What Is Fever?

Temperature of our bodies is amazingly steady despite significant variation in environmental temperature. The thermo regulatory center is in our brain at hypothalamus, which act like a thermostat with a set point at normal body temperature. This is done by balancing heat production (by metabolic activity in liver and muscle) with heat loss through a skin and lung.

Fever occurs when the thermostat set point is raised above the current body temperature. When the body is exposed to infection organisms such as viruses or bacteria a number of so called pyrogens are produced as part of inflammatory response. These pyrogens can then act on the thermostat to raise the temperature set point by the release of a substance called prostaglandin. Now once the set point is raised heat generating action in the body like cellular metabolism in mostly skeletal muscle come into play to raise the temperature to the new set point.

What Is Fever Phobia?

Fever is one of the most common reasons that parents seek medical attention for their children. Parental concern usually arises because of the belief that fever is a disease rather than a symptom of an illness. This misconception and unrealistic concerns about the fever which ranges from thinking about the brain damage, losing their children, and the disease causing the fever is a potentially dangerous one rather than relatively benign one are termed fever phobia.

This parental fever phobia which exists across socio economic classes is strongly reinforced sometimes by the action of pediatric medical professionals, who are widely considered to be the primary resource of the subject. It is even emphasized as a discharge instruction, from emergency department and inpatient facilities as a warning to parents to call or return if fever develops or persists. So there is incongruence between the education of the family and the practice of the pediatrician. This mixed message which remains in existence does cause parents to lose sleep and experience unnecessary stress due to unwarranted concern about the harmful side effect of the fever.

Advice to Parents Regarding Their Febrile Child and Unwarranted Concerns about Harmful Side Effects of Fever:

I know it is hard to resist reacting to a hot little forehead and sad eyes, but if you remember the following, you will know when is the time to worry about your child’s fever and when you can be more patient and do not stress yourself.

1. Make sure your child has really fever (axillary temperature greater than 37.5°C or rectal temperature more than 38°C). Taking temperature by hand can be misleading.

2. Fever is only a sign of a disease and does not indicate the type of the disease or its severity no matter what the level of temperature is, high or low.

3. Remember that, especially in a child less than two to three years, most of the time the cause of the fever is viral infection, which is usually benign, and causes no serious damage to your child.

4. Fever is the body’s way of stimulating immune system, increasing white blood count, and fighting against infection. It also decreases the ability of viruses and bacteria to reproduce. Fever apart from being a sign of disease in your child, it has many beneficial effects and does not go higher and higher and usually not go beyond 41°C.

5. When your child has a fever, look for other signs i.e. Is he playful and looks normal between episodes of fever, is he alert and not weak or lethargic, does he smile, and has a normal color, these are the good signs indicating that the cause of the fever is not that serious and covers most cases of febrile children. If so, you can wait and do not stress yourself and do not need to call your doctor in the middle of the night. There is one exception and that is in a child less than six months of age where the immune system is not mature and the presence of fever may be an indication of a serious bacterial infection, which in that case you should call your pediatrician.

6. If he looks sick or constantly cries and irritable, is not playful, there is change of alertness, has a respiratory distress or swallowing problem, or the fever is persisting for more than two to three days, these are the bad signs and you should consult your pediatrician.

7. Febrile convulsion sometimes happen in kids less than four years, which usually stops after a few minutes and causes no problem, but if your child already had seizure in past or there is history of convulsion in the family, or any sign of neurological or central nervous system insult or problem, he needs more attention and should consult your pediatrician.

Dr. Hossein Sardarizadeh M.D. 
Specialist Pediatrician (Board Certified) 
Al Hafiz International Hospital 

According to recent research the risk for heart disease doubles for women who enter menopause early, women who go through menopause before age 45 have a two to threefold risk of heart disease. Women who have their ovaries removed before age 35 have a sevenfold risk. If you’re older than 35 but still younger than 40, your risk is a only bit lower — about twice the chance of developing heart disease.

In fact, whether you’ve gone through a surgical or natural premature menopause, you’re at a higher risk of heart disease than women who have gone through menopause at the average age.

