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A - Z of Childhood Illnesses

M N O

On this page: Malaria Falciparum malaria Malnutrition Measles Meningitis Meningism versus meningitis Meningomyelocele Menstrual Problems Amenorrha Mental Retardation (M.R.) Mouth-To-Mouth Breathing & Cardiac Massage Mumps Nephrotic Syndrome Nose-Related Problems Epistaxis Obesity

Malaria

Two million cases of malaria are reported every year in our country. Thirty-nine percent of these cases are the more serious types called falciparum malaria which can affect the brain. Typical history A typical case present with shivering and high fever followed by sweating and fall of temperature. The fever comes on alternate days, and in between the child looks well. A history of a child in an area where malaria is common or the child having returned from such an area aids in the diagnosis. A blood test confirms the diagnosis. In another case, the fever may occur every day. Shivering or rigors may not be present. If no obvious cause of fever is to be found and your doctor finds your child has an enlarged spleen, he may like to rule out malaria. Diagnosis It is important that the blood for sample for malaria be taken before treatment is started. This test is not only important for the confirmation of the diagnosis but it is also helps us to know the type of malaria, the precise treatment to be given immediately and to be followed later. If the malaria is due to Plasmodium vivax (the more common type), the treatment is different from the falciparum variety. It is very simple blood test. The blood can be collected from a finger prick. However, if your doctor is not sure of the diagnosis, he may ask for some other blood tests and then the blood may have to be collected from the vein. If you are in an area where even such a simple test for malaria is not available, you may have to follow the advice of your doctor and take treatment for malaria in case the doctor strongly suspects the diagnosis. Falciparum malaria Besides shivering and fever, a child with this type of malaria can become quite sick. He may start losing his alertness, get convulsion and may become unconscious. This should be treated as an emergency. Many lives are saved by appropriate treatment. Drugs in malaria Quite effective drugs for this disease are available in our country. Some children get vomiting with these drugs but most tolerate them well. Oral administration of medicine is better than injections, unless your child does not tolerate the drugs given by mouth. If your child has G-6-PD deficiency (see section on anaemia), you must tell your doctor. Children having this deficiency may react badly to some of the anti-malarial drugs. Prevention You must cooperate with the public health authorities in the prevention of the spread of this disease which can make the patient very anaemic and weak. Some people do not realize the malaria mosquito can thrive on clean water. So we should make sure that the water storage sources in our buildings are well cared for. In areas where malaria is common, all care should be taken to prevent mosquito bites. Those who can afford to have automatic door closers and netting on all the windows should go for them. In the near future, we may have mosquito nets which are impregnated with a medicine to keep the mosquitoes away. It is also possible that your doctor may put on some drug or drugs to be taken regularly once a week if you are living in a malaria-infested area or you are going to visit such an area. However, we must know that after living in a locality with malaria for a numbers of years, quite a few older children and adults can develop partial or complete immunity against the disease. Such persons are not advised this continuous prophylactic (preventive) treatment. But if you live in an area where malaria is unknown, then you must start giving your child the prophylactic medicines 2 weeks before you start your journey for a malaria area. The drug is to be given throughout the stay in that area and to be continued for 2 months after returning home. Indiscriminate use of drugs for malaria has resulted in development of resistance to certain anti-malaria had drugs. So it is advisable not to take such drugs without proper advice.

