Here’s EVERYTHING That Mom and Dad Should Know About Hand, Foot & Mouth Disease

WORDS LIM TECK CHOON

FEATURED EXPERT
ASSOCIATE PROFESSOR DR ERWIN J KHOO
Consultant Paediatrician and Head of Paediatrics Department
International Medical University (IMU)
WHY KIDS ARE VULNERABLE TO HAND, FOOT, AND MOUTH DISEASE

It’s hard to avoid hand, foot, and mouth disease recently, as it’s either affecting children in the country or appearing in the news.

Simply put, young kids are at risk of catching this disease because they are active, mobile, and curious.

According to Associate Professor Dr Erwin Khoo, toddlers tend to have a messy habit of touching and putting everything they come across into their mouths. This puts them at risk of the disease.

THE CULPRITS RESPONSIBLE FOR THE DISEASE

That will be viruses, the most common ones being Coxsackie A16 and Enterovirus 71.

According to Dr Erwin:

  • These viruses can be found in the respiratory tract and faeces, as well as in the fluid-filled blisters that form on the hands and feet of someone with hand, foot, and mouth disease.
  • The usual incubation period—the time period from infection to the first appearances of symptoms— is between 3 and 7 days, but it can also be and can go up to 2 weeks.
  • The virus can remain contagious for several days, even when it’s on hard surfaces.
  • As a result, the virus can spread easily amongst those in close contact with the infected child. One can also catch the virus from touching toys, eating utensils, and other objects that had been handled by the infected child.
  • One can also catch the virus from not properly washing their hands after performing routine childcare tasks on the infected child, such as changing diapers.
COMMON SYMPTOMS OF HAND, FOOT, AND MOUTH DISEASE
  • Fever
  • Sores around the mouth
  • Rashes
Rashes on the feet. Click for larger, clearer image.

Widespread rashes across the body are commonly seen on children with this disease, which may lead some people to confuse it with chickenpox.

Dr Erwin shares that unlike chickenpox, however, the rashes of a child with hand, foot, and mouth disease typically form at the hands and feet (hence the name of the disease) as well as sometimes on the knees, elbows, and buttocks.

IT CAN ALSO AFFECT ADULTS

This disease commonly affects children under the age of 6, but adults can also get infected and develop the disease.

Research has suggested that adults usually experience milder symptoms when compared to children.

Hence, it is possible for adults to pass the virus on to children under their care.

ONE CAN GET THIS DISEASE MORE THAN ONCE

Dr Erwin explains that this is because there are different strains of viruses that cause this disease. Because of this, any immunity developed by the body after an infection is only temporary.

HOW IS HAND, FOOT, AND MOUTH DISEASE TREATED?

“There is no cure or specific treatment for this disease,” Dr Erwin shares.

Currently, treatment revolves around managing the symptoms and making the child as comfortable as possible.

Dr Erwin points out that the disease typically goes away on its own between 7 and 10 days.

OKAY, BUT CAN WE PREVENT THE DISEASE FROM AFFECTING US OR OUR CHILDREN, THEN?

Unfortunately, we currently have no means to fully prevent hand, foot, and mouth disease from happening to us or our children.

SOMEONE AT HOME HAS THIS DISEASE. WHAT SHOULD WE DO?

Dr Erwin advises the following:

  • Be extra careful and limit contact with the infected individual.
  • Practice good hand hygiene. Wash or disinfect hands regularly, especially after caring for an infected child. It’s also good to wipe down common areas, such as the living and dining areas, as well as commonly handled objects such as toys, doorknobs, etc with disinfectant.
  • Don’t share food and eating utensils.
  • Avoid touching the eyes or nose.

Do the above up to 10 days after the infected individual started showing symptoms.

If your child is confirmed by a doctor to have hand, foot, and mouth disease, it is prudent to have the child stay at home to avoid passing the infection on to others.

WHAT CAN PARENTS DO TO HELP PROVIDE THE BEST TLC TO A CHILD WITH HAND, FOOT, AND MOUTH DISEASE?

Dr Erwin advises the following:

  • The paediatrician will prescribe appropriate medications for fever, pain relief, and reduction of inflammation of mouth ulcers. Parents wishing to use medications outside of the doctor’s prescription should consult the paediatrician first.
  • Give the child easy-to-swallow foods, such as soups and porridges.
  • Have the child drink plenty of fluids to avoid getting dehydrated. Offer them their favourite drinks or juices.
  • For painful mouth ulcers, consider using cold treats such as ice cream, jelly, and yoghurt to provide soothing pain relief. Parents can also consider alcohol-free mouth rinses and oral gels for the child.
  • Have the child shower or bathe regularly, as this will help soothe their sores. Avoid using harsh soaps and body scrubs on the child, as these may irritate their skin further.
  • Afterward, apply a towel gently to dry the child, to avoid breaking the blisters on the child’s skin. harsh soaps and scrubs that further irritate the skin.
  • If the child’s sleeping area has air-conditioning, switch it off at night. This is because air conditioning can create a dry environment that will reduce the child’s saliva production. This can cause the child’s mouth ulcers to hurt more.
  • If cooling is needed, such as due to hot weather, a humidifier or even just leaving a bowl of water in the room can prevent an excessively dry environment from forming.
  • If the child can’t sleep or rest due to pain, consult the paediatrician about the use of a pain reliever at night.