Especially if the early menopause is combined with one or more of the traditional cardiovascular disease risk factors:
1- Diabetes
2- Smoking
3- Obesity
4- Hypertension
5- High LDL
6- Low HDL
7- Family History

Estrogen is the hormone that prevents these cardiac risks. We know that ladies who are premenopausal but still producing hormones are at a significantly lower risk for coronary heart disease, heart attacks and strokes than are post-menopausal women or men of any age .

Sources of iron:

• Egg yolks
• Molasses, liver and beef
• Raisin bran, Raisins, Prunes, Dried apricots, Figs
• Kidney beans, Pinto beans, Navy beans, Lentils, Split green peas
• Enriched cereals, Enriched macaroni, rice bran
• Spinach, Greens, Broccoli, Lima beans, Avocado

The following foods can help your body absorb iron better:

• Oranges
• Cantaloupe
• Strawberries
• Grapefruit
• Broccoli
• Brussels sprouts

Foods to Reduce or Eliminate:

Cow’s milk may cause anemia by interfering with iron absorption, so it may be beneficial not to consume dairy at the same time as iron-rich foods or supplements. Eliminate trans and hydrogenated fats, alcohol, processed foods, refined foods and sugar. These substances may interfere with iron absorption.

How sick he can get?
The toxic compound in multivitamins overdose is not because of the vitamins but is because of the iron which is one of the so-called bomb medications meaning it is a medications that lack symptoms early after ingestion, but later have profound toxic course. There is a large variety of children multivitamins that contains different amounts of elemental iron per tablet or teaspoon while adult multivitamins may contain up to 60mg elemental iron per tablet. The toxic dose of iron ingestion is at least 20mg per kilogram of elemental iron and a lethal dose of iron is in the range of 60 – 180mg per kilogram of elemental iron.  Because iron can initially cause nausea, vomiting or abdominal pain, a child with a suspected but unknown amount of iron poisoning can be observed and an iron level can be obtained. If you are not sure about ingested tablet an abdominal radiography can also help. A Child who has no complain and has a normal physical exam after 4-6 hours of observation can be safely discharged home especially if serum iron level is less than 500 mcg/ml. If the ingested iron happens to be significant it can cause, shock, coagulation disorder, myocardial depression and cell death.

Recurrent miscarriage is often due to genetic causes
Fertile couples with repeated miscarriages should be evaluated for the presence of a chromosomal abnormality.
Up to seventy percent of miscarriages are caused by chromosomal errors, Chromosome abnormalities occur in 1 of 160 live births, the most common being extra chromosomes 21, 18 and 13.
Chromosomal abnormalities are more common in women who are over thirty-five. Women (and men) older than 35 have a greater tendency to produce eggs or sperm with chromosomal abnormalities.
One or both partners may have a balanced translocation or other silent chromosomal abnormality like  an aneuploid mosaic that gives the couple a statistically increased odds of miscarriage in each pregnancy.
The transmission of a chromosome abnormality to an embryo can result in a low implantation rate, miscarriage, or the birth of a baby with a genetic disorder.
Aneuploidy refers to an abnormal number of chromosomes. An extra or missing chromosome is a common cause of genetic birth defects. Aneuploidy occurs during cell division when the chromosomes do not separate properly between the two cells.

Is there help for recurrent miscarriage?
Preimplantation genetic diagnosis (PGD) is most frequently recommended for patients who are at risk for genetic disorders such as cystic fibrosis, Tay Sachs disease, or thalassemia.
PGD is also helpful for patients with unexplained infertility, a history of recurrent miscarriage, unsuccessful IVF cycles, advanced maternal age, or the birth of a child with a chromosome abnormality such as Down syndrome. or male factor infertility. In these cases, the most likely cause is a chromosome abnormality.

