Day Cough

There is a common saying amongst Singaporeans about the 100 day cough. This is a cough that follows a throat infection which may last up to 8 weeks. The important thing to note is that you should only conclude that the cough is a 100 day cough when all the other important causes of the cough has been eliminated.

OK, I hope that is enough information for the meantime. This is in no way complete and you may want to refer to these articles for more information:

Your Child's Cough
Patient information on Asthma

Always check with your doctor if you are in any doubt!

Friday, November 17, 2006

Diarrhoea after returning from Genting

Just a quick note to all who may be going to Genting Highlands.

This past few days, I have had patients returning from Genting Highlands with bad Gastroenteritis (Diarrhoea)

For those heading up, you should:

1. Ensure you drink only bottled water
2. Wash your hands frequently
3. Be careful about the food you eat
4. If you have diarrhoea, and can't get hold of rehydration salts. Mix 2 teaspoons of glucose into one glass of water. Or take any soft drink (eg Aloe Vera, Apple juice) and mix 1 part to 4 part of bottled water. Make sure you rehydrate.
5. If really serious, visit the local Klinik there!

Have a safe trip!

Thursday, November 16, 2006

Help Doctor, my child is having Diarrhoea!

Diarrhoea and vomiting in the child is one of those things every parent has to go through. It is important that you know some basic things about diarrhoea so that you can approach the problem with confidence.

What is Diarrhoea?

It is an infection of the bowel where there is frequent passage of loose watery stools. It may or may not be accompanied by vomiting. Most diarrhoeas are caused by viruses and usually lasts for 2 to 4 days. Occasionally, it may go on for 10 days.

What you should know about diarrhoea.

  1. The most serious problem is loss of water (dehydration) and loss of minerals such as sodium chloride and potassium. Dehydration can be prevented by increasing the amount of liquids for your child.
  2. For most cases, antibiotics are not necessary. The doctor will be able to advise you on this.
  3. Vomiting is more serious then the diarrhea itself because it prevents the child from drinking enough fluids and so the child becomes dehydrated. Medications will be prescribed for you to prevent vomiting.
How do I know if the Diarrhoea is serious?

Diarrhoea becomes an emergency when there is too much loss of fluid. You can recognize this by the child becoming listless, always drowsy, very dry tongue and skin, pallor and passing very little urine. You will need to bring him to see the doctor ASAP.

What you should do at home.

If your child is less than a year old and is being breast fed, continue to breast feed your baby.

If your child is on formula, this is what you should do:
  1. Discontinue formula feeding for 24 hours. You can feed your child rice water to allow his digestive tract to rest. Offer the same amount of rice water as the usual formula feeds.
  2. Alternatively, you can offer your child soy formula feeds
  3. Do not offer ½ strength milk feed if your child is less than 6 months old
  4. Do not feed your baby water only, you can offer oral rehydration salts.
  5. Start the formula feeds again when the nature of the stools improve.
If your child is on solids:
  1. Stop solids & offer fluids to your child
  2. After the nature & frequency of the stools improve, you can slowly reintroduce the normal feeds
  3. Avoid giving any milk products eg, yoghurt, yakult, cheese, to your child until 2 days after the diarrhoea has stopped
  4. If your child is vomiting, you can give him a trial of small frequent clear feeds such as rice or barley water. For example, give 10 to 15 mls of fluids every half to 1 hour. If he can tolerate this, you can increase the volume by 10 to 15 mls.
Important notes:
  1. It is dangerous to use anti-diarrhoea drugs to stop the diarroea in young children. It is safer to let them have diarrhoea but ensure that they do not get dehydrated by giving them lots of fluids
  2. Rehydrate with rice water or oral rehydration salts rather than plain water as the abosorbtion is better.
  3. Vomiting is dangerous because the child will not be able to drink fluids and will rapidly become dehydrated. You should seek medical help if you are unsure
  4. Contrary to popular belief, you should give more fluids when there is more diarrhoea. Some parents believe that the more fluids you cause more diarrhoea. This is not correct and may result in severe dehydration which may cause multiple organ damage.
  5. Some diarrhoeas may be due to milk intolerance, if suspected, you should check with your doctor.
  6. When changing diapers or handling your child, make sure you wash your hands because most diarrhoeas are caused by viruses which are easily spread to the rest of the family.
  7. Young infants dehydrate quickly, so it is advisable to seek medical help sooner.
  8. Yellow and green stools are quite common. What you have to worry about are jet black and bloody red stools.
For more information on this topic, please click here

Top Ten things that make the perfect Doctor

This is what I think. Let me know what YOU think!