Malnutrition

By malnutrition, I mean undernutrition, obesity, vitamin deficiency, iron deficiency, calcium deficiency and iodine deficiency. In this section we shall only discuss about undernutrition. Obesity is discussed elsewhere. Undernutrition For the present discussion, we shall consider a child to be undernourished if he is below 80 per cent of his expected weights. (see section on normal weight and height) We should be seriously concerned if the weight is below 65 per cent of the expected weights or if the child fails to gain weight in 3 successive months. Thus, a child whose expected weights is 10 kgs and who weights less than 8 kgs is considered undernourished. If he is less than 6.5 kgs, I would be much more concerned and give extra attention to find the cause of his undernourishment. Normal variations I shall not be tired of repeating this phrase. A child may be much below his average weights, but so long he is active, full of life, gains weights slowly but surely and does not fall ill too often, I would not start investigating him in a hurry. I would observe him for a couple of months and look for other common causes of a lower weights like the small size of his parents, small birthweight and failure to gain weight in the first few weeks of life from any cause which is rather difficult to be compensated later on. Common causes of undernutritions: Premature termination of breastfeeding. Improper artificial feeding. Delayed addition of complementary foods. Infections like diarrhoea’s, urinary infection and tuberculosis and infestation with parasites. Heart disease. Emotional factors. Diabetes. Unknown cause. When I say `unknown cause', I refer to a few children (I see one such child after every year or two) who just refuses to gain weight adequately. Even detailed investigations fail to reveal the cause. Fortunately, quite a few such children have become confident young men and women and are doing well in life. I have purposely avoided less common causes of undernutrition. Causes given above are common to all socio- economic groups. Of course, our less fortunate citizens and their children remain undernourished because of common factors like poor purchasing capacity, lack of education, unsafe water supply, poor environmental sanitation and personal hygiene, coupled with certain wrong notions like starving a child with diarrhoea, undue restrictions of diet in jaundice, delayed addition of solids in a small infant, and giving dal water or thin soup containing very little energy to small infants.

Measles

Measles is a virus infection against which no antibiotic works. Though it causes a lot of discomfort to the child, most cases recover without any specific treatment. Complications in well-nourished children are rare. Children who are malnourished and who have tuberculosis need extra care. Tuberculosis can spread rapidly in the presence of measles. Prevention As it is a highly infectious disease, most of you must have acquired the infection in childhood when the measles vaccine was not routinely given. As a single attack of measles usually confers a lifelong immunity, the pregnant mother passes antibodies to her baby against measles while he is in her womb. These antibodies protect him for about 9 months after delivery, the age at which measles vaccination will be advised for the infant. If there are large number of cases in a particular locality, the vaccine is even given earlier. For better protection, children given the vaccine at 9 months should be given another dose of measles vaccine at 15 months. Alternatively, MMR (measles, mumps and rubella) vaccine can be given at 15 months. After 8-10 days of the vaccine, the child may get a mild measles-like illness. No treatment is required for this. When to suspect measles in your child The diagnosis of measles is suspected in a child who has not received the measles vaccine and after coming in contact with a case of measles, develops fever, dry cough, running of the nose, and watering of the eyes. As the days pass, the symptoms get worse. After 3-4 days a (a day before the rash appears), the child gets koplick spots (white spots, like grains of salt on a red surface) inside the cheek opposite the first and second upper molar teeth. The following day the rash appears, when the fever shoots up (around 104 F). The rash appears first on the hairline and then spreads down- wards. The child looks quite ill and loses his appetite. He may not even want to have water. If he is breastfed, he may demand feeds more often. The fever continues for about 3 days after the appearance of the rash which lasts for 5-8 days. After it fades, the skin may tend to peel off. The rash starts as fine, slightly raised spots which may join together to give a patchy appearance. How to differentiate measles from other similar illness When a mother tells me that her child got a second attack of measles or he had measles after having received measles vaccine, it is often a case of mistaken diagnosis. The child probably had or is now having a measles-like illness and not measles. One such illness is exanthem subitum or roseola infantum. This is also a viral infection in which the child gets high fever like measles. But the child does not look too sick. There is hardly any cold or cough. After 3 days, the fever suddenly returns to normal to be followed next day by a light red rash which is not raised from the skin. It spreads from the trunk or the face and then to the limbs and fades within a day. It may be noticed that in measles, the temperature rises as the rash appears and the fever continues for a few days more along with the rash. But in exanthem subitum the rash appears after the fever returns to normal. Treatment of measles There is no specific treatment. For cough, a home-made syrup of 2 parts of honey, one part of lime juice and tulsi (or ginger) juice is helpful. (Also see section on 'cough'.) A child can be given 1 to 2 teaspoons of this mixture 4 to 5 times a day. Children with measles prefer to stay in the dark as bright light causes discomfort to the eyes. For fever, sponging with slightly warm water can be done or paracetamol may be given. Food desired by the child should be offered. No food restrictions are necessary. Make sure he drinks enough fluids including juice, coconut water and plain water. Daily sponging of the whole body is advisable. A bath with slightly warm water is also allowed. If your child with measles refuses all foods and liquids and if he has fast breathing, earache, persistent headache, drowsiness or vomiting, you better consult your doctor to rule out any complication. Also if the fever and cough persist after about 10 days, you must report to your doctor. Your child with measles is infectious to others from 1 to 2 days before the onset of illness to about 4 days after the rash appears. He should be kept away from other children during this period. If his brother or sister has not had measles before, they should not be sent to school or any crowded place for 10 days. This is to avoid them infecting people they come in contact with.

