school days

Back to school
YOUR HEALTH DR GITA MATHAI

It is that time of year again. Stressed out parents are standing in serpentine queues in front of book, shoe and clothing stores as they attempt to cope financially, emotionally and physically with the dawn of another school year. The transition from “Cartoon Network” holidays to “tuition filled” school days is traumatic. Without adequate and timely preparation, stress levels in parents and children can skyrocket.

There is usually a whole month before a new session starts. So take some steps at least a week before school begins.

Establish a routine. Wake the child up at 6 am and encourage 20 minutes of aerobic physical activity. Running up and down on the road in front of the house will wake up all “sleepy heads”, ensuring that they are “alive and kicking” for the rest of the day. This also sharpens the intellect, improves memory, boosts academic performance, instils discipline and reduces stress.

Unfortunately many schools do not have structured compulsory PT or games periods, especially in the higher “examgoing classes”. Games periods, usually scheduled only twice a week, are often usurped for “annual day” practices or to complete the academic syllabi.

Get the immunisation card verified. Even the most meticulous parent can get caught out with an incomplete immunisation card in these days of “package immunisation deals”. The schedule is complex with combined shots, varying intervals between doses and boosters that finally finish in the 16th year.

Many ailments acquired in school — like jaundice, typhoid, chicken pox, measles, German measles and mumps — are preventable with timely and adequate immunisation. This reduces the number of “lost” school days. Jaundice (hepatitis A and B together) requires five injections. Typhoid boosters have to be given every three years. The newer pneumococcal vaccine protects against pneumonia and repeated ear infections. The meningococcal vaccine prevents a type of brain fever. Influenza vaccine too is available.

Organise teeth, eye and ear checkups. Visual defects and hearing are correctable impediments to academic excellence. It may be a simple blocked ear as a result of wax build up or something more sinister. Poor eyesight, uncorrected with the proper prescription glasses, may result in difficulty in reading alphabets, numbers and copying from the board.

The school bag should be a backpack with padded straps that fit well on both shoulders. The weight of the school bag should not be more than 10 per cent of the total weight of the child. Greater weight alters the centre of gravity, which can cause loss of balance and also result in accidents.

School uniform material should not be of more than 40 per cent polyester (the rest being cotton). This is suitable for our climatic conditions. Undergarments and socks should be made of pure cotton and washed daily. Sweaty socks, “air dried” and worn again, can cause fungal infections of the feet. Shoes should be made out of natural material like leather or cloth. Damaged, torn, worn out, ill-fitting (too large or small) shoes can damage growing feet irreparably.

Transportation to and from school should be safe. Packing 20 or more children into a vehicle (other than a bus) is not a pleasant, safe or advisable way to commute.

Television viewing should be restricted to two to three hours (a movie) on Saturdays. Watching 2-3 hours of cartoons and other mind numbing channels on a daily basis can result in academic underachievement.

These apart, ensure that the child eats a balanced breakfast. Milk (200ml) is not a substitute and should be given after breakfast. If the child refuses to eat, 1 ounce (30gm) of cooked ragi (or finger millet), with milk and sugar added, can be given as a substitute.

A preferably home cooked nutritious snack, like carrot halwa, peanut barfi, kesari, bhajis, samosas and bondas, should be given at “breaks”. Carbohydrate-overloaded, salted, preservative-laden packaged eats or “instant” snacks should be avoided.

Many children attend tuition straight after school. A banana and another snack should be eaten after school is over and before this grind starts. A tired, hungry child will find it difficult to concentrate. Also, a child needs approximately 1.5 litres of water for a school day.

Have realistic expectations from your child. Each child is different, with talents and interests that are individual. There is no point in trying to fit all children (even siblings) into the same common mould. Failure to perceive this causes stress and depression in parents and children alike. Before berating and blaming a child for academic underachievement, reflect and introspect.

Attend all parents-teacher meetings regularly. The regular physical presence of concerned parents prevents bullying, ragging, victimisation and favouritism. Volunteer to help with annual days, plays and sports days. Teachers will remember your actions and your child will benefit.