Dr Erwin points out that there are many “home remedies” being passed around, such as using coarse salts or enzyme water on a child with this disease. There is no evidence that such “remedies” actually work, and in most cases, they only irritate the skin and cause more pain and discomfort!

WHAT ABOUT COMPLICATIONS? ARE THERE ANY?

Usually, plenty of rest at home can help a child with hand, foot, and mouse disease recover, with over-the-counter treatments sufficient to relieve symptoms such as fever, rashes, and/or red spots.

However, in some cases, painful ulcers in the mouth can prevent a child from eating, drinking, and swallowing normally.

“This can lead to dehydration. Serious cases of dehydration require medical attention,” Dr Erwin states.

To keep an eye out for signs of dehydration, parents can do the following:

Take note of poor urine output, dry mouth, and lack of tears when they cry.

These are possible signs of severe dehydration.

Seek immediate medical attention when your child experiences the following:
  • Rapid breathing
  • Disorientation
  • Drowsiness
  • Giddiness
  • Stiff neck
  • Seizures
  • Fever for more than 3 days
  • Not eating and drinking
IT MAY SEEM OVERWHELMING WHEN YOUR CHILD HAS HAND, FOOT, AND MOUTH DISEASE, BUT TAKE A DEEP BREATH

Dr Erwin encourages parents to take a different outlook.

“If you can arrange to take some time off from work, maybe with a doctor’s letter for your employer, just stay home and spend this time with your kids. It is easy to overlook how quickly they grow up!” he says.

Great News! Now More Children Are Eligible for Free Pneumococcal Vaccination!

WORDS LIM TECK CHOON

In conjunction with World Immunization Week from 24 to 30 April, the Ministry of Health held a National Immunisation Day 2023 on 31 May 2023.

The event was a collaboration between various divisions in the Ministry of Health’s Public Health Programme and Immunise4Life (link opens in a new tab).

THE BIG CATCH-UP

The theme of National Immunisation Day this year is ‘Tingkatkan liputan, kurangkan keciciran’ or ‘The Big Catch-up’.

Dr Zaliha Mustafa, our Minister of Health, revealed that this theme is in line with the expansion of Malaysia’s free pneumococcal vaccination programme to those born between 2018 and 2019. This expansion will commence from June 1.

Pneumococcal vaccine was included in the National Immunisation Programme (link opens in new tab) to initially cover children born from January 1 in 2020.

With this expansion, our Ministry of Health hopes to target 70% or 700,000 of the 1 million children aged 4 to 5 under the two-year programme.

“The nationwide pneumococcal vaccination programme will start on June 1 until May 31 next year and it will involve the ministry’s primary healthcare facilities,” she explained.

Interested parents can set an appointment for their children’s vaccination using the MySejahtera app.

WHY KIDS SHOULD GET THE PNEUMOCOCCAL VACCINE

Pneumococcal disease, an infection caused by bacteria called Streptococcus pneumoniae is contagious and may cause severe illness, so early diagnosis and treatment is important.

Children 2 years old or younger are vulnerable to such infection.

Hence, these children are also at risk of developing serious, potentially life-threatening complications such as:

  • Pneumonia, which is the infection and inflammation of the air sacs in our lungs
  • Ear infections
  • Meningitis, which is the inflammation of a membrane called meninges in the spinal cord and brain
  • Bacteraemia, or infection of the bloodstream
Pneumococcal pneumonia is a lung infection caused by the bacteria responsible for pneumococcal disease. Click on the image for a larger, clearer version.

Once the bacteria infect the bloodstream, they can find their way to parts of the body that are normally sterile, such as the peritoneum—that’s the membrane lining our abdominal cavity—as well as our joints and heart. This can lead to many more invasive diseases, such as peritonitis, arthritis, and endocarditis (inflammation of the inner layer of the heart) respectively.

Hence, parents with children that are eligible for the free vaccination should consider taking advantage of the expansion of Malaysia’s free pneumococcal vaccine programme. They can consult a doctor should they have any doubts and concerns about the vaccine.

Doctors Answer Parents’ Burning Questions About Eczema and Children

WORDS LIM TECK CHOON

FEATURED EXPERT
DR MELANIE MAJAHAM
Consultant Paediatrician
Sunway Medical Centre Velocity

WHY DOES MY CHILD HAVE ECZEMA?
Dr Melanie Majaham explains that:

  • Eczema usually happens in a child that already has a tendency for dry skin.
  • The child’s skin becomes inflamed and very itchy when they are exposed to triggers such as chemicals, sweat and heat.
  • Red, dry, itchy patches form on the skin as a result of the inflammation.
  • Because of the itch, the child will constantly scratch their skin, which can lead to further damage to the skin. Blisters, oozing, crusting, and sores are some possible consequences from the constant scratching.
  • Such damaged skin leaves the child vulnerable to bacterial, viral and fungal infections.
HOW IS ECZEMA TREATED?

Dr Melanie says that treatment options will depend on which phase the eczema is in.

Active flare-ups
  • In active flare-ups, the child may need steroid-based creams to reduce the inflammation and break the itch cycle. These steroid creams are safe and will not cause long-term complications when used correctly over a short duration.
  • If the skin is infected, antibiotics and antiviral medications may be needed. Parents should be reassured that steroid creams prescribed correctly and in short duration will not lead to long term complications.
Subacute or chronic case (the skin is merely dry; no active inflammation present)
  • Maintenance therapy is important to prevent flare-ups.
  • Such therapy include intensive moisturizer creams that are free from fragrance and certain chemicals.
  • The child will also need to bathe with soap-free solutions to prevent excessive drying of the skin.
  • While bathing, make sure the water is not too warm. Dr Melanie nots that water that is too warm tend to worsen one’s eczema.
  • Wet skin should be pat dried gently with a towel.
FEATURED EXPERT
DR JUANI HAYYAN ABDUL KARAF
Consultant Ear, Nose & Throat (ENT) and Head & Neck Surgeon
Sunway Medical Centre Velocity
WILL IMMUNOTHERAPY HELP MY CHILD?

