Rheumatic Fever and Your Child

1. What is Rheumatic fever?

Rheumatic fever is usually seen in children between 5 and 15 years where, after an episode of fever and sore throat, child again develops fever, joint pain and joint swellings along with heart disease. There is a strong relationship with the throat infection caused by the bacteria Streptococcus.

2. What kind of children develops rheumatic fever?

Both male and female children are equally affected. In India this disease is rarely seen in children below 5 years. This disease is common in children of poor socioeconomic condition leading to unhygienic and over crowded living conditions. In the above mentioned scenario, the streptococcal bacteria producing sore throat which lead on to rheumatic fever develop commonly and spreads from one child to the other. Along with this, poor nutrition decreases the child’s resistance power to infection. In India when the rate of rheumatic fever in children between 5 and 15 years is around 6 per 1000, in Kerala it is 2 per 1000. Rheumatic heart disease contributes to 40 – 50 % of cardiac patients in a hospital. In S.A.T. hospital, every year, around 100 children get admitted due to rheumatic fever.

3. How does sore throat predispose to rheumatic fever?
Not every child with streptococcal infection of the throat develops rheumatic fever. Some children are genetically susceptible. The antibodies (molecules produced by the body to counter the infection) produced against streptococcal bacteria unfortunately react with the heart muscle, joints and sometimes the nervous system resulting in the manifestations of rheumatic fever.

4. What is the clinical picture of rheumatic fever?
At the onset, please remember that all the manifestations of rheumatic fever may not be seen in a single patient. Diagnosis is often made with the help of certain clinical features and other laboratory investigations.
The main clinical features consist of heart disease, arthritis (inflammation of the joints), chorea (purposeless jerky movements), subcutaneous nodules (swelling seen beneath the skin) usually seen on bony prominences like elbows, shin, back of the head and spine which are non tender and a peculiar rash (erythema marginatum). The rash is faintly reddish, non-itching, which appear as a red spot or as serpigenious. But it is difficult to recognize the rash in Indian children due to the dark complexion of the skin.
Patients who have subcutaneous nodules almost always have heart disease. In India, these swellings are seen only about 5% of patients.

5. How does rheumatic fever affect the heart?
Rheumatic fever affects all the three layers of the heart (pericardium, myocardium and endocardium). It is seen in 50-75 % patients of acute rheumatic fever. Almost 80% of the patients who develop heart disease do so within the first two weeks of the onset of rheumatic fever. In pericarditis there is swelling of the pericardium covering the heart and fluid collection beneath the pericardium. Myocarditis leads to heart failure. In endocarditis, the heart valves are damaged and results in rheumatic valvular disease. Rheumatic valvular disease can be long lasting and it can even cause death of the patient.

6. What are the special features of joint pain due to rheumatic fever?
Knee joint, ankle joint and elbow joint are the commonly affected joints. Rarely smaller joints like joints in the fingers and toes are also involved. Because of the pain and swelling in the joint it is difficult to bend and straighten the joints. 50-70% of rheumatic fever patient’s joint problems are seen within the first few days itself.

7. What is this abnormal movement called Chorea?
Chorea is a late feature usually occurring 3 months after the onset of rheumatic fever. The affected child is emotionally disturbed and drops things he or she is carrying and also there is a deterioration of handwriting. This shivering spontaneously disappears in 6 weeks.

8. Is it necessary to do blood test, E.C.G., Echo test?
Yes. ASO, ESR and WBC Count are elevated. ECG and Echo test are necessary to find out the status of the heart.

9. What is the treatment of rheumatic fever?
Complete bed rest is advised for some period. If there is heart disease, restrict salt intake. Drugs like Penicillin, Aspirin and Steroid are used for the treatment

10. How can we prevent Rheumatic fever?
Do not ignore your child’s sore throat. Consult your doctor. Proper treatment of sore throat can go a long way in preventing the first attack of rheumatic fever. Once the child develop rheumatic fever penicillin treatment is a must because it prevents the development of heart disease due to rheumatic fever.

11. How long does the penicillin treatment to be continued?
(a) Rheumatic fever, no heart disease
Penicillin treatment for 5 years from last attack or 21 years which ever is later.
(b) Rheumatic fever, had heart disease but now there is no sequelae.
Penicillin treatment for 10 years or till 25 years for the child which ever is later.
(c) Rheumatic fever, rheumatic heart disease existing.
Penicillin preferably life long or at least till 40 years of age.