Meningitis

Early diagnosis is important Early diagnosis and treatment of this disease can save a life. Delay can be fatal or child may be left with serious handicaps. So it is important for you to be familiar with this disease. What is meningitis? The disease, which is fortunately not very common, affects the covering of our brain and spinal cord called meninges. Pyogenic meningitis (due to pus-producing bacterial) and TB meningitis are the two important causes. A less serious cause is viral meningltis. Pyogenic meningitis often presents with an acute onset. Compared to that, TB meningitis has a slow, rather insidious onset. When to suspect meningitis The disease can affect newborn babies as well as older children. The child who was perfectly alright develops a fever. He goes off feeds (in newborns and younger infants this may be the earliest symptom even before the fever comes). The child may be very irritable or listless. An older child may complain of persistent headache. He looks sickly and starts vomiting. As the disease advances, he may appear drowsy, avoid light (photophobia), lie curled up to one side with his neck arched backwards, become unconscious and develop convulsions. The soft spot in an infant (anterior fontanelle) is often bulging and tense. With lack of intake of food and vomiting, he may become dehydrated. TB meningitis also has all these features except that they develop slowly over days or weeks. Hospitalization is essential for treatment of meningitis If a suspicion of meningitis even passes though your mind once, consult your doctor. Hospitalization may be advised. Diagnosis is confirmed by examination of the CSF (cerebrospinal fluid) lying between the meninges. This is removed from the back by putting in a needle between the two lower spinal vertebrae. Fortunately, we do have effective drugs for both pyogenic and TB meningitis. Most cases of viral meningitis, unless complicated by encephalitis, recover completely. With early treatment, those with pyogenic or TB meningits often recover fully. This is true even in newborn babies, though compared to older children, they have a poorer prognosis. Meningism versus meningitis Sometimes a psedo-stiffness of the neck presenting with certain other infectious diseases can be confused with meningitis. This is called meningism. Your doctor will be able to differentiate the two conditions by clinical examination and if in doubt by getting the CSF examined. Meningomyelocele Due to defect in the spine, the meninges (covering the spinal cord), and even the spinal cord may protrude out and may present as a swelling over the spine. The spinal defect is called spina bifida. It is commonly present nearer the lower end of the spine. In meningocele, only the meninges come out. If the cord also protrudes out along with the meninges as in meningomyelocele, the child may also have weakness of the lower limbs and loss of control of the bowel and bladder function. Hydrocephalus is also a possible complication. If only the meninges are protruding, the outcome is much better. Such a child should be urgently seen by a surgeon (preferably a paediatric surgeon or a neurosurgeon) who decides if surgery is indicated. In very severe cases, the surgeon may discuss with the parents the poor long term outcome in such cases and may avoid surgery.