Dr Juani Hayyan Abdul Karaf explains that immunotherapy—in the form of shots—is available to treat allergies, but this is specific for certain allergens such as house dust mites.

WILL MY CHILD CONTINUE TO HAVE ECZEMA WHEN THEY ARE AN ADULT?

Children with eczema can develop food allergy, allergic rhinitis, and asthma—a natural progression from infancy to adulthood known as the atopic march.

Dr Juani shares that the atopic march happens when children continue to develop inter-related allergies into childhood that can begin with eczema.

“It can start with a skin condition as it’s the first body barrier that can be breached. The body’s response can continue and manifest later as food allergies, allergic rhinitis, and asthma,” she elaborates.

More than 50% of children with eczema develop asthma later in life, with a further 33% developing food allergies, as well as an increased risk of developing allergic rhinitis .

CLOSING ADVICE FROM THE EXPERTS
  • “Parents should ensure the child is kept cool as heat can aggravate eczema,” Dr Melanie points out. “Constant round-the-clock moisturizing also does wonders in keeping the child comfortable.”
  • Dr Melanie also discourages the use of antiseptic soaps, as these soaps are harsh and can worsen eczema. “Some parents think eczema is caused by poor hygiene and tend to use antiseptic soaps. However, the more appropriate bathing solution would be something soap-free and fragrance-free and rich in emollients.”
  • Dr Juani advises parents to encourage their child to exercise regularly and spend time outdoors to soak up vitamin D.

A Dentist Sets the Record Straight on How Kids Can Have Healthy Teeth

WORDS LIM TECK CHOON

FEATURED EXPERT
DR YOGESWARI SIVAPRAGASAM
Senior Lecturer and Consultant in Paediatric Dentistry
School of Dentistry
International Medical University (IMU)
Tip 1
START EARLY—CLEAN YOUR BABY’S GUMS AT LEAST TWICE A DAY

“It is easy to overlook oral care in babies – after all, they won’t have teeth till months later!” says Dr Yogeswari Sivapragasam,

  • Get a clean, damp washcloth.
  • Use the washcloth to gently wipe clean your baby’s gums.
  • Also gently clean the front of your baby’s tongue.

You should do this after every breastfeeding.

“Besides that, parents should also get advice from healthcare practitioners, such as a nurse advisor at community clinics or paediatricians, on how to care for their child’s oral health from birth, which includes what to do when their teeth first appear,” Dr Yogeswari further advises.

Tip 2
DELAY ADDING SALT & SUGAR INTO YOUR KID’S DIET

Dr Yogeswari advises us to hold back the introduction of added salt and sugar into their child’s diet.

This is because getting your child hooked early on sweet or salty foods can increase their risk of dental problems as well as chronic health conditions (obesity, type 2 diabetes, etc) later in life.

Instead, let your child develop a liking for naturally unsweetened and unsalted foods.

Tip 3
TAKE YOUR KID TO THE DENTIST REGULARLY & MAKE THESE VISITS AS FUN AS POSSIBLE

Children should receive their first dental check-up when they are 1 year old.

“Remember this: first birthday, first dental check-up!” says Dr Yogeswari.

After the first dental visit, you are advised to bring your kid to the dentist every 6 months.

“While it is unlikely that they will have any dental problems at this young age, this will help young children have a positive experience rather than associate dental visits with pain and fear,” Dr Yogeswari further adds. “Regular visits will help to normalize the experience of visiting a dentist and will go a long way towards preventive care.”

Of course, regular visits to the dentist will also help to detect early any potential problems with your kid’s oral health and tooth development, and allow the dentist to address these problems without further delay.

Tip 4
KEEP AN EYE OUT FOR UNUSUAL CHANGES IN BEHAVIOUR

Your child sometimes refuses certain foods or refuses to brush their teeth. “While this may be easily explained as the child being fussy or picky, there could be another reason behind it,” says Dr Yogeswari.

For example, your child may have developed cavities or gum disease, and the constant pain and discomfort may cause them to refuse foods that need to be chewed.

“This may inadvertently lead them to avoid whole foods such as apples and chicken,” Dr Yogeswari elaborates, “and choose softer foods instead, many of which are processed and contain higher levels of salt, sugar and fat. Over time, this may lead to nutritional deficiencies or chronic conditions that can affect a child’s health into adulthood.”

The constant pain can also cause irritability and affect their ability to concentrate during lessons in school.

“In addition, poor oral health can also affect a child’s self-esteem if they are teased due to the appearance of their stained or rotten teeth. This may cause them to avoid social activities or become withdrawn,” Dr Yogeswari adds.

As such, be alert and check for possible dental problems if your child suddenly appears to be unwilling to chew or becomes irritable without any apparent cause.

