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


1. RELIEVERS


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.

The most common drug used is Ventolin, which is also known as Salbutamol. Other brands such as Salbuair, Salamol, Salmol, all contain the same ingredient, Salbutamol.

2. PREVENTERS

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.

The commonly used Preventers are Beclotide, Flixotide and Pulmicort which go by various other brand names as well.

New Anti-Inflammatory Agents

These are a new class of drugs used in Asthma. The one most commonly used is called Singulair 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 <>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.

5. Oral Ventolin has a slower onset of action as well as being less effective then inhaled Ventolin. So if the child has asthma, it is highly recommended that the Ventolin be administered by inhalation.

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


A
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!

Introduction

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.

Asthma

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.
Disclaimer
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.

Friday, November 10, 2006

Top Ten fears of a patient



Putting myself in the patient's shoes.... Remember, I sometimes change roles and become a patient as well!

Top ten fears of a patient

1. I hope it is not a nasty doctor behind that wooden door. (New patients)
2. Is he going to give me MC today?
3. Am I going to die?
4. Is the medicine going to be yuckky
5. Will my hair grow back?
6. Will there be a scar? (After having 10 stitches to the forehead)
7. Is the injection going to hurt? (I don't know of one that doesn't)
8. Is he going to have to look at my private part?
9. Is he going to be unhappy because I went to see another Doctor?
10.So many medications, sure going to cost a lot of money

Please do add your own fears in the comments section below

Thursday, November 09, 2006

Hello and Welcome!

Hello and welcome to my Medical Blog!

After much consideration, I have finally decided that it is alright for the world to know that my cyber-foodiepersona ieat is really a Family Doctor. But over here in this blog, I'm itreat instead.

I have been toying with the idea of personalizing our service through the use of the internet since we starting our clinic last year, but really did not know of a suitable platform.

Then of course came my food blog which opened my mind to many possibilities. This medical blog will serve as a platform for me to pen down some of the thoughts that come to me while working in my clinic. I want it to be something that our existing patients will find useful in that they have a family doctor whom they can interact with in between visits.

It is not my intention to go into details of medical conditions, nor will I be offering medical opinions in the blog. To do so will be to create jobs for my lawyer friends. But I will be writing (I hope) about things that affect our everyday lives here in Singapore.

One of my interest area is childhood asthma which I feel is a condition that can be better managed in Singapore. Asthma affects 1 in 5 children here and is growing and most parents do not know how to manage it. I will be writing from the point of view of both a doctor as well as a parent of 2 young children, so I hope it will be relevant to other parents out there.

I would love to hear from you as to what medical issues are of interest to you which you would like to read about. So please write to me at: leslie.tay@gmail.com

Hope you will find the blog useful and entertaining.

Yours Sincerely,

Leslie Tay
MBBS Sydney

Why Karri?

Probably the second most frequently asked question after "How long before I get better?" is the question, "Why is your clinic called Karri?

The short answer is that it was named after the tallest species of Eucalyptus Tree found in Western Australia. The Eucalyptus as you may already know is used in many herbal remedies and most often as a Balm for soothing aches and pain. Ha, very romantic idea right?

The real story is that we went through a series of names like Health First Clinic, Healthy Family Clinic, Pinnacle Clinic and so on but I was dead set on NOT having another Clinic with so predictable a name. (As you may have already know, I am a bit of a rebel - a tame rebel, but no less a rebel).

So since my partner Suren had already started a company known as Karri Pte Ltd, I told him that Karri Family Clinic has a nice ring to it, and the Karri Tree is a symbol of Integrity, Strength and Dependability but at the same time Gentle and Soothing.

In retrospect, I wouldn't have called ourselves Karri Family Clinic. It would worked well in Australia, but in Singapore, people don't pronounce Karri, Kair Ree, they pronounce it Kar Ree and think that the leaves we used on our logo are Curry Leaves! Oh well, too late now! But at least you know!

Wednesday, November 08, 2006

Who we are

Welcome to our Clinic Blog! Here's where we introduce ourselves.

I'm Leslie Tay. I was born a Teochew to Teochew Parents who were born of Teochew Parents themselves. So I consider myself a purebred Teochew Ah Bah.

I grew up in Toa Payoh, spent my formative years at St Andrew's School and then studied in Raffles Junior College. After NS, we all migrated to Sydney where I studied medicine at the University of Sydney.

After my doing my Housemanship year at Concord Hospital Sydney, I returned to Singapore with my wife and settled here. Why? Because I missed my Teh Tarik and Roti Prata for breakfast!

After working for a couple of years in Government Hospital, I joined Raffles Medical Group as a family doctor, after which we spent 2 years in Bangkok as expats. During this time, I did some mission work as a Doctor in the border regions of Thailand.

After returning home, I spent some time working in the private sector and even joined the EDB's biomedical sector for a short stint. Before starting Karri Family Clinic, I was working at the Children's Emergency Dept at KK Women's and Children's Hospital.

I completed my Graduate Diploma in Family Medicine in 2007, so I guess I am a little smarter than I was before!

Meet my partner, Dr Surendran Baskaran (Baptism name, Marc).

