Annexure to Tonics and Appetite Stimulants

Cyprohepatidine was introduced in Indian market about twenty years ago as an anti-allergic drug. It was promoted across India by the pharma industry using aggressive marketing. After some time, it came to be known that this anti-allergic agent was extremely sedating, indicating potential toxicity to the brain. Also, it was discovered that its therapeutic dose/toxicity ratio was very low. As a result, it lost popularity.

During post-marketing surveillance, it was revealed that the drug increases appetite as one of its side effects. The industry was quick to start marketing  it as an appetite stimulant.As the drug was originally licensed as an anti-allergic, its use as an appetite stimulant is irrational as well as illegal. If a new clinical effect is discovered by chance, then according to provisions of rule 122 of Drugs and Cosmetics Act of India, the drug must undergo a re-trial.

Alert: Cyprohepatidine is too toxic a drug to be used as an ingredient in appetite stimulants. As such, all appetite stimulants are irrational. This drug is not marketed as an appetite stimulant anywhere else in the world and has been withdrawn as an anti-allergic too. 

Nestle in trouble for violating the IMS Act

Tehelka's coverage of Nestle violating the IMS Act : www.tehelka.com/infant-milk-substitutes-act-violation-nestle-haryana-congress/

Please do read it!

Wasteful Expenditure on Child Healthcare: Tonics and Appetite Stimulants

Scenario: Close to 95% parents routinely demand tonics or appetite stimulants from their pediatricians, especially after recovery from an infection/ illness.

Fact: Good appetite is a sign of well-being. It is natural, therefore, that it will be reduced whenever the child is ill (barring exceptions like diabetes, where appetite increases). Appetite will be naturally restored once the underlying disease has been treated. Not surprising, therefore, that our standard textbooks of medicine and pharmacology, have no mention of appetite stimulants. Treat the underlying illness and the appetite will come back. To make up for weakness, increase in the intake of normal balanced diet- this is what we were taught. Indian market is flooded with hundreds of such formulations which sell on the wrong beliefs (peculiar to Indians that such tonics are beneficial). Beware of alcohol in these concoctions which might give feeling of false well being. These are not even manufactured in most countries of the developed world. The marketing gurus took advantage of the Indian psyche and designed these bottles long-necked to resemble a giraffe -symbolic of tall height, a trait that many parents want in their child. We fell prey to such gimmicks.

Further: Drugs labelled 'tonics' are fake and are not recommended. But there are some which contain Iron. These re the beneficial ones and essential to Indian children as close to 80% of Indian women and children are anaemic. These are called 'haematinics' (not tonics). A good haematinic should contain an Iron salt equivalent to 20-30mg of elemental Iron per 5mL of syrup or 50-100mg per tablet (or capsule) for adults. (Cheaper ones are as good as more expensive ones). Dosage must be exacted for each individual as Iron can be toxic in overdose. So- NO SELF MEDICATION, PLEASE.

If a child does not eat well,this can be because of one or more causes:
1. True disease: In this case, get the disease diagnosed and treated
2. Force-feeding leading to food rejection: Never force feed your child.
3. Child having eaten few pieces of candy/chocolate/chips/other junk food just before mealtime: Junk food ruins balanced meals. Parents should propose the condition to the child that a good meal will be ended by sweet dish (one piece of chocolate/candy etc). Young children should not set conditions that they will eat the meal after they get to eat the junk food!
4. Big NO to feeding while watching TV.
5. Starting from breastfeeding, feeding should be child-guided and on demand. Don't follow the clock too strictly.
6. Meal-time behaviour disorders are usually coupled with general indiscipline which is a part and parcel of what we call 'spoilt child syndrome'. To correct this, parents/family are given counselling on one on one basis.

To summarize, appetite stimulants and tonics are useless/unneeded. These are sold mostly in India. Lack of health education, tendency to look for shortcuts and a 'pill for every ill' culture prevalent in our country is propagated by qualified doctors and quacks alike.
Outdoor Play and exercise are the best known appetite stimulants to my knowledge and belief!

Wasteful Expenditure On Child Health: Teething Aids

Teething is an important milestone in childhood and is thus a part of normal growth pattern. Unfortunately, it is often linked to many signs and symptoms , for which many medications are erroneously given to children.