A Cancer Expert Explains What You Should Know About Wilms Tumour

WORDS LIM TECK CHOON

FEATURED EXPERT
DR ENI JURAIDA ABDUL RAHMAN
Consultant Paediatrician, Paediatric Haematologist, and Paediatric Oncologist
Sunway Medical Centre

Wilms tumour is the most common type of kidney cancer affecting children, usually those that are under 5 years old,” says Dr Eni Juraida Abdul Rahman.

FACTS ABOUT WILMS TUMOUR
  • It is also called Wilms’ tumor or nephroblastoma. The name Wilms came from Max Wilms, a German surgeon that first described this cancer.
  • The tumour is the result of mutations of genetic materials in kidney cells, which typically occur after birth.
  • Usually only one kidney is affected, but in 5% to 7% of cases, it can be found in both kidneys.
WHAT CAUSES WILM TUMOUR?

Just like with most cancers, we still haven’t found the exact causes for this cancer.

However, Dr Eni Juraida points out that there are certain genetic disorders that can increase a child’s risk of developing Wilms tumour, such as:

  • Aniridia, or the abnormal development of the iris of the eye due to genetic mutation, usually along chromosome 11 that led to deleted genes and hence missing genetic information.
  • Hemihypertrophy or hemihyperplasia, a condition in which one side of the body or a part of one side of the body is larger than the other in an extent that is greater than what is considered normal.

“Patients with WAGR syndrome have a 45% to 60% chance of developing Wilms tumour,” says Dr Eni Juraida.  WAGR stands for: Wilms tumour, aniridia, genitourinary malformation, and range of developmental delays.

SYMPTOMS TO WATCH OUT FOR IN A CHILD
  • Painless swelling in the abdomen, occasionally noted by parents while bathing the child; the tumour may cause discomfort
  • Haematuria, or blood in urine
  • Hypertension or high blood pressure
  • Fever
  • Unusual loss of appetite, resulting in weight loss
  • Pain in the abdomen
  • Generally feeling unwell
  • Cough and shortness of breath
HOW IS WILMS TUMOUR TREATED?

Treatment options will depend on the stage of the tumour.

Surgery

The mainstay treatment, usually done upfront for stage I and II tumours and sometimes delayed for stage III, is a surgical procedure called nephrectomy. This surgery removes the affected kidney and hence the tumour from the child’s body.

In the rare cases when tumours are present in both kidneys, partial nephrectomy removing only the parts affected by the tumour will be performed to preserve as much of the kidneys as possible.

Chemotherapy

“Chemotherapy are medications that are given to kill cancer cells,” Dr Eni Juraida explains.

For stage I and II tumours, these medications can be given after a nephrectomy, to kill off any remaining cancer cells.

However, stage III tumours are much larger in size compared to stage I and II ones, and chemotherapy will be prescribed before a surgery to first shrink the tumour. This will allow the surgery to be carried out more safely.

Radiotherapy

This may be prescribed in some cases, usually for tumours that has spread to other organs such as the lungs or are not completely resolved via chemotherapy.

CAN WE HELP PREVENT THE DEVELOPMENT OF WILMS TUMOUR IN OUR CHILD?

“Since we don’t know the cause, it is difficult to have any preventive measure,” Dr Eni Juraida points out.

However, for children with WAGR syndrome, having them undergo a surveillance ultrasound of the abdomen on a periodic basis—such as every 6 months—can help detect Wilms tumour.

Food for All: Modifying Food Texture for People With Dysphagia

WORDS AINUL SYAFIQAH MOHD AZAHARI & DR NURUL HUDA RAZALLI

FEATURED EXPERTS
AINUL SYAFIQAH MOHD AZAHARI
Nutritionist and Student of Master Clinical Nutrition
Faculty of Health Sciences
Universiti Kebangsaan Malaysia
DR NURUL HUDA RAZALLI
Dietetic Programme
Centre for Healthy Ageing and Wellness (H-CARE)
Faculty of Health Sciences
Universiti Kebangsaan Malaysia

DYSPHAGIA: IT MEANS DIFFICULTIES IN SWALLOWING FOODS & LIQUIDS

  • Dysphagia comes from  Greek word ‘dys’, which means difficulties, and ‘phagia’, which means swallowing.
  • Medically, dysphagia is a term for swallowing difficulties. Someone with dysphagia takes more time and effort to move food or liquid from their mouth down to their stomach.
  • Episodes of dysphagia can be intermittent or progressive.
IT IS A SYMPTOM FOR MANY MEDICAL CONDITIONS
  • In adults, dysphagia is very common in adult that has a history of stroke, dementia, Alzheimer’s disease, neck cancers, and gastroesophageal reflux disease (GERD).
  • It could also be present in children with attention deficit hyperactivity disorder (ADHD), autism, Down syndrome, and cerebral palsy.
  • Dysphagia can also be a sign that there are some issues with the many nerves and muscles that are involved in swallowing activities.
YOU MAY HAVE DYSPHAGIA IF YOU EXPERIENCE THE FOLLOWING
  • Persistent drooling of saliva
  • Coughing or choking when eating or drinking
  • Bringing food back up, sometimes through the nose
  • Feeling as though food is stuck in your throat or chest
  • Being unable to chew food properly
PEOPLE WITH DYSPHAGIA FACE ISSUES THAT CAN JEOPARDIZE THEIR HEALTH & WELL-BEING

Choking and lung infection

Individuals with dysphagia are susceptible to choking. Due to difficulties in swallowing normally, consumed foods or liquids can accidentally enter the airway into the lungs. This could result in aspiration pneumonia, often known as a lung infection and can be fatal.