11. Does penicillin treatment has any side effect?
Penicillin injection some times produces pain and fever. So it is better to take injections on holidays. Rarely penicillin injections produce severe allergy and sudden death. But parents should understand that such allergy is very rare and if penicillin is not used, heart valves of the child will get severely damaged. So before every penicillin injection test dose is taken. But test dose may be negative and allergy can come on injection. So any allergy is noted and parent should be immediately reported to the doctor and it requires emergency treatment.
Tablets can substitute injections. Penicillin tablets 250 mg two times a day to be taken and to be continued irrespective of the age of the patient.

12. Is there a chance of infection to heart valves due to rheumatic fever?
Definitely yes. There is increased chance of infection to heart valves in those with rheumatic fever than those without it. Due to rheumatic fever, infection can occur to normal heart valves and those with heart disease at birth.

(1) What are the symptoms of infections to heart valves?
Prolonged fever, reduction in weight, body pain, joint pain, head ache etc. The efficiency of the heart decreases. Spleen enlargement, red spots appearing in the skin, bleeding inside the brain, pus inside the brain, paralysis of the body parts can occur.

(2) How does a heart valve get infected?
Usually after dental extraction or after dental surgical treatment, heart valves can get infected.

(3) Does this infection has treatment, if so, how long?
Yes. At least 6 weeks treatment is necessary.

13. How can we prevent this disease to heart valve?
Those with rheumatic heart disease should have their teeth very clean. Very good personal hygiene. Inform the dentist about your heart disease. And while treating dental problems, a good cover of antibiotic treatment is necessary to prevent infection to heart valves.

14. (1) How does this heart valvular damage occurs?
Mainly the mitral valve connecting the two left sided chambers of the heart and the aortic valve connecting the aorta with the left side of the heart are involved. These diseases are called mitral stenosis (constriction of valves), mitral regurgitation (enlargement of the valve ring producing leak of blood while the heart pumps), aortic stenosis, and aortic regurgitation respectively.

(2) What are the symptoms for the child if the heart valves are damaged?
In the beginning there need not be any symptoms. But once the disease progresses, child will develop tiredness, breathlessness, palpitation, difficulty in playing etc.

(3) What treatment to be done once heart valves are damaged?
Once rheumatic fever comes (even if there is no heart disease) penicillin treatment should be continued to prevent the recurrence of rheumatic fever. Recurrence of rheumatic fever causes severs heart valvular damage. Dental treatments should be done under antibiotic cover to prevent infections (infective endocarditis). If the heart function is poor, drugs like Digoxin is necessary and anemia (pallor) should be prevented.

(4) Is surgery is necessary for heart valvular damage?
Surgery may be necessary when there are symptoms like sever tiredness or breathlessness or when heart function decreases irrespective of treatment. Surgery is mainly Valvotomy or valve replacement. Balloon treatment for valve construction is now available and is cheaper nowadays.

(5) Can a child with heart valvular damage go to school and play?
A child with good heart function can go to school, play like any other child. But penicillin treatment to be continued.

(6) A Girl child had rheumatic fever— can she get married, get pregnant and deliver?
If there is no heart valvular damage, there is no problem for marriage or delivery, but penicillin to be continued. If heart valves are damage, special care should be taken during pregnancy and if there is no severe damage to valves, pregnancy can be continued. But delivery for such a lady should be in a hospital with all the facilities. Mitral stenosis can be corrected before pregnancy through surgery. So a lady can undergo surgery and then get pregnant. But somebody who has severe damage to heart valves, better not to get pregnant as during pregnancy or delivery heart disease can get worse or even death can occur.

15. Be Careful
If your child is having any symptoms of rheumatic fever, consult a doctor, take treatment. If you are careful, no need to get worried.

Diabetes in children

Type 1 diabetes is the most common form of diabetes in children: 90-95 per cent of under 16s with diabetes have this type.

It is caused by the inability of the pancreas to produce insulin.

Type 1 diabetes is classified as an autoimmune disease, meaning a condition in which the body's immune system 'attacks' one of the body's own tissues or organs.

In Type 1 diabetes it's the insulin-producing cells in the pancreas that are destroyed.

How common is it?


Childhood diabetes isn't common, but there are marked variations around the world:

• in England and Wales 17 children per 100,000 develop diabetes each year
  
  
• in Scotland the figure is 25 per 100,000
  
  
• in Finland it's 43 per 100,000
  
  
• in Japan it's 3 per 100,000.
  
  

The last 30 years has seen a threefold increase in the number of cases of childhood diabetes.

In Europe and America, Type 2 diabetes has been seen for the first time in young people. This is probably in part caused by the increasing trend towards obesity in our society.

But obesity doesn't explain the increase in the numbers of Type 1 diabetes in children - who make up the majority of new cases.

What causes childhood diabetes?


As with adults, the cause of childhood diabetes is not understood. It probably involves a combination of genes and environmental triggers.