Male Factor Infertility
Approximately one-half of all infertility is caused by sperm abnormalities. Many sperm disorders are due to a chromosome abnormality such as aneuploidy or a structural chromosome abnormality.
Y chromosome deletions are found in approximately 5 to 20 percent of males with a very low sperm count. These deletions appear to impair normal sperm development. While these deletions do not appear to cause any genetic disease, they appear to decrease the chance of men with a low sperm count to successfully fertilize eggs in a normal condition .
Men who carry a balanced translocation chromosome are at risk of producing sperm with a structural chromosome abnormality. Studies have shown that approximately 3 to 8 percent of sperm from normal, fertile men are aneuploid and 27 to 74 percent of sperm from men with severe infertility are aneuploid.
Couples with infertility due to male factor should consider chromosome analysis of the male’s sperm prior to IVF.

Aneuploidy and Advanced Maternal Age
Women 35 and older are at a higher risk of producing aneuploid embryos, which results in implantation failure, Aneuploidy is believed to be a major reason for the decrease of fertility with age. Studies have shown that approximately 62 percent of embryos from women of advanced maternal age might be aneuploid.
Prior to attempting a pregnancy, women in this age group should talk with their physician or a medical geneticist about their chances of having a child with a genetic disease and if PGD should be considered.

The most common anemia in children is Iron-Deficiency Anemia, which can influence physical and mental growth of the child
The blood in your vessels, consist of white blood cells, Red blood cells, platelets and the plasma in which these cells swim in it. Beside the above cells, there are also proteins, lipids, sugars, vitamins and many other little bitty materials. Each of the above has a special function like Red Blood cells (RBC) that contains hemoglobin and has the function of carrying oxygen to the body’s tissues and organs. The decrease of hemoglobin or Red Blood Cells is traditionally called anemia.

The following are the lower normal hemoglobin levels below which children are considered to be anemic:

• Newborn (full term) : 13gm/dl
• 3 months : 9.5gm/dl
• 1 – 3 years : 11.0gm/dl
• 4 – 8 years : 11.5gm/dl
• 8 – 12years : 11.5gm/dl
• 12 – 16years : 12gm/dl

Anemia are of different types and have different causes but the basic problem causing anemia includes:

1.    Decrease Red blood cells production in the bone marrow, like leukemia.
2.    Destruction of excessive Red Blood Cell (hemolysis) in the vessels as in thalassemia.
3.    Blood loss like bleeding, the cause of which could be allergy to cow’s milk protein, parasitic infection or maybe trauma. The symptoms of anemia depend on the age of the child, the cause, and the speed of its development.  Most children with anemia are asymptomatic and infrequently may have pallor, fatigue, tiredness, jaundice, and poor gain in weight.  They may not be critically ill.  In severe chronic cases there may be dyspnea, palpitation, edema, shock, enlargement of spleen and heart, and growth disturbances. History and clinical findings on physical examination with the help of a few simple laboratory tests can reveal the underlying cause of anemia. The pallor and irritability may not show up until hemoglobin is less than 7 – 8 mg/dl.
Among many causes of anemia in children:
The most common is iron deficiency anemia. Where the body is depleted of iron and the red blood cell gets small and pale in shape. This type of anemia can influence the physical, mental growth and the ability of learning in the child. It is usually caused by poor intake of iron, like using cow’s milk, which has low iron with low bioavailability in a child less than one year, bleeding which could be secondary to being sensitive to protein of the cow’s milk, prematurely born baby whish has low iron store, and secondary to different type of sickness. One of the most common causes of iron deficiency anemia in children is low cultural awareness of the quality of foods and feeding, making use of junk foods like chocolate, chips, chewing gum, different type of liquid beverages or taking huge amount of cow’s milk daily, in the second year.