Suren believes that the family doctor plays a central role in the healthcare needs of family's. He studied in NUS and graduated in 1991 and enjoyed working in the public hospitals for 6 years. In 1998 he left to join a corporate clinic Gethin-Jones Medical Group.

After a few years there, he started his own practice in Woodlands. He went on to complete the Masters degree in Family Medicine in 2002.

Suren is also certified to practise Anti-Ageing medicine where he helps to ensure that people have the resources to live a long healthy and productive life.



We are joined this year by Dr Serene Ang who consults during Friday Nights. Serene brings with her many years of experience in Family Practice. She will be focussing on Women's Health and Skin Disorders.

Tour De Clinic



I'll take you on a quick tour around the Clinic (which we designed ourselves). Oh, if you are wondering about the nifty gadget little Jasmine is looking at, its called a Gravitron and I will tell you all about it a little later.



We have tried to steer clear of the traditional HDB clinic look (although we are a HDB clinic) by having warm colours in the waiting room. I personally feel that patients should not have to wait too long to see the doctor. But at times, it just can't be helped. So the best alternative is to provide a comfortable waiting area for the patient.



See, I personally handpicked these chairs from Celine designs so that our friends can sit comfortably while watching TV. And by the way, we don't show ads on the LCD screen. You would be bored to death. No, you get to watch whatever is on the Air. We had a great time during American Idol!



This is our treatment room. You can see the autoclav and the ECG machine in the corner. The treatment room is a second room we use for patients needing the nebuliser or other treatments. It is also used to monitor patients, like when your child has a high fever. We will put the family in the room and teach them how to sponge the child to get the temperature down.



Don't like kids to be bored. So they get to play with my pinball machine while they get their ventolin neb.



Worse thing about an elbow dressing is that it comes off too easily! So we invest in the extra netting to make sure the dressing stays put.



I like all these modern dressing materials like this Alginate Hydrocolloid Dressing which is excellent for ulcers and clean superficial wounds. The gel like dressing sticks well, is moldable and you can bath with it on. Of course these special dressings are a little more expensive. So patients are always given a choice if they want to use them or not.



We also stock Plaster of Paris in case of emergencies. The Plaster of Paris is used to make a backslab in case of a suspected fracture.



This is the way to wrap a finger! Neat and nice.



OK, let's move to the Dispensary. We keep both generic medications as well as all the branded stuff here. Patients are always given a choice as to whether they want the generic product or the original product. The general principle is to keep costs as low as possible, so I usually prescribe the generic medications unless I feel that the condition requires something better.



Everybody is scared of injections! We try our best to make injections as painless as possible for the children by applying a local anaesthetic cream and also to distract them with gadgets like the Gravitron. (I promise I will tell you about it)



At last we come to my favourite room. My room of course. This is where I do all my consultation work as well as my Blogging work. We have designed the room so that it is spacious enough to accomodate the whole family including the grandparents. I love it when everyone is inside the room. I make sure that Ah Gong and Ah Ma have a nice sofa to sit while waiting for the grandkids to be treated.



Here are some of my gadgets that are worth mentioning. The Pulse Oximeter is a device that measures the Oxygen saturation of the patients blood. In short, it gives me an extra piece of information pertaining to the severity of the patient's respiratory condition. It is especially useful in conditions like Asthma and Bronchiolitis where a low saturation score may mean an immediate evacuation to KK hospital. On the other hand, a 100 percent saturation score is very comforting for parents whose child is coughing incessantly.



Another gadget I have in my room is this one which helps me decide on whether to use antibiotics for a certain condition. The beautiful thing is that it only requires one drop of blood and within 5 minutes, the results are known. It does not replace the full blood count, but it does provide extra information for the parents and I to make a clinical decision.



Now we come to the fun part. Kids nowadays are very smart. You can't entertain them just by giving them an old stuff toy and a sweet anymore. No you have to show them something that they have never seen before. These Disney Cubees are only available from Disneyland and most children won't have seen them. At the press of a button, they sing a tune and the face clicks. Stack them together and they sing in parts!



At last we come to the Gravitron! This one never fails to mesmerize the kids and most of the time, the Dads as well. How does it work? Well, you spin it like a top and the magnets in the spinning top and the base repel each other, keeping the top spinning in midair. It can go for several minutes if done properly! Like Magic! This one I usually keep for the most difficult kids!

Well, that is the end of the clinic tour! Do leave a comment and tell us what you think!


What our friends say

Some of our friends and what they have to say about us:



Tuesday, November 07, 2006

Opening Times

Our Consultation Hours are:

Mondays to Fridays
8.30am to 1pm
6.30pm to 9.30pm

Saturdays
8.30am to 12.30pm

Closed on Sundays and Public Holidays



Map to the Clinic


View Larger Map

We are located in the Tampines Central Community Complex. This Complex is one of a kind in Singapore and was officially opened by PM Lee in October 2005. It is unique because one half of it houses the Tampines Central Community Club. The other half houses NTUC, a Food Court, Cafe Arcadia, Elfa Child Care Centre and numerous other enrichment centre for kids. Aside from our Family Clinic, there is also a Dentist just beside us.

There is ample basement parking which is great especially when it rains!

Karri Family Clinic
Tampines Central Community Complex
866A Tampines Street 83
#03-05
Singapore 521866
Tel: 67850311