Author

Dr. Mallikarjuna Swamy H P

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We have learnt during our school days to solve problems in mathematics or physics or chemistry by applying the right formula.  Yes, the right formula aptly applied, solved several problems.  The same formula applied on to a wrongly perceived problem would land us in trouble. 

The same thing holds good in infant feeding.  

Nature’s way of nurturing the newborn or younger children is by providing customized breast milk.  The “customized,” needs to be emphasized here, which means, the breast milk is not only species specific, but also baby specific.  Breast milk is secreted according to the situation of the baby.  For example, a baby born premature needs a different composition milk, which is taken care of at zero cost.  Composition of breast milk is so unique that the initial part helps in quenching the thirst of the baby whereas the later part provides necessary energy and nutrition, thereby providing a full package with no additional need for water.  Breast Milk is the best gift any mother could give to her child. 

There are only a few problems where the formula (Powdered Infant Formula – PIF) is indicated viz., certain metabolic disorders, some of the maternal infections, genuine lactational failure etc.  Here too, formula aptly applied can solve the feeding issue. Thanks to powdered infant formula milk in such cases. For wrongly perceived problems, the same formula may pave way for several issues.

In simple terms, Powdered Infant Formula or PIFs are humanized cows’ milk, manufactured as close as possible to match the human milk.  There are specialized PIFs viz., soya-based formula, extensively hydrolyzed formula, amino acid-based formula, thickened PIFs, lactose-free formula feeds for certain situations like metabolic disorders, cow’s milk protein allergy, regurgitation or lactose intolerance and so on.  Formula feeds are also available as RTF (Ready to Feed) bottled milk.

Let us look into certain perceptions where in the formula is wrongly applied and understand the facts which would help in avoiding that.

Perceptions and Facts:

  1. Perception:  Especially the first time mothers would walk in saying “not enough breast milk.  Can I give formula feeds or any other breast milk substitute?”

Fact:  If the baby feeds around 8-12 times per day for about 20-40 min; gulping sound while on breast; gaining adequate weight, sleeping well, stooling 3-5 times or after each feed and voiding clear or pale yellow urine 6-8 times would indicate adequate lactation. Most of the time, proper counselling would solve this issue of “not enough breastmilk!”

  1. Perception:  “My baby is losing weight.  Should I start top feeds?”

Fact: Almost all breastfed babies lose weight during the first week of life (upto 10% of birth weight) and regain birth weight by the end of the second week.

  1. Perception: “My baby is passing stools once in 3-4 days.  I think the milk is very less?”

Fact: Adequately breastfed babies may pass 3-4 or more stools/day or once in 3-4 days.  As far as the weight gain and urine output are good, nothing to worry even if stooling is delayed up to 7 days.

  1. Perception: “Baby is crying always.  My parents are saying to give some bottle feeds.  Should I?”

Fact: Only language the baby knows during initial months is “cry.”  Look for the other causes like wet diapers, abdominal discomfort, insect bite, some injury etc., before concluding on inadequate breast milk.

  1. Perception: “He keeps sucking at his fingers or the moment we put our finger.  I guess he is hungry in spite of frequent feeding?”

Fact: Sucking is a natural reflex.  Even when fully fed or while asleep, the baby sucks at the finger or pacifier.  That doesn’t always indicate hunger. 

  1. Perception: “My sister’s baby is quite chubby and my baby is tiny.  Both were born on the same day.  Can I start formula feeds?”

Fact: Each baby is different and their rate of weight gain too.  If the weight gain is within the normal limits (as indicated by the growth curve chart), no need to worry.

  1. Perception: “My friend says that at least 2-3 bottle feeds (PIF) would help in gaining weight faster.”

Fact:  Faster weight gain doesn’t always mean healthy.  

  1. Perception: “I need to go to work from next month.  Should I start formula feeds from now itself so that the baby will get used to it?”

Fact: Breast milk is the best at any given point of time during the first two years of life during which time the maximum brain growth happens.  If direct breastfeeding is not possible, the next option would be to feed the expressed breast milk (which can be kept at room temperature for 4-6 hrs and in the refrigerator up to 72 hrs.)  

  1. Perception: “Breastfeeding is more stressful.  Bottle feeding is more comfortable, easy and I can know how much my baby is taking. I can also make sure that my baby takes the exact recommended amount of milk every time.  Please suggest which formula is the best?”