Important Notes:
1. Healthy term infants who are exclusively breastfed are at risk of iron deficiency after 5 to 6 months of age if they not use proper complimentary food besides the breast milk. This is more complicated in premature born infant, as their iron store is less.
2. Although breast milk and cow’s milk contain about the same amount of iron, non-heme iron is absorbed at 50% efficiency from breast milk but at only 10% from cow’s milk.  In addition, cow’s milk may cause microscopic gastrointestinal bleeding in younger infant as a result of mucosal injury, possibly from sensitivity to bovine albumin. In older infants, cow’s milk may interfere with iron absorption from other sources, too.
3. Screening for iron deficiency anemia should be considered for all infants between 9 – 12 months of age specially if:

• Low birth weight
• Consumption of the whole cow’s milk before the age of one year.
• Use of formula not fortified with iron.
• Exclusive breastfeeding (without solid or formula supplementation)    beyond the age of six months).
• Perinatal Blood loss
• Teenage female (if menstruation is heavy or if pregnant)
• Infant living in poverty

4. Iron depletion (with or without anemia) maybe associated with lassitude, and decrease concentration ability and mood swings.
5. Bioavailability of non-heme iron is decreased by phosphates, tennates, polyphenols and oxylates found in cereal, milk, cheese, tea, and complex carbohydrates. It is increase by fructose citrate and specially ascorbic acid found in red kidney beans, cauliflower and banana. In children with iron deficiency, besides the administration or replacement of iron, a Vitamin C fortified fruit juice 30 minutes before a meal makes physiologic sense.
6. Multiple studies have shown an association between iron deficiency in infants between nine and twenty four months old and lower motor and cognitive scores and increase behavioral problems compared with non anemic controls. Some long term studies suggest that the developmental impairments maybe long lasting. Debate remains about whether this relationship remains casual and, if so, whether the correction of anemia leads to reversal of the problems.

Dr. Hossein Sardari-Zadeh
Pediatrician Specialist
Al Hafiz International Hospital  
tel: 04-3990022

Compelling evidence shows that atheroscerotics process (building up of fatty plaque in arteries) begins in childhood and progresses slowly into adulthood. Then it often leads to Coronary Heart Disease, the leading cause of death in many countries. So, elevated cholesterol level early in life can play a role in development of Coronary Heart Disease. There are 3 major Lipoprotein groups which are classified by their density. Very Low Density Lipoprotein (VLDL), Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL).

WHAT ARE THE NORMAL CHOLESTEROL LEVEL OF CHILDREN AND ADOLESCENTS?

Total Cholesterol (mg/dL):

• Acceptable: <170
• Borderline: 170-199
• High: >200
• Accpetable: <110
• Borderline: 110-129
• High:>130

LDL Cholesterol (mg/dL)

WHICH CHILDREN SHOULD HAVE THE CHOLESTEROL MEASURED?

Currently recommendations developed by American Academy of Pediatrics recommended a screening of all children after 2yrs of age, but before 10years, if the following are presents:

1. Family history of parent or grandparents aged 55yrs or younger which documented myocardial Infarction, Atherosclerosis, Angina Pectoris, Peripheral Vascular Disease or Cerebrovascular Disease

2. History of parent with elevated Total Cholesterol more than 240mg/dl

3.Children who may have increase risk of Coronary Heart Disease irrespective of his family such as those who smoke cigarettes ,are overweight, Obese, Diabetic or have Hypertension.

WHAT ARE THE AMERICAN HEART ASSOCIATION DIETARY STARTEGIES FOR ALL CHILDREN OLDER THAN 2 YEARS?

1 .Balance Dietary calories with physical activity to maintain the normal growth
2. Engage in 60 minutes of moderate to vigorous play or physical activity
3. Eat vegetable and fruit daily and limit juice intake
4. Use vegetable oil and margarines low in saturated fats and Trans fatty acids instead of butter or most animal fat in the diet.
5. Eat whole grain breads and cereals rather than refined-grain products.
6. Reduce the intake of sugar sweetened beverages and foods.
7. Use non Fat (Skim) or low fat milk and dairy products daily.