Poor nutrition intake
  • The prevalence of malnutrition among people with dysphagia is reported to be anywhere between 3% and 29%, which is quite a high number.
  • Malnutrition leaves people with dysphagia more vulnerable to diseases, should they not receive enough essential nutrients for optimal body function.
  • Muscle wasting, underweight, and stunting could be other issues that arise. Hence, people with dysphagia needs to be aware of any weight loss, hair loss, feeling of coldness, and fatigue as these are the early symptoms of malnutrition.
Loss of appetite and fear of mealtimes
  • People with dysphagia often lose their appetite in conjunction with their reduced swallowing ability.
  • They might develop some degree of “laziness” when it comes to drinking more often, which may lead to dehydration.
  • Because their eating experiences can be difficult, uncomfortable, and unpleasant, they may develop anxiety during mealtimes.
Inability to talk fluently
  • Dysphagia can hinder one’s ability to talk fluently and, combined with difficulties in eating, may cause the affected person to experience low self-esteem and lead to self-isolation.
  • The decrease in social engagement will give a negative impact in the person’s quality of life.
  • Thus, social support from their carer, family members, and close friends are crucial. A little extra kindness and help will give a huge impact in their life and sometimes even touch their heart.
Proper nutrition management for people with dysphagia involves providing adequate nutrients through modification of food texture and fluid consistency.

We need to also keep an eye out for symptoms of dehydration such as dry mouth or tongue, thirst, headache, and lethargy. 

Also, be alert to any unexplained weight loss, hair loss, feeling of coldness and fatigue—these could be early symptoms of malnutrition.

IF YOU ARE WORRIED THAT YOU OR SOMEONE CLOSE TO YOU HAVE DYSPHAGIA

Consult a speech language pathologist, a healthcare professional trained to diagnose dysphagia, for a proper diagnosis.

People with dysphagia can consult with dietitians for their nutritional concerns or if they want to assess their nutritional adequacy.

TIPS FOR INDIVIDUALS WITH DYSPHAGIA TO ACHIEVE GOOD NUTRITION

Understand the extent of one’s dysphagia

Discuss with the speech language pathologist and other relevant healthcare professionals on the degree of swallowing ability in the person with dysphagia.

Refer to the International Dysphagia Diet Standardization Initiative (IDDSI) Framework

This guideline has seven levels. Flow test, spoon tilt, and fork drips are used as measurement methods to determine each level.

Click to view a larger and clearer image.

Further information can be obtained from the IDDSI website (link opens in a new tab).

Modify foods into certain textures 

For more detailed information on how to modify the textures of various foods, you can refer to this page on the IDDSI website (link opens in a new tab).

  • While modifying the textures of foods into appropriate textures, take into consideration the nutritional content (carbohydrates, protein, fat, as well as vitamin and minerals). Daily meals should provide all the nutrients to improve the person’s nutritional status.
  • Always choose softer food options if texture modification is not possible. For example, choose papaya instead of apple, and ‘soften’ a dish with gravy.
  • Add special thickening powder to watery liquids. This thickening allows for easier swallowing.
Useful tips for eating
  • Have the person with dysphagia sit upright to prevent choking.
  • Have them tilt their heads to prevent liquids from going into their air passage.
  • Encourage the person to take smaller bites, and give enough time to chew the food thoroughly.
  • If small pieces of food or liquid are stuck, have them cough a little.

Dysphagia is a journey of eating experience that may switch an individual’s life 360 degree. Hence support and motivation play an important role in the management of one’s dysphagia.


References:

  1. O’Rourke, F., Vickers, K., Upton, C., & Chan, D. (2014). Swallowing and oropharyngeal dysphagia. Clinical medicine (London, England), 14(2), 196–199. https://doi.org/10.7861/clinmedicine.14-2-196
  2. Shaheen, N. A., Alqahtani, A. A., Assiri, H., Alkhodair, R., & Hussein, M. A. (2018). Public knowledge of dehydration and fluid intake practices: Variation by participants’ characteristics. BMC public health, 18(1), 1346. https://doi.org/10.1186/s12889-018-6252-5
  3. Ueshima, J., Momosaki, R., Shimizu, A., Motokawa, K., Sonoi, M., Shirai, Y., Uno, C., Kokura, Y., Shimizu, M., Nishiyama, A., Moriyama, D., Yamamoto, K., & Sakai, K. (2021). Nutritional assessment in adult patients with dysphagia: A scoping review. Nutrients, 13(3), 778. https://doi.org/10.3390/nu13030778
  4. World Health Organization. (n.d.). Fact sheets – malnutrition. https://www.who.int/news-room/fact-sheets/detail/malnutrition

Small for Gestational Age: When Baby Is Born Smaller Than Normal

WORDS PROFESSOR DR MUHAMMAD YAZID JALALUDIN

FEATURED EXPERT
PROFESSOR DR MUHAMMAD YAZID JALALUDIN
Senior Consultant Paediatrician and Paediatric Endocrinologist
UM Specialist Centre

Most babies seem small when they first come into the world, but for some, they truly are smaller when compared to their fellow babies-in-arms.

This condition is known medically as small for gestational age (SGA for short).

Gestational age, by the way, is the length of time a baby spends growing in their mother’s womb.

Small for gestational age babies that weigh below 2,500 g at birth are additionally considered to have low birth weight.

