Online edition of Daily News

Dr. Ananda Jayasekera senior Lecturer in community Medicine Peradeniya Medical Faculty is writing today on a very important topic for mothers in neonatal care because unlike in the past, today a mother is sent home with the baby within 10 -12 hours after delivery.

As a result it has become very essential for every mother to have some basic knowledge of neonatal health problems. Because she will be facing these problems at home and unless she has got herself educated on the subject, she will be exposing herself for unnecessary worries and troubles over some conditions in the baby which are normal and need no attention. Also she could fail to observe certain conditions in the baby which could lead to serious problems.

Therefore this article is specially for mothers and mothers-to-be and for the young girls who are looking forward for marriage and motherhood. Dr Jayasekera expects that they would read the article and write to him for any clarifications or explanations needed, which he will gladly do through this page.

By definition the neonatal period is from birth to 28 days. It was not long ago, that the mothers who underwent caesarean sections were kept about 7 days in the hospital. Even after normal vaginal delivery average hospital stay was about 3 days.

Today, such practices are obsolete. As a result, the problems (not necessarily illnesses) that are associated with early neonatal period are seen once the mothers have gone home. Earlier such problems were experienced by the mothers while in the hospital where the medical opinion/advice was available readily. Now, most parents are bound to face these problems at home. It is therefore, very appropriate and important to educate the parents on these common neonatal problems. This will certainly help them to relieve their anxieties.

Therefore, I will go through some common problems in early neonatal problems seen in the community.

Probably the commonest problem seen in very early neonatal period. Most mothers would complain that the milk is not enough and they also express their concern over the amount of milk.

It is important to know that the milk requirement will be doubled within 3 days of delivery and trebled in five days time. As the milk requirement is small on the 1st day, the neonates may not vigorously search for milk. However as days go by, the baby too demand milk more frequently. Generally in early days, the babies sleep most of the time, they in fact get up only to natural demands like feeding, passing of urine and faeces (called meconium in first few days).

Therefore, these feeding problems (within limits) probably could be sorted out at home. However, if poor sucking with lethargy is seen it is best to seek medical advice promptly.

In such situations we find baby's urine output is too reduced. This is a good indirect guide to assess whether the baby has had enough milk or not. The golden rule is that try at all times only breast milk up to 4 months.

Yellow colouration in the skin. The mild degree of jaundice seen after 48-60 hours of birth is generally considered physiological i.e. not harmful. This will increase in colour over the next 3 or 4 days and settle thereafter. However, it is important to know when to seek medical advice.

If the onset (even mild degree of jaundice) is less than 36 hours, certainly less than 24 hours needs medical advice. It is important to calculate the age by hours, not by days as the latter could be inaccurate. If the baby is premature, even low level of jaundice can be harmful.

The low birth weight babies (less than 2.5 kg) tolerance level of jaundice is low.

If you feel that jaundice, or yellow colour of the skin increases rapidly, the medical advice must be sought. Jaundice also could lead to lethargy resulting in poor sucking. Hence more vulnerable to dehydration. In fact dehydration can cause matters worse leading to more jaundice.

Therefore, it is very important to keep the baby hydrated by regular feeds. Once again urine output is an important indirect guide to assess the baby's hydration level. If jaundice persists more than 10-14 days, it requires medical advice.

(a) Red patches and spots, seen on the 2nd to 4th day (called Erytheme toxicum). By nature they are transient, some times quite extensively blotchy (disappears temporarily on pressing by thumb). They are harmless, no treatment is required.

(b) Pustules, Pus filled small vesicles indicating skin infection, a common problem, if numerous, needs medical advice.

(c) Nappy rash, Commonly seen in nappy area after about 5 days. Small red spots and patches. These patches do not disappear on pressure by thumb. It is a fungal infection needing antifungal topical application.

This occurs due to maternal hormones a few days after birth. It is utmost important to know that the squeezing of baby's breasts should not be done at all times.

However this condition can lead to acute mastitis which is an infection, needing medical attention and treatment. In mastitis, the breast becomes red. It starts around the nipples and spreads. This requires urgent medical attention.

Again due to maternal hormonal effects, after a few days. Generally no treatment is required.

The naval cord generally falls between 6th & 10th day after birth. Some times, there can be slight amount of pus or discharge at the base of the cord. General cleaning is adequate. However, if the skin around the cord becomes red and spreads, it means naval infection is spreading, urgent medical treatment is required.

At times, a small bead like fleashy mass (a granuloma) is seen. If this fleshy mass continues to produce discharge, it may require surgical removal.

