Alopecia / Hair loss disorder/ Baldness

What is it?

Alopecia is partial or complete loss of hair. It usually develops gradually and may be patchy or diffuse (all over). One can lose up to 100 hair from the scalp everyday.

Baldness is not usually caused by disease. It is also related to aging, heredity or changes in the hormones. There may be male pattern baldness or female pattern baldness.

Who get affected?

• Alopecia can affect males and females in equal numbers. 
• Can occur at any age, but most people get it in their teens, twenties, or thirties. 
• When it occurs in children younger than age 10, it tends to be more extensive and progressive.
• Affects all racial and ethnic groups. 
• If you have a close family member with the disease, you may have a higher risk of getting it, but for many people, there is no family history.

What are the causes?

There are many reasons which include the following:

Hair Disorders

Hereditary thinning or baldness: 

• Also called androgenetic alopecia. 
• Regarded as the most common cause of hair loss. 
• In men, it is seen as a receding hairline as well as hair loss on top of the scalp. 
• In women, tends to have their hairline and have visible thinning of hair  over the front and top of the scalp.

Alopecia areata:

• An autoimmune disease that causes hair loss on the scalp and elsewhere on the body. 
• Develops in people of all ages and hair is lost in patches.
• Persons with certain autoimmune diseases, such as psoriasis, thyroid disease, or vitiligo, are more likely to get alopecia areata, and with allergic conditions such as hay fever. 

Cicatricial (scarring) alopecia: 

• Can develop in  otherwise healthy men and women, 
• A rare condition that destroys hair follicles. 
• Scar tissue forms where the follicles once were and re-growth is not possible. 
• Treatment attempts to stop the inflammation that destroys the hair follicles.

Diseases:

Underlying medical condition: 

• Hair loss is regarded as warning sign for about 30 diseases. 
• Hair loss often can be stopped or reversed with treatment for the underlying disease. 
• Medical conditions that lead to hair loss are thyroid disease and anemia caused by an iron deficiency. 

Cancer treatments: 

• Radiation therapy and some chemotherapeutic medications can also cause hair loss. 
• While hair loss is usually temporary, it can be the most distressing part of therapy. 

Ringworm of the scalp: 

• Hair loss can also be caused due to  fungal infection, which is most common in children, can cause balding and scaling on the scalp. 

Trichotillomania:

• In this people repeatedly pull out their own hair. 
• Aside from a constant urge to pull out the hair on the scalp, sufferers often say they feel compelled to pull out their eyelashes, nose hair, eyebrows, and other hair on their bodies.

Stress and Hormones:

Stress: 

Hair loss can also occur 

• If a person is mentally or physically stressed, 
• After a major surgery, 
• High fever, 
• Severe infection, 
• or even flu. 

Hormone fluctuations: 

• Any change in hormonal levels especially in women. 
• Common during menopause and after childbirth due to falling oestrogen levels. 
• The loss is usually temporary. 
• Hair can be re grown .

Diet:

Weight loss: 

• People having weight issues. 
• Very common, and hair growth does return to normal with proper diet and weight. 

Vitamin A excess: 

• Intake of too much vitamin A through vitamin supplements or medications can also lead to hair loss. 

Protein intake too low:   

• When the body is not getting enough protein, it conserves the protein. 
• It does get by shifting hair growth into the resting phase. 
• Within 2 to 3 months, the person usually sees visible hair loss. 
• This can be reversed and prevented by eating enough protein.  

Iron intake too low: 

• Consuming too little iron can lead to hair loss. 
• Good vegetarian sources of iron are iron-fortified cereals, soybeans, pumpkin seeds, white beans, lentils, and spinach. 
• Clams, oysters, and organ meats top the list of good animal sources of iron. 

Eating disorder:

• An eating disorder such as anorexia or bulimia is the other cause of hair loss.

Medication:
Medications that can cause hair loss include:

• Blood thinners
• High-dose vitamin A
• Medicines for arthritis, depression, gout, heart problems, and high blood pressure
• Birth control pills: Usually occurs in women with an inherited tendency toward hair thinning.

Hair Care Practices:

Hair cosmetics:  

• Frequent coloring of hair. 
• Regular or improper use of dyes, gels, relaxers, and sprays.
• Dermatologists recommend limiting use of these hair cosmetics to reduce hair breakage. 

Blow dryers, flat irons, and similar devices:

• Regular use of a blow dryer tends to damage hair. 
• The high heat from a blow dryer can boil the water in the hair shaft leaving the hair brittle and prone to breakage. 
• Allowing the hair to air dry and styling  it only when dry will lessen this risk. 
• Dermatologists also recommend limiting the use of flat irons, which straighten hair by using high heat, and other devices such as curling irons.

Hairpins, clips, and rubber bands: 

• If hair are held tightly with hairpins, clips, and rubber bands, it can break hair. 
• One should use loosely fitting clips and wear them in different areas of the scalp so that hair breakage is not localized in a specific area.

Too much or vigorous grooming: 

• Regular shampooing, combing, or brushing (100 strokes or more a day) or doing any of these too vigorously can cause hair breakage. 
• When hair breakage occurs, the hair appears shaggy or too thin. 

How diagnosis is done?

Dermatologists can diagnose hair loss by asking questions about medical history, family history. A dermatologist may also carefully look at the scalp  to know the condition of scalp.