Symptoms wrongly attributed to teething	Medicine/Intervention Commonly Used
Pain in the gums	Teethers/ teething gels
Headache	Hair oil and massages
Fever	Various antibiotics and analgesics
Diarrhoea	Ghutti/gripe water, anti diarrhoea medication
General, to ease teething	Calcium preparations (allopathic/homoeopathic)

Fact: Teething is a natural process. Medical textbooks do not mention any medical intervention for teething. Medical science interprets teething as a signal for the child being ready to eat solid food and it advocates initiation of “complimentary feeding”. A normal infant will usually have four to five episodes of viral diarrhoea and four to five episodes of viral respiratory infection, both associated with mild grade fever and headache. As teething is a long drawn process, so people misinterpret coincidence as correlation , but teething does not cause any of these symptoms. Oil massaged on head cannot in any way affect gums! Massages are enjoyable to all mammals, so it is no surprise that infants enjoy it too. I have seen infants developing scalp irritation because of excessive oil application. Expensive almond oil and fancy baby oils are both irrational.

Calcium preparations are heavily overprescribed and mostly irrational. Homoeopathic Calcium medicines for teething are labelled “Made in Germany” but are in fact not even licensed to be used in most of Europe! It is better to give children stainless steel home utensils (with smooth, rounded edges) in place of teethers.

Conclusions: Teethers, teething gels, expensive massage oils and calcium preparations for facilitating teething are all wasteful expenditure on child health.

To my mind, “tooth eruption” is a misleading term. Teeth do not erupt like volcanoes! They are gently unveiled out of gums as the jaw grows.

Wasteful Expenditure on Child Health : Gripe Waters and Ghuttis

Myth: Gripe water/ ghutti are routinely administered to newborns and infants in the belief that they will improve digestion and relieve abdominal pain.

Fact: Exclusively breast-fed children do not require any additional nutrition for the first six months. If the child is bottle/formula-fed, the child will have more diarrehoa and tummy upsets, but ghuttis and gripe water will not help anyway.

Answers to common queries:

• My child has writhes and his/her face turns red. Does this mean he/she has abdominal pain?
  These writhing movements are normal “ choreoathetoid” involuntary movements during infancy, and in fact show normalcy of the neonate. These do not require any medication. Breastfed children are not likely to have abdominal pain. Excessive crying in otherwise normal infants is usually due to fever, defective “latch on” while suckling and hence inadequate milk intake (for details, visit www.bpni.org . You can also find manoeuvres to treat colicky crying on this site). 
  
  
• Why do elders say that ghuttis/gripe water aid in comfortable sleep?
  In the '80s, while working with committee for protection of child consumer , Indian Academy of Pediatrics, our group found that many gripe waters had alcohol content. Many ghuttis were found to contain opium. The children were sedated into sleep, leading to false belief that these aid in comfortable sleep. One of the gripe waters had so much alcohol that three teaspoons of it to a newborn was equivalent to one pint of beer consumed by an adult! We campaigned and got alcohol and opium removed from gripe water and ghutti.

Further : A newborn has reverse sleep pattern, i.e. they sleep during day and are wakeful during the night. All crying in infants does not indicate pain. Crying is the only means of communication a newborn has.

Excessive crying in neonates may be normal communication, fever (for which your doctor will prescribe paracetamol in appropriate dosage) or unexplained colicky crying (for which simple manoeuvres are sufficient).

Ten-twelve stools per day in breastfed children is not indigestion.

Ghuttis/gripe waters are an avoidable wasteful expenditure on child health.

Formula/bottle-fed children tend to have more infective diarrhoea and abdominal pains. Ghuttis/gripe water will have some carminative effect, but that is not a real treatment of any infection. Infections should be treated by a doctor.

Warning: Any medicine that is labelled “elixir” could have alcohol in it and most of the therapeutic effect might be attributed to alcohol rather than other ingredients.

How much sugar is your child drinking?

Packaged drinks tend to have a lot of sugar in them and not many parents realize how addictive it can be. I came across this wonderful picture on http://en.ilovecoffee.jp/posts/view/120 which illustrates how much sugar goes into some popular drinks. Although it was made in the American context, I think it is useful here as well:

Disclaimer: I don't have any rights over this image. It was created by the artist Ryoko at en.ilovecoffee.jp. I am merely sharing it since I believe this is something every parent should know.

