Summer and Sleep

• Children may get sleep disturbance when the days are longer in summer.
• Good quality sleep is absolutely essential for good learning and behaviour.
• Ensure your child has regular routine of going to bed at the same time every night.
• Switch off all electronic gadgets (TV, mobile, ipad and even LED lights) atleast 1 hour before the scheduled bedtime.
• Do some activities like story book reading, or listening to some music over radio, or talking about the activities during the day before bedtime.
• Make sure the room is dark so that the brain can release the hormone ‘melatonin’ which helps sleep. A small non-LED lamp can be kept at a distance if some children are afraid to sleep in the dark.
• Make sure children get adequate exposure to daylight by playing outdoors, so they get tired and fall asleep on time.

Mosquito related illnesses – how to keep children safe?

• Malaria, dengue and chikungunya are some of the diseases spread through mosquitoes. These gradually start appearing with summer and peak during and after monsoon.
• Malaria and dengue can lead to fits and neurological problems in children.
• Timely diagnosis and treatment is important.
• Consult your pediatrician and request a pediatric neurology consult if your child is very sleepy, does not wake up for feeds or has fits.
• Sometimes further investigations like brain scans (MRI) and brain wave testing (EEG) may be required.
• Preventing these illnesses by using mosquito repellant in house and over clothes or skin, and avoiding water to get accumulated around the house or society is very important.

Children and Coronavirus (COVID-19) – what do you need to know?

• Children do not appear to be at higher risk for COVID-19 than adults. This virus is similar to other viruses that lead to cold, cough, fever, vomiting and diarrhea.
• Children need supportive treatment with adequate fluids and nutrition, and medications to control fever. It is best to consult and show your pediatrician if there are any concerns regarding fever, breathing problems or inadequate intake of fluids.
• Children who are susceptible to febrile seizures or epilepsy, may get fits if the fever is not controlled. Give medicines for fever and medicines to prevent fits if recommended by the neurologist.
• You can encourage your child to help stop the spread of COVID-19 by teaching them to do the same things everyone should do to stay healthy.
  • Clean hands often using soap and water or alcohol-based hand sanitizer
  • Avoid people who are sick (coughing and sneezing)
  • Clean and disinfect high-touch surfaces daily in household common areas (e.g. tables, hard-backed chairs, doorknobs, light switches, remotes, handles, desks, toilets, sinks)
  • Clean items including washable plush toys as appropriate in accordance with the manufacturer’s instructions. If possible, launder items using the warmest appropriate water setting for the items and dry items completely. Dirty laundry from an ill person can be washed with other people’s items.

What Is Encephalitis?

Encephalitis is an inflammation (swelling and irritation) of the brain. In most cases, a virus causes this inflammation. Sometimes it can also be associated with inflammation of the lining of the brain (meninges), such cases are called meningo-encephalitis and can be caused due to bacterias or viruses.

What are the symptoms of Encephalitis?

Symptoms in mild cases of encephalitis usually include:

• fever
• headache
• poor appetite
• loss of energy
• a general sick feeling
• drowsiness

Serious cases of encephalitis can cause:

• a high fever
• severe headache
• nausea and vomiting
• stiff neck
• confusion
• personality changes
• convulsions (seizures)
• problems with speech or hearing
• hallucinations
• memory loss
• drowsiness
• coma

It’s harder to spot some of these symptoms in infants. Important signs to look for include:

• vomiting
• a full or bulging soft spot on the top of their head (fontanel)
• crying that doesn’t stop or that seems worse when the baby is picked up or handled
• body stiffness
• poor feeding
• excessive drowsiness

What causes Encephalitis?

Three groups of viruses are common causes of encephalitis:

1. Herpes viruses, such as chickenpox, EBV (Epstein-Barr virus, which causes glandular fever), and herpes simplex (which causes cold sores).
2. Viruses and other germs transmitted by insects like mosquitoes, like Dengue, Malaria, Japanese encephalitis, Chandipura and Chikungunya.
3. Viruses that cause common childhood infections and are vaccine preventable, such as measles, mumps, and rubella. Thanks to immunizations, it’s rare today for someone to develop encephalitis from these illnesses.