Top 10 things that make the perfect Doctor

1. Middle aged with a bit of white hair but not too old that hands shake when giving injections.
2. Supernice and always willing to give MC without asking
3. Become a woman to look after my wife and become a man to look after me
4. Always available 24 hours a day, 365 days a year
5. Always very fast with other patients, but takes his time with me.
6. Knows about the latest news that appeared on the newspaper 5 minutes ago.
7. Medicine so good, take one time only always get well
8. Give injection no pain one!
9. Got lobang to go find some nice makan places (I qualify!)
10.Free service, no need to pay!

Wednesday, November 15, 2006

Help Doctor, my child fell and hit her head!

When I was young, I remember falling a few times and hitting my head on the terrazo floor and developing a Baluku (Swelling). Back in those days, my parents would not even blink an eye at my Baluku. I had 2 brothers, so invariably we would get ourselves into trouble all the time. Luckily, I did not suffer any brain damage... or so I assume.

Nowadays it is not uncommon to see parents bringing their kids to the clinic after they fell and hit their heads.

So how can you recognize if the head injury is serious? And how do you prevent a Baluku from developing?

What happens in a head injury?

The brain, which has the consistency of jelly, is housed very compactly in a rigid case – the skull—and cannot tolerate any increase in pressure. When a head injury is sustained, the most critical event that we try to rule out is bleeding or swelling of the brain which may be fatal.

How do I recognize a serious injury?

How the child injured himself is very important. In general, if you fall from a height twice the height of the child, then you should be suspicious of a serious injury. To put it in everyday terms, if the child falls from a normal bed onto a carpeted floor, the injury is unlikely to be serious. If the child fell from a double decker bed onto a marble floor, hitting the head directly, then it may be serious. Head injuries sustained in violent events such as car accidents should always be assessed by a medical professional.

What signs do I look out for?

• Any unusual behaviour
• Confusion about familiar names and places
• Inability to wake child from sleep
• Increasing or persistent headache
• Seizures (Fits)
• Unsteadiness on feet
• Unusual drowsiness and sleepiness
• Vomiting more than three times
• Double or Blurred vision
• Bleeding or discharge from the ear or nose

In general, if the child falls and cries loudly for a while then afterwards behaves normally, then it is a good sign. If the child falls and loses consciousness or starts vomiting or becomes very lethargic and sleepy, then something is wrong.

A real life example

I had a friend who consulted me over the phone last year. He said his daughter had fallen off from a bicycle and hit her head in a drain. A few hours after the event, his daughter is now vomiting incessantly. I immediately told him to bring the child to the A&E Dept. The child underwent surgery to remove a blood clot in the brain. The surgeon said that if they had waited any longer, the child might not have survived.

What did we learn?
  • The nature of the injury (falling off the bike into the drain) and the signs following (vomiting) is enough to tell you that this is serious.
  • Do not underestimate a head injury. Most of the time it is safe, but when it is serious, it is a matter of life and death.
  • I would highly advise all parents to make sure your children wear helmets when they ride their bikes. It is better than any insurance you can buy for them from your friendly insurance agent.
How do I prevent the Baluku (Swelling) from forming

Get a towel and some ice or better still if you have a cold gel pack (like the one in the picture) and press it against the injured part of the head. By applying pressure and ice, you stop the bleeding underneath the skin and prevent the Baluku from forming. If you can't get ice, never mind, just use a towel and press hard over the area for 10 minutes. No towel? Just use the palm of your hand.

Do I need a Skull X-Ray?

Skull Xrays help to identify skull fractures. However, they do not directly show brain injury or bleeding within the skull. A skull X-Ray is not a reliable indicator of bleeding within the skull or brain injury. They are seldom necessary but the doctor will decide if one is helpful.