The majority of children who develop Type 1 don't have a family history of diabetes.

What are the symptoms?


The main symptoms are the same as in adults. They tend to come on over a few weeks:

• thirst
  
  
• weight loss
  
  
• tiredness
  
  
• frequent urination.
  
  

Symptoms that are more typical for children include:

• tummy pains
  
  
• headaches
  
  
• behaviour problems.
  
  

Sometimes diabetic acidosis occurs before diabetes is diagnosed, although this happens less often in the UK due to better awareness of the symptoms to look out for.

Doctors should consider the possibility of diabetes in any child who has an otherwise unexplained history of illness or tummy pains for a few weeks.

If diabetes is diagnosed, your child should be referred to the regional specialist in childhood diabetes.

How is diabetes treated in children?


The specialised nature of managing childhood diabetes means that most children are cared for by the hospital rather than by their GP.

Most children with diabetes need insulin treatment. If this is the case, your child will need an individual insulin routine, which will be planned with the diabetes team.

• Most now use frequent daily dosage regimes of fast-acting insulin during the day and slow-acting insulin at night.
  
  
• Very small children normally don't need an injection at night, but will need one as they grow older.
  
  
• Increasing numbers of older children use continuous insulin pumps.
  
  

Often in the first year after diagnosis, your child may need only a small dose of insulin. This is referred to as 'the honeymoon period'.

As well as insulin treatment, good glucose control and avoidance of ‘hypos’ (low blood glucose attacks) is important. This is because many of the complications of diabetes increase with the length of time diabetes has been present.

What can parents do?
Living with diabetes can put families under considerable strain, so access to backup support is crucial. This may be from your GP, the hospital team or social services.

Understanding all the different aspects of diabetes and its treatment requires patience, but will benefit your child and family life.

The diabetes team at the hospital can help you with the list below.

• Learn how to administer insulin injections. Insulin is usually injected into the skin over the abdomen or the thighs.
  
  
• Know the symptoms of low blood glucose and diabetic acidosis and what to do about them.
  
  
• Make sure glucose is always available.
  
  
• Measure blood glucose levels and teach your child how to do this as soon as they are old enough.
  
  
• Teach your child how to self-administer insulin injections as soon as they are old enough - around the age of nine is typical.
  
  
• See the doctor on a regular basis, and particularly if your child becomes ill for any reason - treatment is likely to need adjusting.
  
  
• Inform the school and friends about the symptoms of low blood glucose and what to do about them.
  
  
• Contact your local diabetes association for help and support.
  
  

Diet

A trained dietician is usually one of the members of the hospital diabetes team.

It's important to give your child a healthy balanced diet that is high in fibre and carbohydrates.

A healthy diet is the same for everyone, whether or not they have diabetes.

How much your child should eat depends on age and weight. The dietician and parents should determine this together.

Sweets are no longer off limits because the 'diabetic diet' is now a relic of the past.

Once your child gets to know how her body responds to eating and taking insulin, sweets in moderation are possible - accompanied by the appropriate dose of insulin.

Physical activity

Physical activity is important for children with diabetes, who should try to exercise every day.

Physical activity lowers the blood sugar level, so if your child takes insulin, she may need to reduce the dose.

This is because a combination of too much insulin and exercise can lower the blood sugar level and lead to hypos. To counter this, your child should always carry sugar.

Physical activity also affects how much your child can eat. Before your child exercises or plays sport, give extra bread, juice or other carbohydrates.

In the long term

A child who develops diabetes will live with the condition longer than someone who develops diabetes in adulthood.

The longer diabetes is present, the higher the risk of long-term complications such as those affecting the eyes and kidneys.

These can start after puberty, but are usually a concern only in later life.

Regular checkups for late-stage complications begin around the age of nine. From then on, this checkup is done every year.

All about Appendicitis

What is appendicitis?
Appendicitis is an inflammation of the appendix, a small worm-like pouch attached to the large bowel. It can happen at any age but most cases are between 8 and 25 years of age. It is rarely seen in children aged under two years.
For young people, appendicitis is probably the most common cause of stomach pain requiring emergency surgery.

What causes appendicitis?
In most cases, the specific reason for the inflammation is not known but it is sometimes caused by small pieces of hardened stool (faecaliths) that get stuck in the appendix.

What are the symptoms of appendicitis?
The symptoms can be extremely variable but often take the following classic pattern. The first sign is usually a pain or discomfort in the centre of the abdomen. This pain comes and goes in waves and is often thought at first to be a simple stomach upset.
After a few hours, the pain becomes more noticeable and constant in the lower right part of the stomach. It is increased by movement or coughing. The patient often loses their appetite, feels sick, and vomits. The temperature is raised and the complexion becomes flushed. The breath may smell offensive.