Less often, encephalitis can be:

• caused by an infection from bacteria , such as bacterial meningitis
• due to a parasite, like toxoplasmosis (found in infected cat faeces) in people with weakened immune systems

Is Encephalitis contagious?

Brain inflammation itself is not contagious. But the viruses that cause encephalitis can be. Of course, getting a virus does not mean that someone will develop encephalitis.

How is Encephalitis diagnosed?

A high index of clinical suspicion is required to clinically diagnose encephalitis and often doctors would start treatment in suspected cases. Doctors use several tests to diagnose encephalitis, including:

• imaging tests, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), to check the brain for swelling, bleeding, or other problems
• electroencephalogram (EEG), which records the electrical signals in the brain, to check for unusual brain waves
• blood tests to look for bacteria or viruses in the blood. These also can show if the white cell counts are raised or there are other chemicals to prove that the body is mounting a response to fight the germs
• lumbar puncture, or spinal tap, which checks cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) for signs of infection. This is a very important test which can not only prove the diagnosis but in many cases caused by bacteria can also help identify which medications (antibiotics) would work agains the germ. Parents are often worried about this test and the discomfort it would cause their child, however pediatricians are experts in doing this test. In addition, this would not lead to any long term problems (back pain or difficulty walking), nor will it damage any structures like the spinal cord or nerves.

How is Encephalitis treated?

Most children with encephalitis need care in a hospital, usually in an intensive care unit (ICU). Doctors will watch their blood pressure, heart rate, breathing, and body fluids to prevent further swelling of the brain.

Medicines

• Antiviral drugs can treat some forms of encephalitis, such as the type caused by the herpes simplex virus.
• Steroids may be used to reduce brain swelling.
• Anticonvulsants might be given to a child having seizures.
• Paracetamol can help with fever and headaches.
• Antibiotics don’t work against viruses, so aren’t used to treat most forms of encephalitis. But in suspected cases due to bacteria, they are usually given.
• Fluids or feeds to maintain optimal hydration and blood sugar.

Many people with encephalitis make a full recovery. In some cases, brain swelling can cause lasting problem like learning disabilities, speech problems, memory loss, or lack of muscle control. Speech therapy, physical therapy, or occupational therapy can help in these cases.

How long does it take to recover?

Most of the time, the acute phase of the illness (when symptoms are the most severe) lasts up to a week.Treatment can vary from 3 weeks, to sometimes longer in selected cases. Sometimes, the doctors would request a repeat lumbar puncture to ensure that the fluid surrounding the brain is completely clear before stopping the treatment. Full recovery can take longer, often several weeks or months.

Can encephalitis be prevented?

Encephalitis can’t be prevented, but you can avoid the illnesses that may lead to it. Immunizations protect kids from many common childhood illnesses, so follow the immunization schedule recommended by your doctor. Kids should also avoid contact with anyone who already has encephalitis. It’s also important for everyone in your family to wash their hands well and often.

To avoid mosquito bites, kids should:

• Avoid being outside at dawn and dusk, when mosquitoes are most active.
• Wear protective clothing outside, like long sleeves and long pants.
• Use insect repellent.
• Drain standing water from around your home, including in buckets, birdbaths, flowerpots, and tire swings. These are breeding grounds for mosquitoes.

When should I worry about my child having possible encephalitis?

Call your doctor if your child has a high fever, especially if he or she also has a childhood illness (like measles, mumps, or chickenpox) or is recovering from one.

Get medical care right away if your child has any of these symptoms associated with fever:

• a severe headache
• convulsions (seizures)
• stiff neck
• can’t look at bright lights
• double vision
• trouble walking or moving a hand or leg
• problems with speech or hearing
• sudden personality changes or memory problems
• extreme drowsiness
• crying that wont stop
• vomiting or poor ortal intake

Bell’s palsy is a sudden weakness or paralysis on one side of the face that makes it hard for a child to move the mouth, nose, or eyelid. It also can make that side of the face droop or look stiff.