School days should be remembered as “fun days” and not fear and tension filled “bamboo stick” days!

pandemic

Rest is best

Your Health
DR GITA MATHAI

It is the wrong time of year for “flu” (influenza), but the World Health Organization (WHO) has issued a warning that we are on the verge of a swine flu pandemic. This is serious news indeed because the WHO does not like to cause unnecessary panic. Its gradation of influenza varies from phase 1 where the infection is present and circulating only in animals like birds and pigs, to phase 6, the highest level,where the virus has spread to another geographic region and its transmission is increased and sustained. With the scare posed at phase 5 — where a pandemic is imminent — its fears seem justified as the H1N1 virus that causes swine flu has been identified in Mexico, the US, Canada, the Netherlands, Israel, the UK, Denmark, Germany and Spain.

Influenza pandemics occur with devastating regularity. The first wave of Spanish flu occurred in 1918, affected 50 per cent of the world’s population and killed 50 million people. Asian flu in 1957 killed one million and Hong Kong flu in 1968 another one million. The seasonal flu epidemics kill around half a million people a year. In contrast, only 25 million deaths are attributable to HIV and AIDS worldwide.

Flu starts like a common cold, with symptoms like fatigue, fever, headache, runny nose, watery red eyes and muscle pains that set in one or two days after contact with another infected individual. It spreads from one person to another by direct transmission. As an infected person coughs, sneezes or spits, the virus particles are transmitted in the air. The inhaled droplet particles are 0.5 to 5 µm in diameter. A single particle can cause an infection. Each cough or sneeze expels 40,000 droplets into the environment. These can also get deposited on surfaces, contaminating walls, doors, paper, coins and other surfaces. They can be transmitted through unwashed hands from one person to another. High ambient temperatures and ultraviolet radiation kill the viruses rapidly in 5-15 minutes. However, if the virus is expelled enveloped in mucous discharge, it can survive for up to 48 hours. Crowding, with close contact, lack of ventilation and low temperatures in winter facilitate the spread of influenza.

Flu is usually a mild disease from which patients recover spontaneously. Serious illness, complications like secondary bacterial pneumonia and death can occur in the very young and the elderly (extremes of life), pregnant women, those with HIV or heart disease, and in smokers.

The diagnosis is mainly clinical, based on the characteristic signs and symptoms during an epidemic. Rapid diagnostic tests and viral cultures are available and can confirm the diagnosis with an accuracy of 75-90 per cent.

The virus causing influenza is a RNA virus — a virus that has ribonucleic acid as its genetic material — with five genera (family subdivisions). The commonest disease causing ones belong to A, B and C. They are given names like H1N1, H5N1, depending on the human antibody response. These viruses live in birds and animals like pigs. They can suddenly mutate and become virulent enough to cause disease in humans. Since the human population hasn’t been exposed to this new form of the virus, it doesn’t have any immunity. The disease then spreads rapidly in the susceptible population, causing a pandemic.

Outbreaks of influenza usually occur in winter. Since winter occurs at different times in the northern and southern hemispheres, there are two major epidemics a year. In addition, in the tropics an epidemic also occurs during the rainy season. These are the times when usually there is less sunlight and people tend to crowd together indoors. Air travel among regions and hemispheres has blurred these typical occurrences.

To contain an epidemic

Wash your hands with soap after visiting a sick person. Wash your hands several times a day, especially after handling money.

Clean surfaces like door knobs with a disinfectant.

Use a face mask.

Cover the face while coughing or sneezing.

Avoid spitting.

Immunisation is available against the influenza virus. The WHO tries to predict the strain that is likely to cause an infection that year and passes on this information to the pharmaceutical companies. They then have around six months to develop the vaccine. It is 75 per cent effective in preventing influenza.

In people who develop it after immunisation, the disease is less severe and runs a shorter course with reduced complications. The injectable vaccine is available in India. It is recommended for the young, the elderly, the diabetics and those with heart disease. A nasal spray vaccine is available in other countries.