Needs medical attention. A swab is generally taken for microbiological tests (direct smear and culture).

fairly big lumps are seen on the head, commonly on parietal bones (i.e. the top of the head on the side or either side). Generally no treatment is required. It will resolve gradually. It might take weeks.

Crying is the only medium of baby's response to any feeling or experience. It is a powerful message for parental action. It may be due to the variety of reasons. The spectrum of problems may vary from a very simple reason like wet nappy to a very serious illness. Other causes such as anger, hunger, exhaustion, feeling of inadequacy, discomfort etc.

(c)If associated with feeding, it may be due to, too rapid or too slow milk flow

If the crying is unusual, medical opinion is necessary to exclude illness. Some babies cry when passing urine, most of the time, it is a normal phenomenon, yet, if excessive, urine should be tested.

Most babies bring out milk to varying quantities after feeding. More appropriately it is called regurgitation. Generally it does not require treatment. However, if the weight gain is affected and the infants becomes choked, medical opinion must be taken.

If the baby is well, no treatment is necessary. It is perhaps their type of exercise.

Recent onset, with lethargy should always be considered important. It may indicate serious illness. Early medical advice to be sought.

Most mothers are not generally satisfied with their baby's weight gain. Until about 7 days babies lose their weight, going below the birth weight. They regain their birth weight around 10th day. The weight similar to birth weight after about 2 weeks, requires medical opinion.

Early infancy, bowels opening once in 4-5 days not uncommon in breast fed babies. If this is an unpleasant suffering for the baby it needs medical opinion to ascertain the cause of constipation.

Whitish patches on the tongue, with red areas. This can lead to poor feeding. It requires anti fungal oral drops.

Especially, back of the head and on either side, due to pressure effects - No treatment necessary.

A common problem, especially in cold weather. No treatment is generally required.

In most situations, no treatment is necessary, unless, the size of the head becomes inappropriately large (ie. Bigger head circumference) where medical opinion is necessary.

A word of thanks

Dr. Jayasekera has a word of thanks for us too for publishing his last article on 'Food advertising-a healthy probe' in this page on 18.10.02. In his letter dated 21st Oct. 02 he writes "I thank you profusely for publishing my article on food advertising.

I am sure that the article would have been an eye-opener on the subject. And I am sure interested readers would write to the Health watch giving their views on it.

Yes we welcome readers views on it - Health Watch.

Sri Jayawardenapura Hospital Board offers Its : Presidential suite to the public

The Sri Jayawardenapura General Hospital Board headed by Dr. H. H. R. Samarasinghe has recently decided to offer the use of its - 900 Sq. ft. special presidential suite, which had hitherto been kept exclusively for the country's President's use, at his/her discretion to the public.

Explaining as to why this decision was taken, Dr. Samarasinghe in an exclusive interview with the Health watch said:

"Since the new Board took over the hospital ten months ago we were exploring the areas where we could raise the hospital income to meet its increasing expenditure like salaries, electricity, water etc. over which the hospital had no control.

In meeting this requirement one of the changes we decided to do is to offer this special presidential suite which had hitherto been kept exclusively for use of the President at his/her discretion to the public.

Since the hospital was commissioned in 1985 this suite had been used only twice - once by late Lalith Athulathmudali when he was a Minister in late President J. R. Jayewardene's cabinet and was injured in a bomb blast and the other by late Prime Minister Mrs. Sirima Bandaranaike. Dr. Samarasinghe said" Thus we felt there was no point just maintaining this unit which has two bed rooms and all the facilities of a top class apartment which could easily become a rich source of revenue if offered to the public in the high income bracket.

Since no other hospital has an exclusive unit like this, they would go for it for health care in a Presidential suite. It has roughly been worked out that it would cost about Rs. 4,000 a day for a patient to be in this unit, which has all the facilities of a super class apartment in a hotel, and round the clock medical attention as well".

It appears from what Dr. Samarasinghe said, and the documents he showed that parliamentary committee on public enterprises (COPE) on October 10 had commended the Hospital Board for a job well done.

It's on record that the COPE chairman MP Jeyaraj Fernandopulle at the end of the inquiry into affairs of the hospital had commended the way the Board had attended to rectify almost all matters pointed out to them at the last COPE meeting.

COPE chairman had made special mention of the preparation of a corporate plan for the hospital in just under 3 months, which the previous Boards had failed to do for the past 18 years.

He had also congratulated the Board for getting the 2001 Annual report ready, which no other corporation had been able to do.

Dr. Samarasinghe's story of how the Corporate plan was prepared without costing a cent to the hospital is worth recording because it shows that if one has the dedication and commitment for a cause nothing is impossible.