Bell’s palsy happens when a facial nerve is not working as it should, often it occurs after a viral infection.

What causes Bell’s Palsy?

There is a facial nerve on each side of the face. When they are working properly, they carry many messages from the brain to the face. These messages may tell an eyelid to close and one side of the mouth to smile or frown.

But if the nerve swells and is compressed, as happens with Bell’s palsy, these messages don’t get sent correctly. The result is weakness or temporary paralysis of the muscles on one side of the face.

Bell’s palsy is most often connected with a viral infection such as HSV-1 (the virus that causes cold sores), Epstein-Barr (the virus that causes glandular fever), or influenza (the flu). It also can happen with ear infections, bad colds,  trauma to the head or face and sometimes even with cold hair going through the ear.

What are the symptoms of Bell’s Palsy?

Bell’s palsy tends to happen quickly. Some children may feel pain behind or in front of their ears for a few hours or even days before the facial weakness sets in. Because Bell’s palsy only happens to one facial nerve at a time, it only affects one side of the face. Some kids have only slight weakness; others might not be able to move that side of their face at all. This may make one half of the child’s face (especially the mouth) seem to droop or sag.

Other symptoms can include:

• a feeling as though one side of the face is “twisting” or “tugging” (this is caused by the healthy side making facial expressions — the muscles pull on the weak side)
• headache
• trouble tasting at the front of the tongue
• trouble producing saliva
• sounds seeming louder than usual in one ear
• difficulty fully shutting one eye, causing watering and sometimes dry irritated eye
• difficulty eating and drinking as food may spill out from the side of the mouth that is weak

Bell’s palsy affects only the facial muscles, so if other parts of the body are stiff or paralyzed, talk with your doctor right away, as it may be a sign of a different condition.

Diagnosis and Treatment

There isn’t a specific test for Bell’s palsy. To make sure the paralysis is Bell’s palsy and not another condition, your doctor will ask how long it took for the symptoms to develop and where the weakness or paralysis is.

People who have strokes usually have weakness only in the lower half of their face and may have it in their arms and legs as well. The problems caused by tumors usually take longer to develop (the symptoms start more slowly and get more serious over a longer period of time) than Bell’s palsy does.

The doctor will ask if your child is having weakness or paralysis in other parts of the body, or is having other problems, like double vision or trouble swallowing. The doctor will also want to know about any head injuries.

If the facial paralysis lasts more than a few months, the doctor is likely to recommend further tests —such as magnetic resonance imaging (MRI) of the brain— to rule out other problems. The doctor also might recommend that your child have an electromyography (EMG), which tests the nerves’ signals and how well the muscles are responding to them.

Usually, the virus or infection that leads to Bell’s palsy has passed, so there’s no specific treatment used for the condition. It goes away once the swelling of the nerve goes down and the nerve recovers from any damage. The nerve has to renew itself and that can only happen with time.

In some cases, doctors recommend medicines to help reduce the swelling (steroids) or prescribe an eye patch (opticlude eye patch) or eye drops (refresh eye drops) if the eye is dry. Most children also need regular facial physiotherapy (blowing a balloon and moving the muscles of the face) and occasionally older children may receive facial nerve electrical stimulation to help recovery.

Most people recover fully within 1 to 3 months, whether or not the condition is treated, although very few may have permanent weakness in their face afterward. It is very unusual for anyone to get Bell’s palsy twice.

Making sure your child eats well and gets plenty of sleep are important to healing. Activities and sports participation don’t have to be limited as long as your child can close the eye (to protect it). If the eye can’t be closed, talk with the doctor about using protective glasses or a patch to prevent eye damage.

What Is Guillain-Barré Syndrome?

In Guillain-Barré syndrome (GBS), the body’s immune system attacks the nerves and its lining. This causes temporary weakness or even paralysis (being unable to move) in parts of the body.

GBS is rare, but can be serious. If it affects the chest muscles, for example, a person can have breathing trouble and need to use a ventilator for a while. The good news is that the condition is treatable and most children make a full recovery.

What happens in GBS ?