SMALL FOR GESTATIONAL AGE CAN BE MEASURED AND DETECTED AFTER A BABY IS BORN

After a mother has given birth in a hospital or clinic, nurses will clean the newborn and giving them a quick check for any abnormalities. The nurses will also measure the length and head circumference of the baby as well as weigh.

These measurements inform healthcare professionals whether or not a baby is small for their gestational age.

POSSIBLE CAUSES OF SMALL FOR GESTATIONAL AGE

Pregnant women should go for their antenatal check-ups to monitor for and manage any problems that might result in a small for gestational age baby

The mother’s health during pregnancy
  • Presence of infections or medical conditions such as heart disease, uncontrolled diabetes, thyroid disease, or high blood pressure
  • Drinking alcohol or smoking
  • Poor nutrition during pregnancy
The mother’s age

The risk of having a small for gestational age baby is significantly higher for women aged 30 and above that have never given birth before, as well as all women aged 40 and above, compared to women in their 20s.

The mother’s height

Women that are short are at risk because their smaller wombs and shorter birth canals influence the growth of their foetus.

Family history

Interestingly, research has shown that the risk of having a small for gestational age baby can be influenced as far back as two generations.

If the pregnant woman and/or her own mother were small for gestational age babies, the foetus has a higher chance of being born small for gestational age.

Issues with the placenta during pregnancy
  • Placental insufficiency, which happens when the blood vessels in the uterus that are supposed to transform into the blood vessels of the placenta do not change as they should, can lead to placental infarction
  • Placental infarction sees the disruption of the blood supply to the placenta, resulting in the death of placental cells, placental abruption (the placenta partially or completely separates from the uterus before childbirth), and structural abnormalities of the placenta
  • All these conditions cause the foetus to receive insufficient nutrients and oxygen from their mother, thus affecting their growth
Chromosomal or genetic abnormalities

These abnormalities include those that give rise to Down syndrome and congenital abnormalities such as structural defects of the heart, kidneys, lungs, or intestines.

Other possible causes

Catching an infection while in the womb or being part of a multiple pregnancy (twins, triplets, etc) can also negatively affect a foetus’s growth.

SMALL FOR GESTATIONAL AGE COMPLICATIONS AFTER DELIVERY
  • As they have only small amounts of fat or energy stored away, they may have a low body temperature at birth. This can result in hypothermia, where the body loses heat faster than it can produce it. If this condition is prolonged, the baby can die as their heart and brain cannot function well at these sub-optimal temperatures.
  • The lack of fat and glycogen stored in a small for gestational age baby’s liver can cause hypoglycaemia, where they have low blood sugar levels that are unable to match their body’s needs. This can cause the baby to have seizures and/or brain damage. If the hypoglycaemia is prolonged, the baby may die or develop long-term neurodevelopmental deficits, including cerebral palsy.
  • As they are deprived of sufficient nutrients in the womb, small for gestational age babies become ‘programmed’ to hoard whatever nutrients and calories they receive. This means that after birth, they can very easily put on weight if their caloric intake is not carefully monitored. Thus, these babies are prone to obesity and its associated conditions (diabetes, high blood pressure, high cholesterol, osteoarthritis, heart disease, etc). This “programming” lasts throughout their lifetime.
  • Their growth rate can influence when they achieve puberty. Small for gestational age babies that catch up in their growth very quickly might experience early puberty. On the other hand, if they are slow in growing, their puberty might be delayed.
  • Persistent short stature.
SMALL FOR GESTATIONAL AGE, FORTUNATELY, CAN BE MANAGED

Generally speaking, small for gestational age babies should be able to catch up in their growth within the first six months to two years of their life with good nutrition.

In fact, 85% of these babies achieve normal height and weight for their age and gender by two years of age.

Some children require a longer time and there is still some leeway until the age of five to allow them to catch up in growth to their peers.

However, by five years of age, 8-10% of small for gestational age babies would still be smaller than normal, and this is the time that parents and doctors need to start discussing treatments for the child.

Growth hormone therapy
  • The main treatment for small for gestational age babies that do not manage to catch up in growth by the time they are four to five years old
  • Will enable them to achieve their optimal final height as adults, through improving muscle and bone growth
  • Helps increase the breakdown of fats, to address the tendency of small for gestational age babies to accumulate fat and become obese
Good nutrition
  • Nutrition plays a critical role in the first two years of life in promoting a child’s growth
  • Their diet must be carefully monitored as they are prone to becoming overweight; on the other hand, when they are not fed enough, they might become stunted
  • Parents need to do a careful balancing act when it comes to feeding their small for gestational age baby
Regular physical activity
  • As the child grows, parents also need to encourage and allow their child to be active
  • Doing so will prevent excessive weight gain and help stimulate the natural production of serotonin and growth hormone to help the child grow
  • Such physical activity must be vigorous enough that the child’s heartbeat increases and they sweat.
Proper sleep
  • It is critical that children are asleep at the latest by 9 pm, as the peak time for the body to produce its natural growth hormones is between 10 pm to 12 am.
  • Sleeping later, as many Malaysian children tend to do, will cause them to miss this critical period of growth hormone secretion.

What Every Parent Should Know about Congenital Heart Defects in Children

WORDS DR CHOO KOK KUAN

FEATURED EXPERT
DR CHOO KOK KUAN
Consultant Paediatrician and Paediatric Cardiologist
Subang Jaya Medical Centre

The most common heart disease among children is known as congenital heart defects.

This condition occurs when the heart or the blood vessels near the heart do not develop normally before birth.