Clinically abnormal signs and symptoms as mentioned above are much more reliable than skull X-Rays as predictors of brain injury or bleeding within the skull.

A normal skull X ray does not rule out bleeding within the skull or brain injury.

What do I do after seeing the Doctor

Continue to monitor for the above signs for the next 72 hours and return to the Doctor if you see any of the signs or if you feel uncomfortable.

More information can be found by clicking here

Trans Fats: Why the Fuss?

Trans Fats seem to be a hot topic nowadays, but after talking to some patients this morning, I found that actually a lot still don't know much about it. So let me just highlight a few points and link you to some articles which will give you more details.

Sorry, but I couldn't resist taking this picture of Trans-Cab which has nothing to do with Trans-Fats.

Years ago, when people started to use vegetable oils, everyone was so happy because vegetable oils contained polyunsaturated fats. These fats are liquid at room temperature and are better for you as compared to Saturated Fats that you find in animal fats like Butter. The thing is that it is difficult to spread a vegetable oil, so they developed a process called hydrogenation which turned the oil into a fat ie a semisolid at room temperature. Hooray!! Now they have a substitute for butter which can be used for making cookies and other pastries.

So after many years of believing that vegetable oils are better for you, some really smart scientist found out that the hydrogenation of vegetable oils produces trans fatty acids. Then they discovered that trans fatty acids are actually as bad for you as saturated fats!

Both trans fatty acids and saturated fats raise the bad cholesterol (LDL) and lower the good cholesterol (HDL) and by doing so increases the chances for your artery to get clogged up resulting in a heart attack or stroke.

So now some manufacturers are cashing in on the opportunity to highlight that their products contain no trans fatty acids. And quite rightly too. You as the consumer should look at the labels carefully and choose the right foods for the family.

In a nutshell, if you are buying any processed foods such as cookies, margarine, peanut butter or fried stuff such as potato chips (hydrogenation helps to prevent fats from going rancid and increases the shelf life of such products), then look at the label to see if there is any trans fats.

The WHO recommends that trans fats make up less then 1% of your total fat intake per day. This is roughly less than 2g of trans fats per day. When you eat a pack of pototo chips, it typically contains 3g of trans fats.

I promised to keep it short. So that's it from me. If you need more information please click Here and Here.

Tuesday, November 14, 2006

My Newborn has a Rash on her Face!

One of the most frequently seen conditions in newborns is this atopic eczema on the cheeks of babies. This is a mild case in one of our little patients. Some children may also have the red scaly rash on their arms and legs.

For mild cases like this all you need to do is to observe some basic tips:
  1. Avoid soap and perfumed products in the bath
  2. Apply a mild moistursing agent to the skin (make sure it is baby safe)
  3. Avoid using hot water, use tepid water instead
  4. If the rash is on the body as well, use 100% cotton clothing
When you need to be concerned:
  1. When the rash can get so bad that it starts to weep and infection sets in.
  2. When the baby is very irritable because of the itch.
What can be done:
  1. The doctor may prescribe a mild steroid cream and anti-itch medication for more severe cases

The good news is that most of the mild cases will usually clear up by the time the child is 1 to 2 years old, like this little one year old (different child) who had a similar rash last year. Now the skin is as smooth as .... well......a baby's bottom.

This is only a very short blog on the topic of atopic eczema specifically on the newborn infants' cheek. For a more complete article on Eczema in kids please click here

Always, always consult your doctor if you are unsure.

Sunday, November 12, 2006

Help Doctor, my child is having a FEVER!

This is the first in a series of educational blogs aimed at parents. I will be writing from the point of view of a parent with 2 young kids. When my kids have a fever, I panic too! OK, I will concede that I panic less then my wife (who is not a Doctor). The only reason is because I know a bit more than her. Knowledge empowers. So let me just share a few pointers which I hope will empower you to handle your child's fever.

What temperature constitutes a Fever?

Fever means that the body temperature has risen by 0.5 degrees above normal. Normal body temperature is dependent on which part of the body you take it from. So in a nutshell:

  1. If you stick the thermometer in the mouth, anything above 37.5 degrees is a fever
  2. If you stick it in the armpit, anything above 37.2 degrees is a fever (armpit less warm)
  3. If you have a ear thermometer, anything above 38 degrees is a fever
BUT, don't just depend on the thermometer! Temperatures rise and fall. So if your child looks sick to you and is behaving abnormally, chances are that he is sick! The temperature is just another indicator of illness.