Fact: I understand your concerns.  But, everything comes with a cost.  The bottle feeding can cause dental and palatal abnormalities over time.  It can also make the infant prone for ear infections.  Most of the formula feeds cause constipation.  The cost of each tin or packet of formula feed adds on to the financial burden.  Moreover, the preparation error while adding water may lead to more diluted feeds thereby less calorie and protein intake.  Contamination is another issue, which can lead to respiratory and gastrointestinal infections.  Though formula feeds are prepared to closely match human milk, still it lacks certain unique features of breast milk such as immune boosting, gut priming, protection towards asthma and allergies in later years etc.,

  1. Perception: “By giving formula feeds, I can take breaks and be free as anyone else can feed the baby.  I can afford the best formula in the market.  Please suggest?”

Fact:  Motherhood is a unique gift by nature. You can take breaks even while breastfeeding by expressing and storing the milk.  One of the biggest advantages of breastfeeding is the development of bonding between you and your baby which may not happen with formula feeds.  

  1. Perception:  Encountered mostly with first time mothers.  “I’ve tried my best to exclusively breastfeed.  Maybe I’m having lactational failure.  Shall I start formula feeds?”

Fact: Many a time the lactational failure is not genuine.  Simple corrections like proper positioning, rectifying nipple issues (painful or cracked nipples due to improper feeding techniques) with the help of trained lactational consultants would solve this.  These retracted or flat nipple issues could have been taken care of during pregnancy itself.

Approximate price range for Powdered Infant Formula milk (Regular milk powder stage 1)

PIF milk brandIndian Market (400 gm/tin)US Market (12.7oz/tin)
Brand A Rs. 350 USD 7
Brand BRs. 750USD 15
Cost comparative table

Average number of tins (400 gm or 12.7oz) consumed by a baby per month may range from 4-5 tins in 1st month (Rs. 1,750 – 3,750 or USD 35 – 75) to 10-12 tins by 6th month (Rs. 3,500 – 7,500  or USD 85 – 180).  Note:  Cost of specialized formula and maintenance (bottles/accessories/containers/spoons/sterilizers etc.,) are not mentioned. 

“If your only tool is a hammer, then every problem looks like a nail (Abraham Maslow)” whereas “a problem well stated is a problem half solved (John Dewey).”

Also Read Antibiotics – Diligent Restrained Use For A Secure Tomorrow Part – 1 and Part – 2

Antibiotics – “A savior if used judiciously, slayer if not!”

Early diagnosis and judicious treatment of bacterial infection is a must in order to prevent further spread or deterioration.  

With an effort to supervise judicious prescription of antibiotics by clinicians and followed adequately by the patients, “Antibiotic stewardship” program was brought into existence.  Stewardship programs are conducted by infectious disease specialists to create insight into above concerns by ensuring judicious use of antibiotics.

Also read Antibiotics – Diligent Restrained Use For A Secure Tomorrow (Part – 1)

“Judicious use” of Antibiotics – Rule of Five explains all

  1. Right Choice
  2. Right Dose 
  3. Right Interval between the doses
  4. Right Duration 
  5. Right Route (viz., oral or injection)
Five Rules – Right CDIDR !

Right Choice of Antibiotics

Antibiotics – A Magic Bullet; But Not for All! The choice of antibiotic depends on several factors like the site of infection, type of bacteria and so on.  For example, antibiotics prescribed for respiratory infection are different from those prescribed for gut infection.  And, even for respiratory infection, the choice depends on the site of the respiratory system involved.

Right Dose

The amount of antibiotic prescribed differs from patient to patient, especially in paediatrics, where the dose is calculated based on the body weight.  Parents need to be alert while the doctor explains the dosage and be vigilant while buying at the pharmacy.  Commonly noted errors: Syrups are available in different strengths.  E.g., Antibiotic A may be available in two dosages a. 125mg per 5ml and b. 250mg per 5ml; if the doctor has prescribed 5ml of antibiotic , 250mg per 5ml, and parent ends up buying 125mg per 5ml, the parent has inadvertently reduced dosage to half! End result – no response or partial response leading to further complications or drug resistance.

Right Interval

Between the doses: Some are taken once a day, some twice, thrice, or even four times a day depending on the type of antibiotic prescribed and the infection diagnosed.  It becomes necessary to strictly follow the prescription for optimal results.  

Right Duration

Antibiotics are prescribed for a specific number of days depending on the infection.  Many patients/parents fail to follow the exact number of days due to certain misconceptions like, “Off fever = Off Infection” or, suspicious thinking like, “Doctor has prescribed for 10 days, but previous doctor for previous infection had given for 5 days.  Maybe this is an overdose.  Better I shall stop at 5 days.” Or “Bottle empty = Course completed”, the syrups vary in concentration and the volume.  Most of the times, patients may need two bottles.  Parents may buy one with plans to buy the next one later.  By the time one bottle gets emptied, fever settles and parents too!  