How is appendicitis diagnosed?
The doctor takes a medical history from the patient and checks their temperature. Blood and urine tests are performed to look for infection.
The doctor examines the patient by pressing on the lower right part of the abdomen and sometimes by inserting a finger in the anus (back passage) in order to exclude other causes of pain. Women are often given a vaginal examination.
There is no one test that will diagnose appendicitis with certainty. Surgery is performed on the basis of the doctor's examination and results of the tests. Many diseases can cause the same symptoms as appendicitis which is why surgeons find a normal appendix in 3 out of 10 operations.

How is appendicitis treated?

• Surgical removal of the appendix (appendicectomy) is the most common procedure. A 3 to 6cm horizontal incision is made in the lower part of the abdomen on the right side, through which the appendix is removed. It is performed under general anaesthesia.
  
• In some hospitals, the appendix is routinely removed by a keyhole operation or the insertion of a three-fibre optic camera through the stomach (laparoscopy). This technique does not seem to have any advantages over ordinary surgery.
  

In uncomplicated cases, a two to three day hospital stay is typical. The person can go home when their temperature is normal and their bowel starts to function again. The stitches are removed 10 days after the operation by a GP. A return to ordinary daily life within four to six weeks is usual.

What can go wrong during the operation?
About one fifth of the patients who undergo surgery turn out to have a ruptured (perforated) appendix. This causes peritonitis or inflammation of the peritoneum, which is the membrane around the internal organs.
Nowadays, this condition can be treated with antibiotics which makes it less dangerous than it used to be but there is still a risk of abscess formation in the abdominal cavity which will require draining.
Adhesions from postoperative scar tissue may develop and block or obstruct the bowel. This happens in a small number of all patients who have their appendix surgically removed. The condition usually occurs within three months of the operation. A bowel obstruction may require emergency surgery.

What is a cold ? (common cold)

A cold is a contagious viral disease which infects the soft lining (mucous membrane) of the nose. There are more than 100 different viruses which can result in a cold. The characteristic symptom is a runny nose.

Usually, it is a mild condition, recovery taking place within about a week. However, sometimes the same symptoms occur with other illnesses like influenza.

It is most common during the cold winter months and affects children and adults of all ages. Most people will catch a cold two to four times a year.

How do we catch a cold?


A person is contagious from the day before the illness breaks out until one to three days after they feel better. The infection is spread by airborne droplets when the sufferer coughs or sneezes.

It can also be spread by hand if someone has the virus on their hands and then puts them close to their eyes or nose. This is possibly the most common way of catching a cold.

What are the symptoms of a cold?

• A sore throat
• There may be pain on swallowing.

• Sneezing.
  
  
• The nose begins to run with a water-like secretion which gradually becomes thicker and more yellow.
  
  
• As the mucous membrane of the nose swells it may be hard to breathe through the nose.
  
  
• An oppressive feeling in the ears.
  
  
• Headache.
  
  
• Coughing.
  
  
• A feeling of being unwell.
  
  
• A high temperature. Children are more likely to run a temperature than adults.
  
  

What can you do to avoid catching a cold?

• If possible, stay away from people with colds.
  
  
• Avoid crowded places where the risk of infection is greater.
  
  
• Do not touch your nose or eyes after being in physical contact with somebody that has a cold.
  
  
• Wash your hands thoroughly, especially after blowing your nose.
  
  
• Keep rooms well aired.
  
  

How does the doctor make a diagnosis?


Consultations with a doctor are unnecessary, unless the cold causes other infections.

Outlook

Usually a common cold causes no serious trouble and symptoms will clear up in one to two weeks. Possible complications include inflammation of the eyes, sinusitis, inflammation of the middle ear, tonsillitis, and pneumonia. The reason for these complications may be that a germ infects the irritated mucous membrane.

How do you treat a cold ?

• There is no effective way of treating an ordinary cold. If the sufferer has no other diseases than the common cold, and it goes away in one to two weeks, there is no reason to see a doctor. Since a cold is caused by a virus, antibiotics are not appropriate.
  
  
• Symptoms such as cough, sore throat, nasal congestion and headache can be relieved by a variety of over-the-counter medicines. You can get advice from a pharmacist about which are most suitable for you and your symptoms.
  
  
• There is no need to reduce daily activities but you should expect to become tired more easily.
  
  
• The symptoms can be relieved by warm drinks.
  
  
• Nasal decongestants may ease breathing.
  
  
• Sleep with the head on a high pillow.
  
  
• Avoid smoking; it irritates the mucous membrane of the nose further.
  
  
• Throw away paper tissues after use to prevent the spread of infection.