 

Dr. Hossein Sardari-Zadeh 

Specialist Pediatrician

Al Hafiz International Hospital

Tel: 04-3990022

1. Asthma is the most common chronic inflammatory condition in Children characterized by reversible small airway obstruction, Smooth muscle contraction in the wall of airway; edema and mucous production are the contributing factors for the obstruction. The above change in airway usually follows a stimulating agent which originates from gene-environment interaction that may start in early life and even during pregnancy.
2. The initiating or stimulating causes are usually allergens like cold air, perfumes, high humidity and most commonly viruses like viruses causing common cold or cigarette smoke and many others.
3. Asthma comes in a form of attack and causes symptoms like persistent coughing, shortness of breath and a musical sound in the chest called wheezing which is because of airway narrowing.
4. Breast feeding especially in first 4-6 months of life seems to be protective against later asthma.
5. Early complimentary or solid feeding in infant may put the children at high risk for developing allergy (atopic dermatitis and asthma)
6. Vitamin D intake through diet, sunlight or supplementation may be beneficial in the prevention of asthma.
7. Antibiotic use has been shown to be associated with development of asthma in the later stage of life especially the use of broad spectrum antibiotic in 1^styear of life.
8. Maternal smoking both during pregnancy and after birth is associated with measurable harmful effect, including greater risk of developing asthma symptoms in early life.
9. Respiratory viral illness during early life has been associated with as increase likelihood of asthma.
10. The connection of asthma with psychological aspects seems logical because data showing a connection between stress and immune cells of the human being.

Dr. Hossein Sardari-Zadeh
Specialist Pediatrician
Al Hafiz International Hospital
Tel: 04-3990022

Apart from autism, there are four other neuropsychiatric disorders, which are characterized by problems with social interaction, verbal and non-verbal communication, and repetitive behavior of varying degree of severities. Autism disorder is the first in the list. As to the etiology, no known etiology can be found in 80% – 90% of cases, a genetic syndrome such as fragile X-syndrome or chromosome 15q duplication is found in 10% – 30% of cases. There is strong family component. There has been many claims regarding possible environmental triggering factors especially vaccines and in particular measles, mumps, and rubella. But so far, no link between the uses of MMR vaccine with autism has been found.

WHAT ARE THE 3 ESSENTIAL FEATURES OF AUTISM?

1. Impaired social interaction (extreme aloneness, failure to make contact)

2. Absent or abnormal speech and language development

3. Narrow range of interest and stereotype or repetitive responses to objects

WHAT BEHAVIORS OF CHILDREN SHOULD AROUSE SUSPICION OF POSSIBLE AUTISM?

1. Avoidance of eye contact during infancy

2. Relating to only part of his body (e.g. the lap) rather than to the whole person.

3. Failure to acquire speech or speech acquisition in an unusual manner (e.g. repeating another person’s speech)

4. Failure to respond to name when called

5. Spending long period of time in repetitive activities and fascination with movement (e.g. spinning records, dripping water)

6. Failure to look in the same direction when directed by an adult

7. Absence of pointing to show or request something

8. Excessive lining of toy or other objects

9. Limited pretend or symbolic play

WHEN SHOULD SCREENING BE DONE FOR AUTISM?

It is recommended that all children receive autism specific screening at 8- 12 months and whenever there’s a concern for autism. A younger sibling of children who has autism has 10-20 fold increased risk of autism. Problem with pre verbal gestural language and deficit in social skill is present in most children by 18 months of age. The 23 Autism M-CHAT (modified version of checklist for autism in toddler) is probably the most commonly use screening questionnaire. Positive result, warrant referral to more detailed testing.

DOES EARLY INTERVENTION AND/OR THERAPY IMPROVE THE OUTCOME IN CHILDREN WITH AUTISM?

In general, early diagnosis and involvement of therapies on children with autism does appear to improve outcomes such as decreased need for social education in later years and an increase in the chance for independence as an adult. Certain subsets of children with autism such as those with no co-existing cognitive deficits will fare better. Additionally, early recognition and intervention may assist families in understanding and coping with potentially challenging medical co morbidities and social and behavioral issues. When autism is suspected the child should be referred to specialist in this field, also, referred to speech and language pathologist to get therapy started as soon as possible. All autism needs audiology evaluation because of their language disorder.

Dr. Hossein Sardarizadeh
Specialist Pediatrician
Al Hafiz International Hospital