HOW COMMON IS THIS CONDITION?

According to our Ministry of Health, the incidence of congenital heart defects among children is about 8 to 10 per 1,000 live births.

With an average of 500,000 deliveries in Malaysia each year, the number of children born with congenital heart defects is about 5,000 a year, of which two-thirds will require surgical intervention.

THE CAUSES & RISK FACTORS

Most congenital heart defects have no known cause.

They may sometimes run in families.

Some congenital heart defects may be associated with genetic disorders, such as Down syndrome, Turner syndrome, Williams syndrome, etc.

Some children have a higher risk of developing congenital heart defects if the mother has diabetes or rubella, or has taken certain medications such as anti-epileptic drugs, during pregnancy.

DETECTION OF CONGENITAL HEART DEFECTS

Sometimes a heart defect can be diagnosed before a baby is born.

However, defects are usually identified days or even months after birth, when symptoms become obvious.

Less serious congenital heart defects may not show any noticeable signs or symptoms, so they may only be diagnosed later in childhood.

It is also possible to have a heart defect and show no symptoms at all.

POSSIBLE SIGNS THAT A BABY OR YOUNG CHILD MAY HAVE CONGENITAL HEART DEFECTS
  • Rapid breathing
  • Bluish discolouration commonly noticed around the lips, fingernails, palms of the hands, and soles of the feet
  • Shortness of breath during feeding, leading to poor weight gain
  • Poor growth
  • Recurrent lung infection
WILL A CHILD WITH CONGENITAL HEART DEFECTS BE OKAY?

As a result of medical advancements, the outlook for congenital heart diseases is increasingly positive.

Most children with this condition reach their adulthood.

In fact, children with simple conditions may lead completely normal lives, while those with more complex conditions usually face more challenges that can nevertheless be addressed with the right measures in place.

6 THINGS THAT EVERY PARENT OF CHILDREN WITH CONGENITAL HEART DEFECTS SHOULD KNOW AND DO
  1. Heart medications can be very strong and dangerous if not given correctly. Parents must understand how much medicine to give and how to give it. If the child takes a blood thinner, parents must have clear instructions on how to give this medicine safely.
  2. Ensure the child eats well and receives adequate nutrition. They often tire when eating, so they eat less and may not get enough calories.
  3. Prevention of infections is crucial. Although an infection in the heart (endocarditis) is uncommon, children with heart defects have a greater risk of developing this. Good dental hygiene goes a long way toward preventing endocarditis by reducing the risk of tooth or gum infection. Parents can get more information from cardiologist about the latest guidelines on antimicrobial prophylaxis against infective endocarditis. These children must also get all the recommended vaccinations.
  4. Most children with a congenital heart defect can be physically active without restrictions. In fact, children are encouraged to be physically active to keep their hearts fit and to avoid obesity, unless they have a few specific heart conditions.
  5. Emotional support will help children who may have self-esteem issues because of how they look. They may have scars from surgery, and they may be smaller, or have limits on how active they can be.
  6. As children transition to adulthood, parents can gradually teach them about their heart defect and guide them in how to care for their own health without being overly protective.

Children More Vulnerable to Infections During These Post-Pandemic Times?

WORDS DR LIM YIN SEAR & DR MAHFUZAH MOHAMED

FEATURED EXPERTS
DR LIM YIN SEAR
Senior Lecturer of Paediatrics
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
DR MAHFUZAH MOHAMED
Guest Lecturer of Paediatrics
School of Medicine
Faculty of Health and Medical Sciences
Taylor’s University
NEW NORMAL LEADS TO NEW ‘CULTURE SHOCK’ FOR A CHILD’S IMMUNE SYSTEM

For the duration of the COVID-19 pandemic, children were predominantly confined to their home and as a result, were less exposed to common bacteria and viruses. This will render younger children’s immune system to develop poorly.

From March 2022 onwards, as life seemed to make its way back to normality, children started to attend school, enrichment classes, and sports activities again.

This has led to many young kids falling ill with diseases such as influenza, hand-foot-and-mouth disease, and lung infections. An elevated frequency of visits to the doctor has worried many parents that their children may have weakened immune system (we say that these children are then immunocompromised).

ARE CHILDREN REALLY MORE PRONE TO INFECTIONS POST-PANDEMIC?

Currently, there is no scientific data to show that children are more prone to infections after the pandemic.

HOWEVER, THERE ARE CERTAIN FACTORS THAT CAN INDIRECTLY UP THE RISK OF INFECTIONS IN CHILDREN

A briefing by UNICEF on the impact of COVID-19 on children has shown that the prevalence of unhealthy diets such as snacking has increased. This may be due to a lack of easy access to fresh food and financial constraints, possibly leading to childhood obesity and malnourishment.

Additionally, a sedentary lifestyle and the lack of exercise could contribute to childhood obesity, escalating vulnerability to infections.

Another major issue that arose during the MCO period was the disruption of essential health services including childhood immunisations. In a recent WHO pulse survey, 90% of countries reported disruptions to routine immunisations. Immunisations are of utmost importance for preventing certain infectious diseases.

Another important issue that needs to be taken seriously is the mental health of children and their caretakers. The Adverse Childhood experience (ACE) study showed that adverse childhood experiences in categories of abuse, household challenges, and neglect are not only associated with worse mental health outcomes, but also with chronic health conditions such as diabetes, heart disease, chronic obstructive pulmonary disease, liver disease, and cancer.