If you are unfortunate enough to contract flu, stay at home and rest. Recovery will be faster and you will not be spreading the virus to the general public. Take paracetamol for the fever, aches and pains. Generally aspirin and other salicylic acid preparations should be avoided. Though they are generally safe medication, they can cause dreaded complications if given with flu. Specific antiviral medication like oseltamivir (Tamiflu) can be taken under medical supervision for prophylaxis and also to reduce the duration and severity of the illness.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in
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feeling the pulse

Feel your pulse Your Health DR GITA MATHAI Our heart works to keep us alive. As it beats, pressure waves travel along the blood vessels as a “pulse” which can be felt at the wrist, in the armpit, on either side of the neck, in the thigh, behind the knee and in the foot. The pulse rate is an indication of the heart rate. The wrist is the easiest place to measure the pulse. Place the tips of the index, second, and third fingers on the palm side of the other wrist, below the base of the thumb. Press lightly with the fingers. The pulse can be distinctly felt as a steady beat. The rate is usually counted for 30 seconds, and then the value obtained multiplied is by two. The pulse is expressed as the rate in one minute. The rate varies at the different stages of our life. It is normally: • 100 to 160 in children less than 1 year old, • 70 to 120 in children between 1 and 10 years, • 60 to 100 after that, • 40 to 60 in trained athletes. It can go up to 200 with exercise, anxiety or fear. For running, jogging, swimming and other forms of aerobic exercise to be efficient, the “target heart rate” has to be achieved. This is 60-80 per cent of the predicted maximum heart rate (the highest rate achieved during maximal exercise, and calculated by deducting your age from 220). So if you are 35 years old, your predicted maximum heart rate is 185 and target heart rate is 60-80 per cent of this — 111-148. As athletic conditioning improves, the target heart rate is achieved within a few minutes. Once the exercise is stopped, the rate returns to normal equally fast, usually within two minutes. Newspapers and television all over the world have been publicising the benefits of regular exercise. In spite of knowing that exercise is good for us, 70 per cent of adults over the age of 50 years do not get adequate exercise. To ensure that the exercise is efficient and adequate, the target heart rate should be achieved and maintained for a minimum of 30 minutes for five days a week. (A slow stroll in rubber slippers while gossiping vociferously obviously will not do the trick). Pure yoga, Tai-Chi or other stationary exercises are good for acquiring muscle strength and improving balance and posture. But they have to be combined with active movement for efficient heart protective exercise. Before the discovery of stethoscopes, electrocardiograms and X-rays, physicians had little evidence to go on, except the pulse rate. By feeling the wrist they were able to arrive at a variety of diagnoses. Anxiety and excitement increase the rate, producing a rapid, throbbing pulse. This is the basis on which patients sometimes say, “The doctor felt my pulse and diagnosed pregnancy!” An overactive thyroid gland, anaemia and heart diseases have the same effect. Coffee, tea and many cola drinks, containing caffeine, increase the heart rate if taken in sufficient quantities. The pulse may be slow in well-trained athletes, if the thyroid levels are low, and if there are diseases of the heart, especially heart blocks. Certain medication used to treat high blood pressure also slow the heart rate. A resting pulse rate of more than 76 doubles the risk of heart disease. To lower the rate to desirable levels check with your doctor and then start exercising. If your life has been sedentary, the intensity of exercise should be graded and increased gradually. You should feel a warm glow as you start the exercise and should be able to speak a complete sentence at all times while exercising. It is important to have a five-minute slow walk to “warm up” and a similar one to “cool down” at the end to give the heart time to adjust. This prevents muscle injury as well. Although 30 minutes is the minimum recommended, it does not all have to be done at one stretch. It can be broken up into five or 10-minute slots and done several times a day. The other way to exercise adequately is to buy a pedometer, clip it on and try to complete 10,000 steps a day. As age advances, it becomes important to remain fit and maintain a healthy heart. Studies have shown that fitness levels can be calculated by measuring the pulse rate. Individuals with a low resting pulse rate, rapid acceleration to target levels and quick recovery are likely to live longer and have active and healthy lives. The amount and intensity of the exercise is important. It is, also, never too late to start. At any age from five to 100, it is important to start moving and keep on doing so. Adults who have taken up regular exercise even after the age of 70, have remained independent and mobile, and have reduced their risk of dying before the age of 90 by nearly 30 per cent. DR GITA MATHAI IS A PAEDIATRICIAN WITH A FAMILY PRACTICE AT VELLORE. QUESTIONS ON HEALTH ISSUES MAY BE EMAILED TO HER AT yourhealthgm@yahoo.co.in

Copyright © 2009 The Telegraph. All rights reserved.

uterus?remove it!