Menstrual Problems

The first menstruation (period) The first menstruation or period begins somewhere between 10 and 16 years. If you notice signs of enlargement of the breasts, your daughter would probably have her first period 2 years after that. When you find the she is having a sudden increase in her weight and height, she will have her first period about a year after that. It is important to discuss the normal phase of growing-up with your daughter. If you do not feel comfortable, let another responsible person - a doctor, a counsellor, or a relative discuss it with her. A few months before the beginning of menstruation, girls may normally get a white discharge from the vagina. This is called 'physiological leucorrhoea' and does not need any treatment. Absence of menstruation (Amenorrha) You should meet your doctor if your daughter has not started menstruating at 16 years of age or has missed her period after having started menstruating. It is possible that it may be a normal variation. Do not start worrying until you have discussed this with your doctor. In some families, periods are normally delayed to begin with. They are also delayed in thin girls who are otherwise normal - e.g. athletes or those who practice regular dancing. In athletes who run extensively, low hormone levels related to onset of menstruation are reported. The same is true of thin girls having a chronic disease, anorexia nervosa or malnutrition. It could also be due to certain drugs. In any case, you should see your doctor as the cause may be something different, requiring investigations and treatment. Even pregnancy should be kept in mind. Normal irregularity of periods in the first year or so The first couple of periods in a girls are usually not associated with the release of ova, the female egg. These periods can be irregular, scanty, prolonged or heavy. In case of any doubt, see your doctor. Discomfort during menstruation Even if you had painful menstruation, do not pass on this information to your daughter in a negative way. When she starts menstruating, you may just ask her how it is going. Remember that the periods which take place without ovulation (release of female egg) are not painful. If you suggest to her in advance about the possibility of pain, she may start complaining about pain due to psyschological factors. Even cycles with ovulation are not necessarily associated with pain. However, if pain occurs, you should see the doctor. If no disease is detected, the doctor may reassure your daughter and, if required may give her a relatively safe drug called ibuprofen (400mg four times a day). Drugs containing analgin and aspirin should be avoided. The drug is started as soon as the periods begin and is discontinued when the pain stops. Children who have regular exercise or those who take part in sports, are less likely to have cramps before or during menstruation. Mood disturbances in between two periods Quite a few girls get a feeling of depression, headache and cramps a week or two before the periods. If required, ibuprofen mentioned above may be prescribed by your doctor. Most cases improve merely with reassurance, healthy diet and exercise. Use of tea, coffee, cola drinks, sugar and salt may be restricted. Unexpected bleeding from the vagina While bleeding from the vagina in a newborn and in an adolescent who is otherwise well is normal, bleeding in other children could be could be due to some disease. A doctor must be a consulted. It could be due to a generalized bleeding disorder, hormonal disturbance, precocious puberty occurring before the expected age, injury, a foreign body in the vagina, sexual abuse or even a tumour.

Mental Retardation (M.R.)