POSSIBLE SIGNS THAT YOUR CHILD MAY HAVE A WEAK IMMUNE SYSTEM 
  • Frequent and recurrent pneumonia, bronchitis, sinus infections, ear infections, meningitis, or skin infections
  • Inflammation and infection of internal organs
  • Blood disorders, such as low platelet count or anaemia
  • Digestive problems, such as cramping, loss of appetite, nausea, and diarrhoea
  • Delayed growth and development
  • Autoimmune disorders, such as lupus, rheumatoid arthritis, or type 1 diabetes
TOO CLEAN ISN’T ALWAYS GOOD

Some parents go to the extreme to create a “super clean” environment to protect their children and forbid the children to play or touch anything or anyone that has not been sanitised. This isn’t necessarily a good thing, and here’s why.

In the early years, our immune system is a blank canvas. Although infectious disease is a legitimate cause for concern, and a certain level of cleanliness is necessary, children need to develop an immunity to common pathogens.

Overprotecting children from germs is detrimental to their development. Therefore, parents need to balance between a clean environment rather than a sterile environment.

HOW ABOUT HAND-WASHING AND SANITISING?

Studies have shown that soap and water are better equipped to remove more germs from one’s hand than hand sanitiser does.

However, it is still recommended to use hand sanitisers when washing with soap is not an option.

LET’S TALK ABOUT VITAMIN D

Generally speaking, children with a balanced diet and outdoor activities would attain the daily requirement of nutrients.

A minimum of 400 IU (10 µg/day) of vitamin D is recommended for children and adolescents, especially among exclusively breastfed infants and all children and adolescents who are not routinely exposed to sunlight.

Vitamin D supplementation is only recommended to those who are unable to obtain an adequate amount of vitamin D from their diet or have inadequate exposure to sunlight.

Care should be taken while consuming vitamin D supplementation. A daily vitamin D intake of 2,000 IU or more puts one at risk of vitamin D toxicity. The signs and symptoms of toxicity include headache, a metallic taste in one’s mouth, pancreatitis, nausea, and vomiting.

Minister of Health Officiates New Child Health, Safety, and Well-being Programme

WORDS LIM TECK CHOON

On September 15 2022, our Minister of Health YB Tuan Khairy Jamaluddin officiated the launch of Healthy Little Bloomers programme and the roll-out of its maiden campaign Junior Germ Busters. 

The Healthy Little Bloomers programme aims to promote child health, safety and well-being through a network more than 30,000 early childhood care and education centres nationwide, potentially benefiting more than 800,000 children.

This is an initiative led by the Malaysian Paediatric Association (MPA) in collaboration with 10 prominent early childhood care and education organisations from both private and government sectors. These organisations are Jabatan Kemajuan Masyarakat (KEMAS), ECCE Council, Malaysian Association of Professional Early Childhood Educators (MAPECE), Persatuan Tadika Malaysia (PTM), Jabatan Kebajikan Masyarakat (JKM), Persatuan Pengasuh Berdaftar Malaysia (PPBM), National Association of Special Education, Malaysia (PPKK), Majlis Kebajikan Kanak-Kanak Malaysia (MKKM), Persatuan Tadika Sabah (PTS) and Association of Kindergarten Operators Sarawak (AKO).

In his speech during the launch, YB Tuan Khairy highlighted the following:
  • Young children, especially those under the age of 5, are vulnerable to health and safety threats, such as infectious diseases, injuries, abuse and neglect
  • Children who are overweight or obese are 5 times more likely to become overweight and obese adults
  • Child abuse survivors are at higher risk of becoming abusers or getting involved in abusive relationship during adulthood
  • Unmet emotional and mental health needs during childhood will lead to difficulties and problems during adolescence and adulthood
PROGRAMME IN STEP & LINE WITH MALAYSIAN GOVERNMENT DEVELOPMENT GOALS

YB Tuan Khairy is pleased with the launch of Healthy Little Bloomers because, as he puts it: “Children are the nation’s future. Therefore, addressing their health, safety and well-being needs holistically is one of the government’s key priorities. It has been part of the Malaysian government development goals since the 1960s and outlined in our latest Child Health 2021-2023 national framework”.

He applauds the campaign as an initiative that brings together MPA and partner organisations for bringing together medical professionals and early childhood care and education experts in a systematic and potentially long-term collaboration to help bring to fruition the goals of the government.

This is a vital programme as many young children spend most of their waking hours in kindergartens and children centres every week, abd studies have shown that health promotion intervention in kindergarten and childcare centres can be effective, especially if parental engagement is involved.

THE PROGRAMME IN MORE DETAIL

Professor Datuk Dr Zulkifli Ismail, Chairman of Healthy Little Bloomers, shares that the programme is meant to be cover all key domains and aspects of child health, safety and well-being in a holistic manner.

He further elaborates that the programme will take an annual thematic approach.

WHAT THE HEALTHY LITTLE BLOOMERS PROGRAMME OFFERS
  • Training for early childhood care and education operators and personnel
  • Fun, exciting, and interactive lessons for children; the programme is inclusive and will cater to children from various population segments, including those that are underprivileged and with special needs
  • Information and educational materials for parents and primary caregivers; available in Bahasa Malaysia and English
  • Roadshows to cater to less advantaged children, featuring activities that will consider the needs of those with hearing or vision impairments.

Visit healthylittlebloomers.my to get more information as well as free educational materials.