Remedial removal retraced

YOUR HEALTH DR GITA MATHAI

The ancient Greeks believed that women developed bizarre behaviour or “hysteria” because they had a hystera (Greek for womb or uterus) while men did not. Removal of the uterus, therefore, came to be called “hysterectomy”, a nomenclature in use even today. Women are advised to have their uterus removed for a variety of medical conditions. In the developed countries 35 per cent of the women over the age of 60 have had this surgery. Ninety per cent of the surgeries were done for harmless illnesses, which perhaps could have been tackled with medicine. We, in India, are fast catching up and the surgery is performed for a multitude of indications. If you are a woman, it pays to be informed about the surgery, its indications, contraindications and after effects. It is easy to fall into the trap of “my child bearing days are over, what do I need this organ for?” Or, “it bleeds irregularly without warning, hurts and needs to be regularly evaluated for the presence of cancer.” If it really was that useless, in all probability, it would naturally fall off at a certain age, just like our milk teeth. A hysterectomy can be total, when the entire organ is removed, or partial when the lower part, called the cervix, is retained. The ovaries, which produce the eggs (ova) and the female hormones, can be removed at the same time, or left behind. Even if the ovaries are preserved, they usually cease to function in one or two years once the uterus is removed. If the cervix is left behind, any disease process that may develop in it at a later date is difficult to tackle. The subtotal operation has fallen into disrepute and is rarely done. (If you are having a hysterectomy make sure that the surgeon is going to remove the whole organ). There are several techniques for surgery. It can be done through a curved incision along the bikini line. The visualisation is good; the scar disappears into a natural crease and is barely visible. The person is less likely to develop a hernia at a later date. A straight incision leaves a long visible scar. A hernia may develop if the person puts on weight, or there is post operative infection. Surgeons can remove the uterus through “button holes” using a laparoscope. It can also be removed through the vagina without an abdominal incision. The operation is required — • If there is cancer of the uterus, cervix or ovaries. • Sometimes, as a follow through for cancer of the breast, since that tumour may be dependent on the hormones produced by the ovary. • If the uterus itself has descended (prolapsed) and can be seen partially outside the body. • Frequently for uterine fibroids called myomas. These are non-cancerous tumours in the muscle of the uterus. They can be troublesome as they can grow to a large size, press on the urinary bladder and interfere with urination. They also cause stomach pain and increased bleeding. • Sometimes if the menstrual tissue, which lines the uterus and should be shed during menstruation, grows abnormally into the muscle of the uterus (adenomyosis) or into the abdomen (endomteriosis). • If there is uncontrolled and frequent bleeding. Fibroids can be tackled without hysterectomy, with alternative surgical procedures like myomectomy (the uterus remains preserved and the woman retains her reproductive potential) or uterine artery embolisation (a minimally invasive means of blocking the arteries that supply blood to the fibroids). The lining of the uterus, which bleeds uncontrollably or irregularly, can be destroyed by a surgical process called ablation. Medications and hormones, if used appropriately, can control pain and bleeding. An open hysterectomy allows an excellent view of the abdomen so that the surgery can be meticulously done and bleeding controlled. However, it is a major procedure. There can be unexpected bleeding or infection. Recovery takes four to six weeks. Surgical menopause occurs abruptly if the ovaries are removed at the same time. It is different from the natural menopause, in which case the hormone levels fall gradually over a period of time so that the body adjusts to the changes. The sudden lack of hormones leads to night sweats, weakness, depression and insomnia. The bones lose calcium and become osteoporotic. This can lead to fractures, particularly in the vertebrae. As the protective effect of the female hormones disappears, the lipid profile changes and the risk of heart disease increases seven fold. The vagina becomes dry and sex may become painful. The urinary bladder loses part of its supporting wall. It may prolapse into the vagina and urine may be retained. There may be urinary incontinence (involuntary leakage of urine). Recurrent infections can occur. Similarly, the rectum can protrude into the vagina causing constipation. Problems with uterus are also time bound. They will cease with menopause. The after effects of a hysterectomy persist for a lifetime. Before contemplating surgery, consider. Is the disease worse than the cure? Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