When a child is of below average intelligence and has difficulty adjusting to his surroundings, he is said to have mental retardation. Because a child is slow in learning certain skills, it does not always mean that he is mentally retarded. There is a normal variation in achieving the milestones of development. Some children are slow in picking up a particular skill but are smart in all other respects. This could be normal. A child who is retarded is slow in almost all milestones of development. Sometimes lack of proper stimulus at the right age may also delay the process of development in an otherwise normal child. For example, some children who are brought up in an institution may be slow, but as soon as they are adopted, the loving stimuli provided by the adoptive parents helps them progress with an unbelievable rapid pace. Ultimately they succeed in catching up with children of their age. In any case, if you suspect that your child is slow in learning new skills, your doctor may like to see the child on a few occasions and then decide if he should be referred to a specialist for an expert opinion. The specialist does certain tests to assess the development of the child. Your doctor may also find out if the child has any other handicaps like impaired hearing, visual defect, a specific learning disorder, attention deficit, cerebal palsy etc. This is important to guide you for proper management of your child. In some cases, the diagnosis of mental retardation can be made at birth. A child with all features of Down's syndrome can be diagnosed at birth. In certain cases, it may not be possible to suspect retardation at an early age. The handicap may be suspected later from observations by parents, grandparents, a caretaker or a school teacher. Guidelines for parents of children with mental retardation Do not feel guilty You may not believe the doctor who first tells you that your child is retarded. Most parents refuse to believe this. But once you have accepted the diagnosis, you may feel guilty that it is because of some carelessness on your part that all this has happened. You must understand that in most cases of M.R. we are not able to even find the cause of retardation. Moreover, what shall you gain by carrying the guilt? Nothing. On the contrary you shall harm yourself and in the process your child will not get best possible attention. Say to yourself : This child needed me and nobody else. At some stage, you may also wonder why has God dealt with me like this? After sometime, you may answer yourself as did a mother whose child had congenital hydrocephalus (excessive water in the brain) with M.R. She said: 'Doctor, I think God felt that I am the one who was meant to give the best possible care to the child. Nobody else could have done so. I have been given this responsibility and I will do my best.' Don't overdo it You may now start going from pillar to post in the fond hope that ultimately your child will become normal. You may start getting conflicting advice. Magic remedies and `brain tonics' may be offered to you for your child. Do not fall prey to all this. Be guided by your doctor. Also, you may protect your retarded child to such an extent that unwittingly you may interfere with his growth and development. Besides this, your husband and other children may start feeling neglected. An understanding husband will respect your feelings and will support you but you must not forget that he is also human and that your other children also need you. In this connection, I remember a child (let's call him Neil) was admitted under me in a hospital in the UK for pneumonia. He was brought to me by the neighbours who were looking after him as well as his older brother (let's call him Richard) who was retarded. The parents of these children had gone for a holiday. Two days later, the panic-stricken parents arrived in our hospital. They were informed by the neighbours telegraphically that their son was admitted to the local children's hospital. They did not know which of the two children was sick until they met me. The moment the mother realized that it was Neil, she exclaimed, ‘Thank God it was not Richard.' Education and training is the key Let your child start getting help from experts in the field as soon as possible. Early intervention can make a lot of difference in the ultimate outcome. In some major cities, such expertise is available. If you can't locate such a facility, go to the nearest medical college teaching hospital for guidance. The team of experts will first try to find the possible cause of M.R. and then plan the management for your child. They will also discuss about the ultimate prognosis and answer any queries that you have about the possibility of your future children getting affected. Aim at getting your child admitted to a school for normal children Let the team of experts decide if your child should be admitted to a school for normal children. Some schools encourage such an approach. Children who do not have severe retardation are taught in such schools under supervision. Do attend to the general health of the child Make sure your child gets a nourishing diet, proper exercise, enough sleep and a friendly environment. Avoid foods that will make him fat. (See section on obesity.) This is specially important for children who are physically handicapped. Sometimes, you may have to bodily lift him up. Let obesity not become an added problem for him. Also make sure that he gets proper dental care. Some of these children may not chew their food well and extra sugar may cause caries of the teeth, as well as add to the weight of the child. Drugs are often not helpful There is no `brain tonic' which helps these children. However, the experts may give some drug(s) for tackling certain specific problems. Prefer home care to care in an institution More and more people are realizing that such children are better looked after in a home rather than in an institution. However, situations can arise when parents find it impossible to cope with a severely retarded child. Then institutionalized care may become necessary. Fear of sexual abuse If you have a female child with M.R., you need to be extra careful about the possibility of the child being sexually abused. Avoid leaving the child alone with people who may take advantage of her handicap. Some parents may raise the question of contraception for such children. Others may be concerned about the difficulty the child may face in managing her periods. Discuss all these issues with your doctor. You may even be advised to get the child's uterus removed to help care with her menstrual problems later and to avoid the danger of an unwanted pregnancy. Discuss this matter with other members of the family and then take a well considered decision. Your daughter may need the operation. But I have seen parents who in their wisdom decided against the operation because they felt that they were capable of managing the girl themselves. Genetic counselling In some cases of M.R., there is a possibility that the next child may have similar condition. Discuss this with your doctor. Sometimes the help of a genetic counsellor is needed in such cases.