Right Route

Antibiotics are given either by mouth or through injections. This “Tug of war” is a very well-known one in most of the in-patient care cases.  Let us say antibiotic injections ( when no oral alternatives are available) are planned for 10 days and by the 7th day child looks fine – this may prompt many to get discharged from the hospital before completing the injection counts. Needless to say this goes against medical advice.

If any of the rules is not obeyed either by the doctor or by the patient/parent, the savior can turn into slayer, either by allowing the bacteria to overpower the situation or by causing adverse effects.

Once the bacteria overpowers the situation, strains start developing resistance to antibiotics.  This forces the physician to go for higher antibiotics.  And, the vicious cycle continues till a day comes when we are left with no further choice of antibiotics.   In fact, we are already in this situation especially while taking care of hospitalized patients.  Antibiotic resistance is a global emergency, as the infections do not respect international borders.  Resistant microbes spread with the spread of population across the world.

Adverse effects – Most of the antibiotics have side effects like vomiting, diarrhoea, and abdominal pain.  Prolonged antibiotic use brings down the immunity, further exposing them to secondary infections like fungal or other bacterial or viral.  These are simple adverse effects. 

Serious antibiotic related life-threatening adverse reactions may happen, though rare – Slayer at its worst!

Heavy on pockets …too!

Higher on the use of antibiotics, heavier would it be on the pocket.  Antibiotics are a costly affair and on top of it they come with adverse effects. Forceful climbing up on the ladder of antibiotic potency, would result in the vicious cycle as mentioned above.  

For example, a simple viral fever could be taken care of with supportive care, which costs nothing but patience.  Adding on a fever control medicine, would cost anywhere between Rs. 10 to Rs. 50 depending on the strength.  Even a simple antibiotic would increase the cost by around Rs. 100 to complete the course. Higher antibiotics may be priced Rs. 250 onwards. The story does not stop here.  Most of the antibiotics cause diarrhea, so many would add probiotics and other supportive medicines to take care of adverse effects.  The fever which could have been treated with small amount may end up in thousands.  If financial costs are the tip of the iceberg, then adverse effects on long term health are the mountain beneath the surface, which may even prove fatal.

As the saying goes, “You cannot clap with one hand.”  It is the duty of both the physician and the patient/parent to judiciously use the antibiotic.  

“A Penny Saved Is a Penny Earned!”

Disclaimer:  The above article is only to create awareness regarding antibiotic use.  The given information should not be used as a substitute for doctor’s consultation in case of any clinical symptoms mentioned above.

Antibiotics – A Magic Bullet; But, Not For All!

The word Antibiotics comes from the Greek words ‘anti’, meaning ‘against’, and ‘biotikos’, meaning ‘concerning life’.  Antibiotics are mainly active against bacteria.  They do not cure infections caused by viruses or parasites or fungi, though some antibiotics may act against parasites.  Looking at the second part – “biotikos”, whose life is at concern?  It’s not just the life of bacteria, our lives too!  Antibiotic usage goes with the idiom ‘double edged sword’ – something that can be seen as a benefit and a liability.’ A diligent restrained use of antibiotics is a must for a secure tomorrow!

Antibiotics are one of the most commonly prescribed medicines only next to paracetamol!  There are several reasons for this (ab)use.  To list a few –