What you should know about Fevers.

You should understand that a fever is the body's normal response to infections. The body's defence system (immune system) works better in a warmer environment, so the brain actually raises the internal thermostat. (Like how you adjust the aircon temperature) Studies have shown that a child 's length of illness is shorter when the fever is not too aggressively controlled. If you aggressively control fever, the illness actually lasts longer!

So why do we control the fever?

A few things can go wrong with high fevers especially in children.
  1. Brain damage can occur with prolonged high fevers above 41.5 degrees. But of course we are KiaSu (very careful), so in general we don't like the fever to go beyond 39 degrees for too long.
  2. In children between 6 months and 6 years, a fever can sometimes cause fits.
What do I do?

From a parent's point of view, the real question is: When do I need to bring my child to see the doctor? Here are a few pointers:
  1. If the child looks sick, ie she is not as active, lethargic, vomiting, in pain, anything that makes you uncomfortable, you should go see the doctor.
  2. If the child is running around, laughing and playing and the fever is less then 38.5 degrees, then the situation is not immediately urgent. But you should be on the lookout for any changes that might occur. Things like rashes, mouth ulcers, wheezing, vomiting are some of the signals that you should be bringing your child to the doctor.
Here is what you can do in the meantime:

  1. Give panadol syrup. Everyone knows about panadol syrup! But please know this
    • Panadol syrup only works for fever and pain. It does not stop a runny nose.
    • The dose of Panadol syrup is dependent on a child's weight. Use as directed on the bottle. When you come to the clinic, we will weigh the child and customise the dosage and frequency to your child's needs.
  2. Give the child plenty of fluids.
  3. Sponge the child. Those forehead gel pads really give you false security. By the time I see the children, they are already warm and do very little. This is what you should do. Take a small bucket, fill it with room temperature water. Take a towel, wet it, squeeze dry so that it doesn't drip but not too dry, and wipe the child's head, neck and body area. Keep doing it for 15-20 mins making sure that the child does not start shivering.
  4. For older children, put them under the shower with tepid water for 15 mins.
  5. Generally, we prefer to use Panadol syrup because it is safer. Brufen is the other medication that is sometimes used. But if Panadol syrup and sponging does not bring down the fever, it may be wise to seek medical help.
Other Important Points
  1. Teething does not cause fevers
  2. I think most parents know by now that wrapping with a blanket is not a wise thing to do for a child with fever as it would raise the body temperature. (I was wrapped up myself when I was a kid. Lucky it did not result in brain damage.... or maybe it did!)
  3. A fever that lasts for around 5 days and stops with the appearance of rash may be due to Dengue fever. So you MUST bring the child to the doctor.
  4. Some viral fever can last a long time, up to 14 days. No amount of antibiotics will help.
  5. A blood test may need to be done in prolonged fevers
  6. In general, it is better to monitor the child over a few days to look out for definitive signs of particular diseases rather then to start Antibiotics on day 1 of the fever. For example, if the child is going to have Chickenpox or Hand, Foot and Mouth disease and you bring the child to the Doctor on the first day, you may miss the rash and the mouth ulcers that will appear in the next 24-48 hours. So giving antibiotics would be a waste.
  7. I would advise any parent to bring the child to the doctor if the fever lasts more than 3 days.
  8. A prolonged and recurring fever may be an indication of chronic diseases like juvenile rheumatoid arthritis.
  9. If you have just been to a Malaria infested country, please let the Doctor know because Malaria can be deadly
  10. A fever accompanied by a sorethroat in a child between 4 to 14 years of age should be seen by a doctor sooner. Antibiotics may need to be given to prevent long term complications such as kidney failure. Children in this age group are susceptible to certain bacterial infections which may cause terrible complications.
This is by no means exhaustive. I try to keep everything concise and bring up only the most important points. If you have other questions or points to bring up, please write in the the comments. Remember it is always best to bring your child to the doctor if you feel uncomfortable.