Mouth-To-Mouth Breathing & Cardiac Massage

Timely help can save a life All those reading this book must be ready to face a situation when a person near us may suddenly stop breathing. Timely help can save a life. You must practice the technique of mouth-to-mouth breathing in advance. Get in touch with your local hospital and request them to arrange a session for you and your friends to learn this method. Remember that if a child does not breathe for 4 minutes he may die. Steps to be followed if the child stops breathing. Step 1. Shout for help to get an extra hand and to summon a doctor. Step 2. Clear the mouth. Check if anything is struck in the mouth or throat. Pull the tongue forward. Remove any foreign object or food that can be removed easily with your fingers. If removal seems difficult, follow the section on choking. Step 3. Let the child lie on his back on the ground or any other firm surface like a strong table. Tilt his head back so that his nose faces the roof or sky. Open his mouth wide. Step 4. If he is still not breathing, start mouth-to-mouth breathing. For this, take a deep breath. For an infant, place your mouth over his mouth as well as the nose. Press firmly so that no air leaks. Then blow gently to make sure that his chest rises a little. Do not blow with too much force in an infant because you may rupture his lungs. In case of an older child, pinch his nostrils with one hand and place your mouth only on his mouth. Breathe into the child's mouth forcefully to ensure some lifting of his chest. Give two such breaths. If the chest is not moving, follow Step 2 again. If the chest rises with mouth-to-mouth breathing, remove your mouth from his mouth and after every breath, take a deep breath and breathe again into his mouth at a rate of about 20 breathes per minute until he starts breathing on his own or until you are sure that he is dead. This effort may be needed for about an hour. Step 5. Sometimes the heart also stops beating in such a situation. After the first two breaths, check the pulse. In small infants, put two fingers gently to feel for the pulse in front of the elbow. In older children feel for the pulsation in the neck a little away from the windpipe at the level of the Adam's apple. If you cannot feel the pulse, you must begin cardiac (heart) massage by pressing on the breastbone lying in the middle of the chest. Step 6. If you have help, let one of you do the cardiac massage while the other does mouth-to-mouth breathing. In case of an infant, press on the breastbone with three fingers, placed a little below the level of the nipple. Press the bone about an inch at a rate of about one hundred per minute. If you are alone, give one breath for every five compressions (or massage). For an older child, you may need to apply more pressure, using the heel of the hand. For an adolescent, you may also need to place the heel of one hand on top of the other hand and then press down about one and half inches. Continue this exercise until you can feel the pulse or until you are sure that the person is dead. It is worth trying this for half to one hour before you give up. Mouth-to-mouth breathing and drowning If the child is not breathing on his own, follow the same procedure as given above under mouth-to-mouth breathing. Do not waste precious time trying to get water out his chest. In fact, the person trying to rescue the child is advised to start mouth-to-mouth breathing, as soon as he reaches waters shallow enough to stand in.

Mumps

A typical case of mumps This disease may herald with a swelling below one or both ears. It is quite painful. The child may have pain while chewing or opening the mouth. He is likely to have had contact with a child having mumps. The swelling is because of the saliva producing glands (parotid glands) and lasts for about 10 days. The illness often starts with fever, loss of appetite, nausea, vomiting and headache to be followed with parotid swelling within a day. But some children may only have the swelling of the gland. If the child has had MMR (measles, mumps and rubella) vaccine in the past and swelling is noticed below the jaw bone rather than the ears, the diagnosis may be different. Let your doctor decide. If the enlargement of the glands below the jaw bone is due to throat infection, the doctor may offer the child antibiotics. Treatment of mumps Mumps does not need any treatment, except for handling the pain. For this paracetamol and soft foods (fruits, juices, soups, khichdi, curds) are advised. Complications of mumps Mumps can occasionally get complicated with involvement of the brain, testes and pancreas. A testicular involvement is seen only in adolescents and not in younger children. If the child with mumps gets acute pain in the abdomen, swelling of the scrotum, or starts behaving abnormally, you must report it to your doctor. Spread of mumps to others and its prevention Mumps spreads fast. The patient is infectious from 1 or 2 days before the onset of illness and remains infectious until the parotid swelling disappears. MMR vaccine is now freely available in our country. It is usually prescribed around 15 months of age in children who have received measles vaccine at 9 months. If measles vaccine has not been given to your child, you can give him the MMR vaccine after his first birthday.

Nephrotic Syndrome

This disease of the kidney generally affects preschool children. A typical case The typical story is of a child between 18 months and 5 years whose mother finds that he has swelling of the face, which is more marked on waking up in the morning. She then realizes that lately he has not been his normal self and has been eating poorly. She also notices that the child is passing less urine and the swelling is increasing each day till his whole body is swollen. The doctor gets his urine and blood examined and finds certain well defined abnormalities. With treatment, almost all children with this disease improve dramatically. Unfortunately, even with best possible treatment, relapses are very common. Most patients, however, do get cured after one or more attacks. Treatment Although we are not sure of the cause of this disease, almost all children with nephrotic syndrome are given corticosteroids with excellent response. New drugs are also sometimes prescribed. If the swelling is marked, drugs (diuretics) to increase the urine output may be needed. Your doctor shall prescribe antibiotics if he suspects bacterial infection. Children are often prone to such infection. Corticosteroids will increase the swelling of the face. The abdomen may also appear to be big. This should not worry you so long the child does not have swelling on his legs and below his eyes. In the case of these children an attack of any viral infection can also lead to a temporary swelling of the body. Your doctor may wait for some time before starting any medication. In such cases the swelling disappear spontaneously as the viral subsides. However, it is important to keep in close touch with your doctor in all these cases.