killing heat

Summer blues

YOUR HEALTH DR GITA MATHAI

The killing heat” is not just a figure of speech. Every summer, newspapers report deaths from sunstroke, heat and dehydration. This may only be the tip of the iceberg as medical documentation and statistics on illness in India are still unsatisfactory. We really do not know exactly how many people are affected. Human beings are sensitive to outside temperature. To survive, the body has to maintain its internal body temperature at 98.4°F. If it is cold outside, we have to insulate the body by covering ourselves. If it is hot, the temperature has to be brought down. The skin is provided with four million sweat glands distributed all over its surface. As the temperature rises, the brain sends chemical signals to these glands and they start functioning. The body becomes drenched in a film of sweat. As this evaporates, the temperature drops. The volume of water lost in sweat daily is highly variable, ranging from 100 to 8,000 millilitres a day, depending on the outside temperature and the extent of physical activity. Sweat is not pure water. It contains small amounts (0.2 - 1 per cent) of chemicals like sodium (0.9 gram/ litre), potassium (0.2 gram/litre), calcium (0.015 gram/litre), magnesium (0.0013 gram/litre) and other trace elements. When a person moves from a cold climate to a hot climate, adaptive changes, called acclimatisation, occur in their sweating mechanisms, regulating not only the fluid lost but also the chemical content. Summer months are vacation months when people travel to the hills from the plains and vice versa. If you are travelling to a warmer environment, it takes your body a couple of days to adjust to the new temperatures. The maximum rate and quantity of sweat has to increase and it has to become more dilute. This acclimatisation period is the time when people are most vulnerable to the effects of heat. The sweating mechanism is inefficient and immature in children till the age of about four. It does not function well in the elderly, the obese and those with diabetes. The system also breaks down with some of the medications taken for high blood pressure and depression. This subset of the population is, therefore, more vulnerable to the effects of heat. The body’s natural cooling mechanism can fail: • If sweat cannot evaporate because the outside environment is humid. The internal temperature continues to rise even though the body remains bathed in sweat. • When inadequate fluid intake with dehydration prevents adequate sweating. • Due to continuous physically taxing work or exercise in a hot environment without sufficient intake of fluids. Heat exhaustion occurs first. You may get a headache, giddiness, a feeling of weakness, palpitations and painful cramps in the leg muscles. The body temperature rises and may eventually be as high as 104°F. If heat exhaustion is not recognised and treated, this can progress to a heat stroke. The temperature rises even to 105°F. There may be confusion, disorientation, seizures and even death. Unfortunately, children often cannot express the early symptoms of heat exhaustion. The only sign noted by the parents may be the temperature. Fearful of fever, they may cover up the child with inappropriate warm clothing and bed sheets. Thirst may be ignored. This accelerates the progress to a heat stroke. To deal with the summer • Try to stay indoors as much as possible, going out only before sunrise and after sunset. • Confine exercising outdoors to the same time. Even swimming in the hot sun can lead to heat exhaustion and stroke. • Avoid synthetic garments. Wear clothes made of cotton, linen, jute and other natural fibres. • Drink plenty of fluids. Do not wait to feel thirsty. The best liquids are tender coconut water or lightly salted lime juice and buttermilk. • Avoid aerated drinks. They add unnecessary calories. Many of them are hypertonic and will not quench your thirst. • Dehydration and the ill effects of heat are aggravated by caffeinated beverages, whether they are colas, tea or coffee. • nAlcohol has a similar effect. If you suspect heat exhaustion • Immediately move the person to the shade, under the fan or to an air-conditioned or air-cooled place. • Give plenty of fluids, preferably with salt. There are many commercially available oral rehydrating solutions that conform to World Health Organization standards. These sachets can be reconstituted and administered. Most of us live in heat radiating concrete jungles where we have to go out to work in the summer. Frequent power cuts and inadequate voltage make amenities like fans, coolers and air conditioners dysfunctional. In this scenario we have to be careful about the effects of the summer heat, particularly on the vulnerable young and old members of our families. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