The peripheral nerves send signals from the brain to the muscles and tell them to move. They also send sensory signals (such as touch, pressure, temperature, and pain) to the brain.

Guillain-Barré syndrome temporarily damages the the nerves and its coating, which interrupts the signals. So someone with the condition may have weakness or problems moving, or may feel pain, numbness, or tingling in the arms or legs.

What causes GBS?

Many children with GBS have had a viral or bacterial infection in the 2 weeks before symptoms began. The infections usually are in the respiratory system or gastrointestinal tract. These infections trigger the immune system to produce proteins called antibodies. Normally the antibodies help destroy invading bacteria or viruses. But in GBS, these antibodies mistakenly damage parts of the peripheral nerves and its coating.

What are the symptoms of GBS?

Symptoms of GBS, in the order that they usually happen, include:

• tingling or pain in the toes and fingertips
• weakness or pain in the legs that causes trouble walking, this can then progress to involve hands and arms
• loss of reflexes (for example, the knee doesn’t jerk when it’s tapped)
• facial weakness
• inability to move the eye in some cases
• breathing problems

How is GBS diagnosed?

Doctors ask questions about the symptoms and do an exam. If GBS seems likely, the doctor clinically suspects a diagnosis of GBS and start treatment. They also might order tests to support the diagnosis, such as:

• a spinal tap (lumbar puncture) to check for cells and chemicals in the spinal fluid
• nerve conduction velocity (NCV) test to see how fast electrical signals move through a nerve
• MRI to look inside the brain and spinal cord

Sometimes these tests may be normal when done early, hence it is important that the management of GBS is clinically driven once the doctor suspects it.

How is GBS treated?

Treatments that can speed recovery include:

• Immunoglobulin (IVIg) therapy: This injection of healthy antibodies helps lessen the immune system’s attack on the body.
  And/Or
• Plasmapheresis or plasma exchange (PLEX): A machine pumps blood out of the body, removes the cells producing the antibodies and the antibodies attacking the nervous system, and returns blood to the body.

Most children with the condition usually get medicines to ease nerve related pain (gabapentin/pregabalin/ amitryptiline) and to prevent blood clots (stockings/blood thinner injections) if they can’t move their legs easily.

Most children with GBS get care in a hospital so doctors and nurses can check how they’re doing. Sometimes they’re cared for in an intensive care unit (ICU). This lets doctors and nurses regularly check on vital signs, such as blood pressure and heart rate, and pay close attention to how the body is doing. Some children need brief period of ventilation and a nasogastric tube to support their feeding.

How long a child stays in the hospital depends on how serious the symptoms are. Some children are in the hospital for only a few days, while others stay for several weeks.

Even after coming home from the hospital, children might need some time before feeling better. Some children with GBS might use a wheelchair or a walker until they regain their strength. Most will need physiotherapy to get their bodies moving well again.

What are febrile seizures?

Febrile (fever related) seizures are convulsions that can happen when a young child has a fever above 100.4°F (38°C). The seizures usually last for a few minutes and stop on their own.

Febrile seizures can look serious, but most stop without treatment and don't cause other health problems. Some kids might feel sleepy after one, while others feel no lasting effects.

Who gets febrile seizures?

Febrile seizures happen in kids 6 months to 5 years old. They're most common in toddlers 12–18 months old. Most children outgrow having febrile seizures by the time they are 5 years old.

Kids are more likely to have a febrile seizure if:

• They have another member in the family who has febrile seizures.
• They’ve already had one previously. About 1 in every 3 kids who have had one febrile seizure will have another, usually within 1–2 years of the first.
• They had a first febrile seizure when they were younger than 15 months old.

Febrile seizures are not considered epilepsy (seizure disorder). Kids who have a febrile seizure have only a slightly increased risk for developing epilepsy.

What are the symptoms of Febrile Seizures?

There are two types of febrile seizures:

1. Simple febrile seizures are most common. They’re usually over in a few minutes, but in rare cases can
last up to 15 minutes. During this type of seizure, a child may:

• rythmically shake or jerk all the four limbs
• roll the eyes
• become unconscious
• urinate (pee) during the seizure
• vomit after the seizure ends

2. Complex febrile seizures are uncommon and may need review by a pediatric neurologist and further investigations.

During this type of a seizure:

• the seizure can last longer than 15 minutes.
• happen more than once in 24 hours
• involve movement or twitching of only one part or one side of the body

What causes Febrile Seizures?