Nose-Related Problems

Bleeding from the nose (epistaxis) Causes Nosebleeds can occur because of direct injury to the rose and due to nose picking. Sometimes it may also be a manifestation of a generalized bleeding disorder, or because of an infection or a foreign body in the nose. Treatment Step 1. Let the child sit up in bed or on a chair or on the floor. He should be leaning slightly forward. Do not show any panic. Step 2. Pinch the nose for at least 10 minutes. The child can open his mouth if he likes. Often, the nose bleeding would stop with this procedure. Step 3. If bleeding continues, try to get in touch with a doctor. In the meanwhile take some cotton, roll it into a thick wad large enough to occupy the nostril which is bleeding. Leave a part of this wad of cotton outside the nose. If some hydrogen peroxide is available, moisten the cotton with it or lubricate with vaseline. But do not waste precious time searching for these things. Just a wad of cotton would serve the purpose. Now again pinch the nostril for at least 10 minutes keeping your child upright. After the bleeding stops, leave the cotton in the nostril for the day or overnight. Then take it out gently. Make sure that the child does not pick at the nose. Step 4. If the bleeding still continues, you should see your doctor. In the meanwhile, you may try pressing on the big vessels that go up the nose. For that put a wad of cotton between the upper and the gums below the nose and press firmly on the cotton from outside. For prevention of nosebleeds, keep the child's nails short and explain to him that he should avoid picking his nose. If you notice a crust near the opening of the nose, apply vaseline to it. A child who bleeds in a particular season may be helped by application of vaseline inside the nose, twice a day, all through the season. Foreign body in the nose Toddlers are apt in putting small beads, pebbles, buttons etc. into their nostrils. Some children will report it to their parents. Others forget and a few days later, a foul discharge comes from the nostrils. Sometimes this foul-smelling discharge is also accompanied by blood. If the foreign body is lying near the opening of the nose, you can attempt to remove it with your tweezers. Otherwise, you press against the clear nostril and ask the child to blow out forcefully from the blocked side. If this also does not help, take the child to the casualty department of a hospital for the removal. Direct injury to the nose Cold compresses with ice for about an hour is all that is needed. If you find that there is obstruction to free flow of air through the nostrils or if you notice any obvious deformity see your doctor.

Obesity

The term obesity refers to the excess of fat tissue in the body. A child is said to be obese if the weight is 20 per cent more than the standard weight for his age and height. Parents of obese children often get worried for the wrong reasons. They wonder if the child has some endorcrinal or a hormonal disorder. Obese male children seem to have a small penis. Actually the penis is of the normal size but it appears small when it gets buried into the fatty tissue at the base of the penis. The apparently small size of the penis coupled with obesity raises doubt of a hormonal disorder in the minds of the parents. Although certain hormonal disorders can give rise to obesity, most of the cases that I have seen were not due to any hormonal disturbance. What causes obesity? The three main causes of obesity are a family history of obesity, inactivity and poor family food habits. Emotionally disturbed children may also eat more. Television viewing adds to inactivity. The problem gets worse if the child is allowed to eat while watching the television. Fortunately, most obese toddlers lose the extra fat around five years of age But a fat school child is likely to remain obese, especially if the parents are fat. Healthy food habits (Also see under the heading of `Healthy Habits'.) It is important that the whole family co-operates with the child. Junk foods like cold drinks, icecreams, cakes, pastries, french fries, sweets and sugars in drinks should be avoided. A minimum of ghee or oil should be used for cooking. More of fruits, vegetable, wholewheat grains, beans, pulses and sprouts should be eaten. Consumption of meat should be restricted. Snacks should consist of fresh fruits and fruit juices, low fat milk and dahi, paneer, khakhra (very thin roasted chapatis from Gujarat), raw vegetables, puffed rice, channa, corn on the cob and popcorn without butter. Obese children tend to eat fast and at irregular hours. They should be encouraged to eat slowly, chew properly and stick to regular mealtimes as far as possible. Exercise This subject is discussed at length under `Healthy Habits'. This is as, if not more important, as diet control, for reduction of weight. Encouragement Discuss the risks of obesity with the child. Do not starve youngsters. They need enough calories. Let them feel responsible and stay away from drugs to cut down their appetite. Spend more time with your children and encourage them in whatever efforts they make towards reducing their weight.