letters

Hole in my ear

YOUR HEALTH DR GITA MATHAI

Q: I developed a hole in my eardrum and I think it is due to prolonged use of the mobile phone. I cannot manage without my phone. A: The hole (perforation) in the ear drum is unlikely to have been caused by the use of a mobile phone. Usually it develops as a result of an ear infection (otitis media), an injury with a sharp object or a sudden loud sound near the ear. It needs to be evaluated. You should consult an ear, nose and throat (ENT) surgeon. It may heal and close with antibiotics and the use of ear drops. A long-standing non-healing perforation may require an operation called a tympanoplasty. In any case, why not use the speaker phones option? Tingling feet Q: My 72 years old father, is a diabetic, whose blood sugar is well controlled by oral medications. He has a lot of discomfort in his lower legs and feet. He had consulted a neurologist and after certain tests was found to have neuropathy. Although he was given vitamin combinations he has had no relief. A: Diabetic neuropathy is a nerve disorder that can occur as a complication of diabetes usually if there is poor blood sugar control. It can cause problems with the sensation in the feet. The symptoms are numbness, pain, or tingling in the feet or lower legs. There may be difficulty in walking and balance. The first step is to bring blood sugar levels under control. You could purchase a glucometer and check the sugar level regularly at home. Make sure he always wears well fitting shoes. Walking regularly, taking warm baths, or using elastic stockings may help relieve leg pain. Analgesics, low doses of antidepressants, and some anticonvulsant medication can be prescribed, in addition to vitamins, in severely affected individuals. Potty tot Q: I have a son who is three and half years old. He has been suffering from acute constipation for the last one year. He passes hard stool, with pain. Sometimes small amounts are passed 10-12 times a day. He eats well and his diet includes 1,000ml of milk, which I give in a bottle at night. A: The quantity of milk that you are giving is far in excess of what he requires. He needs only 400ml of milk a day at the very most. It can be split into two 200ml feeds, in the morning and evening, not at night. At three and a half years he is far beyond the stage of feeding bottles. Encourage bowel movement in the morning by making him sit in the toilet at a fixed time even if he does not feel the urge. If the constipation persists a further evaluation with a paediatrician can be done to rule out thyroid deficiency or bowel malfunctions. Worried about AIDs Q: Does a married couple need to have sex with a condom? I want to prevent HIV infection in myself and my wife. I am worried about AIDS. A: If either party has had prior sexual encounters, it is better to use a condom until you check for HIV and hepatitis B. It is better to check again after six months when the window period for HIV infection is over. If you go to a Voluntary Counselling and Testing Centre, the tests are free. Married people need to use condoms as a contraceptive device if they wish to prevent pregnancy, or if one of the parties is HIV or HbAg positive (hepatitis B). Seeking perfect eyesight Q: I want perfect eyesight. What diet should I eat and what can I do? A: Green leafy vegetables like spinach, beetroot, carrot and drumsticks help eyesight because of their vitamin and antioxidant content. Overcooking destroys heat sensitive labile beneficial vitamins of the B group. Steaming or microwave cooking vegetables or eating them raw is, therefore, better. Eating two raw tomatoes a day will give you all the vitamins you need. There are eye exercises in yoga which, done regularly, help to maintain and improve your eyesight. More children Q: I am 41 and my wife is 35. We have an eight-year-old daughter. We decided to try for a son. Despite our best attempts over the last one year, we failed. Although my wife’s periods are irregular, no tests have been done. We have received all kinds of tablets from various doctors. Now we read that some of them have potentially dangerous side effects. A: All medicines have some side effects even if they are aryuvedic, homeopathic or herbal. The tablets used to induce ovulation can be dangerous if given for too many cycles in improper doses. Before proceeding consider • You already have a healthy daughter. • Do you really want another child? •Test yourself — do a semen analysis • Do an ultrasound for your wife to see why the periods are irregular. Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in

irritating itches

That irritating itch!