No one knows why febrile seizures happen. But evidence suggests that they’re linked to some viruses and the way that a child's developing brain reacts to high fevers. In some families, different members may be affected by it, implying a genetic predisposition.

What to do when your child has a febrile seizure?

If your child has a febrile seizure, stay calm and:

• Gently place your child on the floor or the ground.
• Remove any nearby objects.
• Place your child on his or her side (recovery position) as the seizure comes to an end as it prevents choking on secretions or vomit.
• Loosen any clothing around the head and neck.
• Watch for signs of breathing problems, including bluish color in the face.
• Try to keep track of how long the seizure lasts.
• If possible, ask a family member to video record the seizure.

If the seizure lasts more than 5 minutes, or your child turns blue, it may be a more serious type of seizure — call 108 right away.

It’s also important to know what you should not do during a febrile seizure:

• Do not try to hold or restrain your child.
• Do not put anything in your child’s mouth.
• Do not try to give your child fever-reducing medicine by mouth.
• Do not try to put your child into cool water to cool off, or pour water on to their head.
• Do not close eyes, make your child sniff shoes or onions.

When the seizure is over, take your child to the nearest children’s hospital to see a pediatrician. In some cases, they may refer the child to a pediatric neurologist for review, specially if they have had a complex febrile seizure.

How to manage the fever?

• The doctor may recommend the standard treatment for fevers, which is paracetamol and in some cases ibuprofen. Ibuprofen should be given only on advice of a pediatrician. The doses of paracetamol should be optimal for weight and age.
• It is wise to strip the child off the clothes and keep him in a well ventilated room. Covering the child with more blanket or clothes during a fever as they are experiencing a chill is not helpful.
• Similarly, pouring water over the body during a fever is likely to cool the external skin, making the internal core temperature even higher and risking occurrence of a febrile seizure. Hence, tap water or cold sponging is not recommended any more in routine fever.

In some cases, the doctor may prescribe a medication to be given when the child has an intercurrent illness and is showing features of fever, to prevent occurrence of a febrile seizure. Such medications, like clobazam, is usually given for 3 days and do not cause any long term neurodevelopmental problems.

If the child has experienced a longer seizure, or stay far away from hospital facility, the doctor may train the parents to give a medication called midazolam through the nose. This medicine given correctly is able to stop the seizure from lasting for long.

When to call 108?

Get emergency medical care if your child:

• has a febrile seizure that lasts longer than 5 minutes and does not respond to nasal midazolam
• the seizure involves only some parts of the body instead of the whole body
• has trouble breathing or turns blue
• isn’t responding normally an hour after the seizure has stopped
• has another seizure within 24 hours

A child who has missed getting some vaccines and has a febrile seizure could have a higher risk for meningitis. Get medical care right away if your child has any signs of meningitis, such as:

• a stiff neck
• vomiting, poor eating
• in babies, a bulging soft spot on the head
• drowsiness which is excessive

Febrile seizures can be scary to see. But they’re fairly common and not usually a symptom of serious illness.

Muscular dystrophy (MD) is a group of genetic conditions that are characterized by weak muscles that get progressively weaker with age. MD mainly affects the skeletal muscles, but in some cases muscles of the heart and bowel are also affected. In some children, their intelligence is also affected.

Duchenne muscular dystrophy (DMD) is the most common and most serious form of MD. DMD mainly affects boys and appears before 5 years of age. DMD is characterized by muscle wasting and poor walking ability. Most boys with DMD end up completely dependent on wheelchairs by 13 years of age and will eventually have difficulty breathing.

Other forms of MD can be much less severe. There is no cure for MD, but medications and therapy can improve your child’s quality of life.

What are the signs and symptoms of muscular dystrophy?