The pomegranate myth

Myth: Pomegranate/ pomegranate juice increases haemoglobin or blood

Fact: Pomegranate does not have much iron, so it has little or no effect on blood.  ( Full nutritional details of pomegranates can be read from here : en.wikipedia.org/wiki/Pomegranate#Nutrients_and_phytochemicals) 

Further: Children should be given whole fruit and as many different types of fruit as they are willing to eat.

Yellow fruits like mangoes and papayas for vitamin A, citrus fruit like oranges, guavas and 'ber' for vitamin C. From six months to two years, children require many calories for growth, so they should be given thick, cooked gruel like cereals, pulses, khichdi, cooked green vegetables etc. Cooking is recommended because it destroys germs. Fruits can be risky because if overripe, they can cause infective diarrhoea. 

While pomegranates are delicious, there are many other inexpensive fruits and vegetables that provide far more vitamins and minerals. 

Baby Walkers: Dangerous and Detrimental

Baby walkers are used in the belief that it would help in learning how to walk.

Fact: Use of walkers delays natural walking, as the weight falls on the pelvis and children learn to push it with both feet. Children takes steps (natural walking) only when weight falls on the soles of the feet, preferably naked feet. 

Further: Walkers have been officially banned in the UK (http://news.bbc.co.uk/2/hi/health/735786.stm) and many other countries (for example, Canada: https://ca.answers.yahoo.com/question/index?qid=20130724063326AAqedWZ) because of risk of injury due to toppling, especially from staircases.

Mild lip and gum injuries are common, while serious head injuries may also occur (which caused the ban).

You can also read about dangers of baby walkers in the New York Times: http://consults.blogs.nytimes.com/2010/02/22/the-dangers-of-baby-walkers/?_php=true&_type=blogs&_r=0

Medicine for Children

Children cannot be treated as miniature adults. Therefore, medication for children have different specifications. A medication for adults cannot simply be “scaled down” to become a children's medicine by merely reducing the dose. Ideally, a paediatric drug should be separately tested for safety and efficacy in different age brackets. For example, 0-7 days / 7days-1month / 1month to 1year old children etc. , but this is seldom done. There are some drugs which are allowed for adults but are banned for paediatric use. Let us take the example of two such medicines -

1. Ofloxacin : Allowed for adults but not recommended for children under 18 years of age. It is not even listed in authentic PDR (Physician's Desk Reference), but is heavily prescribed and also dispensed without prescription in India for common infections. The syrup form is even labelled “for paediatric use”, which just illustrates the dismal state of drug regulation. Please beware!
2. Nimesulide : It was banned in dozens of countries about four years ago due to a cases of liver failure reported in the United Kingdom. Yet, it is continued sold with and without prescription in India, even after being banned for children after prolonged efforts consumer activists.

Please, do not self-medicate your child! Please cross-reference safety and efficacy of children's medication from the internet, reference books or package inserts. Don't rely entirely upon your doctor or the pharmacists. Many developed countries dump their discarded drugs into the developing world.Many freely available drugs are not suitable for children.

Introduction

I am an MD paediatrician (Registration Number: MCI2919) with 35 years of professional experience and 25 years of work in protection of child consumer, some of which was done as a member of Committee for Protection of Child Consumer, Indian Academy of Paediatrics. I was motivated by reading a chapter on child advocacy in one of my textbooks way back in 1977. It was stated that as children cannot speak for themselves, every qualified pediatricians must speak for them , in matters that adversely affect or pose a danger to their health, be it medicines, toys, clothing, toiletries/cosmetics, electrical fittings or baby food. In my day to day practise, I have found that at present there is no organization that is willing to undertake this awareness campaign. The reason is obvious- the money involved in marketing children's products is enormous. No individual can counter the propaganda and misinformation of multinational giants that pump out advertisements, inducement and commissions offered for sale of these products especially vaccines, medication and cosmetics. The intention of this blog is to disseminate authentic information with references as well as personal clinical experience.

I, Dr. Dinesh Khosla do hereby swear in full adherence to Medical Council of India's code of ethics that I have not for past years, and will not in future accept any financial inducements in cash or kind, from any manufacturer of children's consumer goods.