Dr. Samarasinghe said, when the COPE mentioned about the corporate plan for the Hospital which has been lagging behind for so many years and wanted to know how much of time the new board would need to get it done. Dr. Samarasinghe had asked for 6 month's time, which the COPE had granted.

Dr. Samarasinghe went on to say following that meeting, he had made inquiries from several secretarial firms how much they would charge to prepare a corporate plan for the hospital.

Finding that it would cost over Rs. 400,000 he had decided to do the plan by himself with the assistance of a few Board Members.

The Director, Secretary and Accountant of the Hospital had teamed up with Dr. Samarasinghe, to do it. They had first attended a workshop on preparation of those plans, which was in progress at that time in Colombo. This had given them the knowhow and the basic knowledge needed to do up a corporate plan.

Thereafter for about a month the four of them had regularly worked every night for a few hours and got the plan ready within 3 months - half the time asked for. This was all voluntary work on their part, Dr. Samarasinghe said.

The Hospital administration has also resolved a long-standing frustration felt among some of its young doctors who were PGIM Board Certified Specialists, but were serving in the hospital as mere MOs (Medical Officers) owing to lack of openings in the Hospital's Specialists Cadre.

The plight of these young doctors had been considered, and as a half-way solution to their problem a new category of specialists designated as 'staff Specialists' had been created absorbing all those doctors into it.

These doctors are getting only an additional Rs. 5000 allowance to their MOs pay, but no Specialists salary. Yet they are happy, Dr. Samarasinghe said as their dignity has been preserved.

Since the new staff Specialists category has been created these doctors have been conducting additional specialists clinics in the hospital, adding reasonably to hospital income.

Strict discipline is now enforced in the hospital covering the entire staff to minimise lapses on the part of the staff and thus ensure high quality patient-care. Dr. Samarasighe disclosed that recently two doctors were fined for leaving the hospital during working hours without the Director's approval.

It is common knowledge that smoking, hypercholesterolaemia, hypertension, diabetes, obesity lack of exercise and stress are risk factors for heart attacks. Another risk factor for heart attacks which is not well known is hyperhomocysteinaemia (high serum levels of homocysteine) Homocysteine is an amino acid normally present in our blood and high serum levels of homocysteine is responsible for a number of diseases.

Hyperhomocysteinaemia is an established coronary risk factor especially in the young coronary artery disease patients and doctors have been prescribing folic acid (which is one of the B-complex vitamins) and vitamin B 12 to treat patients with coronary artery disease. Until recently doctors were not aware of the exact mechanism of action by which lowering of serum homocysteine by folic acid and B 12 helped coronary patients. In the August 2002 issue of the Journal of the American College of Cardiology Dr. Frank F. Willems et al have proved, using double blind controlled trials, that lowering serum levels of homocysteine improved the endothelial function thus reducing risk of getting heart attacks.

Dr. Frank H. Willems and colleagues used ischaemic heart disease patients whose diagnosis have been confirmed by coronary angiography and using repeated angiographic studies they proved that the endothelial dependant coronary blood flow increased after administration of folic acid and B 12 to these heart patients. Folic acid (5mg per day) reduced the serum homocysteine level by 25% whereas vitamin B 12 reduced the homocysteine level by 7%. Thus out of the two vitamins, folic acid is better.

Ideally serum homocysteine level has to be estimated before and after treatment with the vitamins; but facilities for estimation of serum homocysteine are not available in the government hospitals of Sri Lanka. In the private sector, it costs about Rs. 1,000 for estimation of serum homocysteine levels. Folic acid is one of the cheapest vitamins and cost of a 5mg tablet (which is the daily dose) is only 14 cents. Folic acid in a dosage of 5 mg does not cause any side-effects.

Some of the general physicians and cardiologists have been prescribing this vitamin to all ischaemic heart disease patients for some time. Folic acid can be bought from any chemist without a doctor's prescription. It is advisable for all physicians to prescribe this very useful vitamin to all coronary artery disease patients and those who are predisposed to coronary artery disease with a view to reduce the incidence of heart attacks in the community.

I am 74 years (and my wife is 70), and presently in retirement from a state executive job. Both of us are devoted Buddhists and vegetarians. I have never tasted liquor or a cigarette, and are free of all ailments - we have no pressure, cholesterol troubles or such complaints and live very happily at the above address at present. Our children are doing well abroad, and they are constantly in touch with us.

We have repeatedly turned down their request to go and live with them as we like Sri Lanka and a Buddhist atmosphere. We have substantial means, and we wish to get into an elders' home on monthly payment, in respect of the sum involved, if we can get a hut or a separate room, where we would be looked thereafter well, attended by a doctor, as we will very soon be immobilised. We don't mind a place away from the city if the above needs are there.