Signs and symptoms differ for every child. Symptoms depend on the type of MD. The main symptom of MD is weakness of the affected muscles. This weakness may cause your child to:

• walk later than most children the same age (over 18 months of age)
• waddle
• have difficulty climbing stairs
• fall easily
• unable to jump
• enlarged calf muscles
• walking on toes
• weakness of the shoulders and arms
• inward curvature of the lower spine
• difficulty getting up after falling
• weakness of other muscles like the shoulder or face

What causes muscular dystrophy?

MD is due to a defective gene. The genetic mutation is passed on from one or both parents to a child.

With DMD, the defective gene is carried by the mother. A boy born to a woman who carries the DMD gene has a 50% chance of having the disorder.

Other types of muscular dystrophy can be inherited through the mother, father, or both parents. In today’s age, with appropriate genetic testing, a conclusive answer can be found for most cases.

What a doctor can do to help your child with muscular dystrophy

Once an MD diagnosis is confirmed, your child will be referred to therapists for supportive treatment.

• Physiotherapy may help to stretch your child’s muscles and ensure gait is supported.
• Occupational therapy can assist in daily living activities and upper limb function.
• Orthotics can help with aids like braces and splints.
• Involvement of other specialists like endocrinologists, orthopaedics and lung physicians may be important.
• Steroids are recommended when the child with DMD starts having difficulty walking and can be continued for optimal upper limb and respiratory functioning. They have side effects like thinning of bones which would need monitoring and treating under the guidance of endocrinologists.
• Newer medications and gene therapies are available in the western countries, and some research has been initiated in India as well. For further information and to be sign- posted to the right centre, discussion with the pediatric neurologist is essential.

As the condition progresses, your child may need assistance moving and breathing. Wheelchairs and home-ventilators are common aids used to help adolescents with MD.

What you can do to help your child?

Ask for guidance and assistance from the team of medical specialists working with you and your family. Since children with MD pass through different stages, it is important to have good communication and support from your medical team.

You may need to help your child with physical therapy to improve flexibility. You may have to teach your child how to use a wheelchair, braces, or scooter so they can be mobile. Eventually you may have to set up a ventilator to help your child breathe.

Whenever possible, try to give your child independence and the ability to enjoy social situations with other children. It may be helpful to other children at school if they learn about MD from you, the teacher, or a school nurse.

What is EMG?

EMG is a test that looks at how muscles and nerves work together. Nerves carry messages to and from the muscles. If the nerves or muscles or the junction between the two are damaged, the muscles might not work properly.

EMG can tell the doctor:

• If your child has a problem with the nerves or muscles or the junction between them
• Why the muscles feel weak, stiff, or painful

What happens during an EMG test?

The test usually takes up to 30-60 minutes.

Your child will lie on a comfortable bed. The test has two parts, one testing the nerves and other testing the muscle.

• Nerve conduction tests: in this test the doctor will apply stickers to different parts of hands and foot, and send a small electric current to look at how the nerves are working. The electric current is not painful, but can be slightly uncomfortable. It is often fun to see how the hand or foot twitches when this is done and the doctor may ask you while playing a game whether the hand moved or did you feel a weird current.
• Electromyography: the doctor will put a very thin needle that looks like a wire into 1 to 4 different muscles. The needle will stay in each muscle for about 30 seconds. If your child can, the doctor or nurse will ask your child to relax the muscle and then tighten the muscle. The number of muscles the doctor will test depends on your child’s problem. The doctor and nurse will always tell you and your child when and where they will put the needle. Putting the needle in the muscles may hurt a little, just like it does when your child gets a regular needle. The doctor will try and use a cold spray to make it less painful, or may give some creams to apply to numb the skin.

In younger children, the doctor may give a sedative to start testing the nerves first as it is quite difficult to obtain accurate readings when the child is upset or refusing the test or moving frantically to avoid the test. Subsequently, he may wake up the child for the muscle testing or in most cases the child wakes up when the needle is inserted into the muscle.

After an EMG test

Your child can go back to her usual activities right away. The muscles that were tested might hurt a little for a short time after the test.

The doctor will take time to analyse the findings and prepare the report, this will be then given to you.