	YOUR HEALTH   DR GITA MATHAI

Eczema is a strange disease. If you have it, the frustrating itching and scratching starts and then just never seems to go away. The number of people with eczema is increasing. One in five now develops it in childhood. Many factors, such as early weaning, chemicals (preservatives and pesticides) in the human diet, perfumes and pollution, have been blamed. The fact is no one really knows the cause of eczema, but we do know that exclusively breast-fed infants are less prone to it.

Eczema appears as red, itchy, dry and flaky skin, with or without small pustules. A few months of constant itching may make the skin permanently rough, thick and hyperpigmented.

The classification of eczema is not very clear. It can be due to atopy (tendency to develop allergy), allergic contact, infantile seborrhoea (dandruff-like condition of the head that occurs in infants) or varicose veins.

Atopic eczema is the commonest form. It usually occurs in childhood as an itchy rash distributed on the head and scalp, neck, inside of elbows, behind the knees and on the buttocks. It has a hereditary component and runs in families.

Infants can develop an eczema variant called cradle cap — with a greasy, itchy flaky scalp. This can extend to the eyebrows, face and the trunk. Although the condition is self limiting and harmless, the physical appearance can be distressing to the family.

Irritant contact eczema can be distinguished from the atopic form by the typical distribution and family history. It occurs as an immediate or delayed reaction to contact with an allergen. It may be nickel in the safety pins used on clothes, fashion jewellery containing unacceptable metals or colouring, plants in the garden or chemicals in the workplace. Makeup or face powder can cause an idiosyncratic reaction. Sometimes the contact eczema may be photosensitive and flare up only when the skin is exposed to sunlight. Eczema caused by a specific chemical or disease process can be cured if the underlying factor is removed.

Bacterial, viral or fungal infection of the skin, or infestations with skin parasites like scabies or body lice can cause secondary itching and eczema. Poor blood circulation to the legs as a result of varicose veins can lead to itching and discolouration, particularly near the ankles. These forms are totally curable and tend to disappear forever when the infection is treated or the blood circulation is improved.

Unfortunately most varieties of eczema do not fall into the curable category. They recur time and again, and sometimes become self perpetuating as scratching and picking the skin becomes a habit.

Dry skin aggravates eczema. Therefore it pays to keep the skin moist and oiled. Coconut oil can be applied to the skin half an hour before a bath. A teaspoon can also be added to the bath water. Mild and non-perfumed soaps should be used. The body should not be scrubbed with a loofah. The skin should be patted dry, and not wiped. After the bath a non-greasy oil or lotion can be applied.

There are several baby oils, aloe vera preparations, ceramide (a natural oil in the skin) and vaseline-based creams available in the market. If it says "non greasy" it means that it is unlikely to stain your clothes. Traditional oils, like coconut, stain the clothes and that is why they need to be applied before a bath.

Salt water reduces eczema. People who immerse themselves regularly in the sea improve gradually over a period of time.

Detergents are widely used to wash clothes. Most contain chemicals like sodium lauryl sulphate, which remain behind in the clothes in small quantities. They can penetrate the skin when sweating occurs, aggravating eczema. Commercially available "hypoallergic" or "doctor tested and recommended" detergents have unsubstantiated claims and have not been proven safer. Since clothes have to be washed and kept clean, it is preferable to use non-allergic soaps made from neem oil. They are marketed in India by the government run chain of khadi stores.

Eczema disappears when steroid creams are applied. These should be used under medical supervision for a short period, till the symptoms subside. After that antihistamines (to control itching) and moisturisers should be continued. Patients, unfortunately, purchase and apply the ointments themselves. Prolonged use of topical corticosteroids causes side effects like thinning of the skin and secondary bacterial or fungal infection. Small quantities of the more potent steroid creams can become absorbed in the body through the skin. If they are inadvertently applied to the eye, cataracts and glaucoma can result.

Specific pinprick allergy testing can be done to identify allergens. Without this, drastic potentially harmful changes should not be made to the diet (particularly a child's) presuming that the eczema is precipitated by allergies to milk, fish or certain vegetables.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at yourhealthgm@yahoo.co.in