I am sure you will appreciate our position (and presumably of a large number of others) and consider this probe as a meritorious deed with great future reward.

As far as I am aware best elders home in Colombo district where you and your wife will get the above facilities is "SANHINDA" (Telephone number 823718).

In above elders home which has been built for Sri Lankan Buddhists there are separate rooms for families and you will get the required medical facilities. Telephone number of the manageress is 583764. Of course, you will have to pay for all the services and you and your wife can live in a Buddhist atmosphere for the rest of your life.

A patient of mine recently showed me an article written to the Health Watch where it states that statins are not helpful in the over 70's. This is not quite right in the present context for, the MRC/British Heart foundation Heart Protection Trial put a stop to any medical debate about the value of statins in particular patient subgroups.

This trial targeted patients under-represented in other trials including the over-70's, women, and others.

The relative risk reduction was remarkably consistent among all of these. On the basis of this and other studies we can calculate that five years of statin treatment will prevent a heart attack, stroke, or other vascular event in 100 of 1000 patients with a previous heart attack, in 80 of 1000 patients with angina, and in 70 of 1000 patients with a stroke, peripheral vascular disuse or diabetes.

The remarkable thing about statins is that it has beneficial effects other than simply lowering cholesterol and it is not outrageously expensive too. Thus, the cutoff point for treatment is clearly a philosophical or political matter rather than for a doctor treating an individual patient.

In the light of all this incontrovertible evidence, it would not be wrong to say that "a statin a day would keep the doctor away".

I hope you would publish this letter to clear any misconception that the public may have with regard to the value of statins.

This is with reference to the article "Consultation practice a mockery" in Health Watch of 11.10.2002. I was an in-patient for a couple of days at one of the private hospitals in Colombo having consulted a physician who wanted me admitted.

In the course of two days as in-patient I was herded along by an attendant with another ten in-patients to this Consultant's Room on two occasions for his advice/observation on the therapy recommended. What has anyone to say on this practice of herding the in-patients to the Consultant's Room instead of the in-patient being visited by the Consultants in the privacy of the patient's room for which the patient pays. The professional fees charged for this method of visiting the patient are about six times the Consultant's normal fees. I am told is this ethical?

Honey has long been known for its property of sweetness and its nutrient value assigned to the presence of micro quantities of vitamins, sugars, enzymes and the like. In point of fact, current research presented at the American Chemical Society held in Boston in Aug 2002 reveals that "sweetening your cup of tea with honey is a healthier alternative to sugar", not merely because honey contains unrefined sugars and the aforementioned ingredients, but for additional reasons as well.

Scientists have known for several years that honey is a rich source of "anti-oxidants" that deal with the "free-radicals" existing in the body, before the latter can cause any damage. In fact, honey is known to contain a similar range of anti-oxidants, as found in apples, pears, bananas and, in fact, some varieties of honey contain as many anti-oxidants (by weight) as in leafy green vegetables, such as spinach.

The current research conducted at the University of Illinois, U.S. (Engeseth and co-workers) attempts to discover what effects these high anti-oxidant levels have on human blood. The research group tested seven varieties of honey ranging in colour from the darkest brown coloured honey to the lightest pale brown acacia honey.

In vitro tests revealed that "the darker the honey, the higher the resulting anti-oxidant capacity of the blood" confirming the proposition that dark honeys contain more anti-oxidants.

This study has geared itself to work with rabbits, in order to determine whether honey anti-oxidants may confer any beneficial inhibitory effects on atherosclerosis, (i.e.) the hardening of the arteries, which is one of the major causes of heart disease. Additionally, the group expects to find that the intake of honey would cause the slowing of the oxidation of a certain lipoprotein that is associated with the onset of heart disease as well as the reduction of plaque deposition in the arteries.

The anti-oxidants found in honey are ployphenolics, similar to those found in tea and red wines, but includes two "novel anti-oxidants not found in either tea or red wines. So it appears that geography and floral source influence both the colour and chemical composition of honeys and will soon be proved to be a greater source of health and pre-emptive medication than even thought of earlier.

To those whose concerns centre round the adverse effects of sweetening agents on their teeth, there is a bonus factor, revealed by the same researchers that some types of honey inhibit bacteria such as streptococcus mutants, which cause tooth decay and it appears that the middle of the dark to light range of honeys provide the greatest protection against these bacteria.

Dr. A.R.L. Wijesekera of Inner Vandervert place Dehiwala has sent this honey piece to the Health watch.