  • Parental anxiety/Parental pressure/Parental Misconception– A common scenario found in most of the outpatient clinics.  Any child with high fever, a runny nose, loose stools, vomiting etc., parents’ first remark would be, “Doctor, my child is having an infection, please give him some antibiotics to make him feel better as early as possible!”
  • Physician’s anxiety – Mostly seen with young or newly started physicians.  “What if I don’t write an antibiotic and this child doesn’t get better?  What if the child is taken elsewhere and doesn’t come back?  I may lose more patients because of this one parent who may say to others – ‘this doctor is not good.  He did not prescribe antibiotics and my child’s condition deteriorated’ and so on.”
  • Pharmaceutical companies – They pressurize the health care professionals to meet the target or to move the products in exchange for some incentives.
  • Luxury of insurance coverage This has been trending over the last few years.  It is commonly heard from parents – “Doctor we have insurance.  Please write the best possible antibiotic.”
  • Corporate or Private Health center’s pressure – A pharmacist or the supervisor walking into the doctors’ chambers saying “Doctor, look at this list of antibiotics, not moved at all…expiring in next few months!”
  • Weekend Syndrome – This syndrome owes its origins to the busy life schedules of the modern world. A busy parent may think, “Today is friday/saturday!  Doctor may not be available for the next 1-2 days.  What if my child doesn’t recover?  Better to take an antibiotic.”  A Doctor’s thought, “Let me give them antibiotics, just in case?”  Both these thought processes aid each other – with the end result being an antibiotic prescription.
Living weekend to weekend - causes tremendous pressure among working couple
Living weekend to weekend – causes tremendous pressure among working couple
  • Lengthy Line – Lack of Time Syndrome – This mostly happens with busy practitioners.  To evaluate any child with fever, it takes at least 10-15 minutes.  If there is a line of 60-80 children, the evaluation time can range anywhere between 10-12 hours nonstop.  Practically impossible for a human mind to focus on such extended periods of time.  The easiest option would be to prescribe anti-biotic – thereby saving time.
  • Play safe policy – “Why take chances?”
  • Let’s make others happy attitude!  Quick antibiotic – Parents are happy.  Pharmacists and pharmaceutical companies are happy. It all looks like a win-win situation.  
  •  Lack of forethought – Not thinking of what will happen if the antibiotic becomes useless tomorrow due to development of resistance, which by the way is not a farfetched idea. The devil is just around the corner.
  • “Quack – Quack” Found mostly in sub urban or rural areas.  In many rural areas where there is dearth of qualified doctors, unqualified practitioners prescribe anti-biotics as quick fix – without understanding the consequences. In many cases these “Doctors” acquire their knowledge through internet and through “Medical Representatives’ University”.
  • Working parents’ apprehension: More the number of days lost in taking care of a sick child, more to lose at the workplace.  They end up pestering the doctor for antibiotics.

Myth Busters –Clinical scenarios commonly we come across

  1. Myth: Fever = Bacterial infection.  Many parents believe that fevers are due to bacteria and don’t get cured without antibiotics. 

Buster:  Most of the fevers in pediatrics are viral and don’t need antibiotics.  Good nutrition and hydration, fever control and adequate rest are all that is required.

  1. Myth: Loose stools (diarrhea), vomiting, abdominal pain = Food poisoning due to bacteria and an antibiotic is a must.

Buster: Most of the gastrointestinal symptoms are either due to a virus or preformed toxins or self-limiting bacterial infection.  A good (re)hydration with ORS or tender coconut supported by proper nutrition, adequate rest, probiotics (benefit of doubt) – yoghurt or commercially available probiotics and other micronutrients like Zinc should suffice and/or anti-emetics.

  1. Myth: Runny nose, fever, throat pain = Throat infection due to bacteria.  Better to start antibiotics early!

Buster: Most of the upper respiratory infections are due to viral etiology, unless proved otherwise.  Supportive care should work most of the time.

  1. Myth: Injury/ Wound = Antibiotic is needed to prevent further infection.

Buster: Unless it is case of major or contaminated wounds – proper cleaning and local care should do the trick.

  1. Myth:  Too much cough = Severe bacterial infection.

Buster: Most kids cough either due to a viral infection or some allergy which should be taken care of without anti-biotics.

  1. Myth: Fever has disappeared after 2 days of antibiotic; So why take it for a prescribed number of days?  Let’s save it for the next fever/infection!

Buster: Properly diagnosed and treated bacterial infection usually responds to antibiotics in 48-72 hours.  That doesn’t mean the infection is totally cleared.  It is necessary to complete the prescribed course to eradicate the infection completely.  

  1. Myth: I have the same symptoms as last month – so I bought the same medicines from pharmacy – but it’s not working this time- what’s wrong?

Buster: There are several bacteria which can cause similar symptoms; Let the doctor do his assessment. A doctor is professionally trained to identify these subtle differences and prescribe suitable medicine. Do not try to be a doctor! 

  1. Myth: “Doctor!  The antibiotic you gave worked like magic.  One dose and I’m alright.”

Buster: Effectively treated an infection responds quickly; if the response is so quick with one dose, it is most unlikely a bacterial one.

With an effort to supervise judicious prescription of antibiotics by clinicians and followed adequately by the patient/parents,Antibiotic Stewardship program was brought into existence.  Stewardship program would guide us to use antibiotics diligently, in a restrained manner for securing tomorrow’s concern while treating infections.

To Be Continued…

Disclaimer:  The above article is only to create awareness regarding antibiotic use.  The given information should not be used as a substitute for doctor’s consultation in case of any clinical symptoms mentioned above.