Key history: 

• Onset, duration, quantity and rate of loss 
• Localized or generalized loss 
• Associated symptoms (e.g. pruritus, scaling, pustules) 
• Systems review including fever, acute illness, surgery, stressors 
• Endocrine features 
• Past history including skin disorders, cancer, thyroid disorders 
• Family history of hair loss

Key examination:

• General review with emphasis on endocrine system and examination of scalp 
• Look for exclamation mark hair, ‘white bulb’ hair, state of bald patch (clean, scaly, scarred or inflamed) and the unusual pattern of trichotillomania

Key investigations: 

• FBE/ESR 
• Pituitary hormones (FSH/LH/prolactin/FSH) 
• Hair pull test 
• Trichogram 
• Scalp biopsy 
• Skin scrapings and hair sample for fungal microsurgery and culture

How management is done?

Treatment of hair loss depends upon the cause of disease. 

Minoxidil: 

• Applied to the scalp. 
• Can stop hair from getting thinner and also stimulate hair growth on the top of the scalp. 
• Only hair re-growth product approved for men and women. 
• A dermatologist generally combine minoxidil with another treatment.

Laser devices: 

• Brushes, combs, and other hand-held devices that emit laser light also stimulate hair growth. 
• These devices might make hair look more youthful in some people. 
• The long-term effectiveness and safety for these devices are not known.

Prescription medicine:

Finasteride: 

• FDA approved 
• Treat men with hair loss. 
• Slow hair loss in most (about 88%) men. 
• Helps stimulate hair re-growth in many (about 66%) men. 
• Works by stopping the body from making a male hormone, dihydrotestosterone (DHT).

Corticosteroid: 

• If hair loss is caused by inflammation in body, a dermatologist may inject a medicine called a corticosteroid into scalp. 
• This can help stop the inflammation that happens when a person has alopecia areata. 
• A corticosteroid is different from an anabolic steroid.

Procedures:
The type of procedure will depend on how much hair you have lost. To achieve the best results, a dermatologist may use one or more of the following procedures:

Hair transplantation: 

• Skin on the scalp that has good hair growth is removed and transplanted to areas of the scalp that need hair.

Scalp reduction: 

• Bald scalp is surgically removed and hair-bearing scalp is brought closer together to reduce balding. 
• Scalp reduction surgery can be performed alone or in conjunction with a hair transplant.

Scalp expansion: 

• Devices are inserted under the scalp for about 3 to 4 weeks to stretch the skin. 
• This procedure may be performed before a scalp reduction to make the scalp more lax. 
• It also can be performed solely to stretch hair-bearing areas, which reduces balding.

Scalp flaps: 

• A hair-bearing segment of scalp is surgically moved and placed where hair is needed.

References:

1. Atkinson K. John Murtagh's general practice companion handbook 6th edition. Australian Journal of General Practice. 2016 Jul 1;45(7):528.
2. https://www.nhp.gov.in/disease/skin/alopecia-hair-loss
3. https://rarediseases.org/rare-diseases/alopecia-areata/
4. https://www.niams.nih.gov/health-topics/alopecia-areata

World Autism Awareness Day 2022: Inclusive Quality Education for All

What is it?

Autism/ Autism spectrum disorder (ASD) is a range of complex neurodevelopment brain disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped pattern of behavior. It typically affects a person's ability to communicate with others. ASD form of disease generally begins in childhood and last through adulthood. 

When is it Celebrated?

World Autism Awareness Day (WAAD) is observed every year on 2nd April to raise public awareness of autism. First it was celebrated in 2008. WAAD highlights the need to help and improve the quality of life of those with autism so that they can lead full and meaningful lives as an integral part of the society.

The focus of World Autism Awareness Day 2022 is: "Inclusive Quality Education for All"

What are the types?

Autistic Disorder/ "classic" autism: 

• Most general form of autism. 
• Typically have significant language interruption, social and communication challenges, and unusual behaviors and interests. 
• May also have intellectual disability.

Asperger Syndrome: 

• Have mild symptoms of autistic disorder. 
• Might have social challenges and unusual behaviors and interests. 
• Typically do not have problems with language or intellectual disability.

Pervasive Developmental Disorder- Not Otherwise Specified (PDD-NOS): 

• It is called as "atypical autism". 
• People who meet some of the criteria for autistic disorder or Asperger syndrome, but not all, may be diagnosed with PDD-NOS. 
• Usually have fewer and milder symptoms than those with autistic disorder. 
• The symptoms might cause only social and communication challenges.

When it starts?

• ASDs generally starts at or before the age of 3.
• May last throughout a person's life, even though symptoms may improve over time. 
• May exhibit hints of future problems within the first few months of life. 
• May show symptoms until 24 months or later. 
• Some children seem to develop normally until around 18 to 24 months of age and then they stop gaining new skills, or they lose the skills they once had.

What are the symptoms?

A child with an ASD might:

• Does not react to his/her name by 12 months
• Does not play by 18 months
• Generally avoid eye contact and stay alone
• Also have difficulty in understanding other people's feelings or talking about their own feelings
• May show delayed speech and language skills
• Repeat words or phrases over and over (echolalia)
• Give unrelated answers to questions
• Does not like even minor changes
• Have obsessive interests
• Some time they flap their hands, rock their body, or spin in circles
• Have unusual reactions to the way things sound, smell, taste, look, or feel

What are the causes?

• The exact causes of ASD are not known. 
• Likely to be associated to genetics and environment factors.  
• Studies have also found irregularities in several regions of the brain. 
• Other studies suggest abnormal levels of serotonin or other neurotransmitters in the brain. 
• Could result from the disturbance of normal brain development early in foetal development caused by defects in genes that control brain growth and that regulate how brain cells communicate with each other, possibly due to the influence of environmental factors on gene function. 

How to diagnose?

• Diagnosis can be difficult as there is no medical test, like a blood test. 
• Physician may look at the child’s behavior and development to make a diagnosis. 
• However, the children might receive an audiologic evaluation and a screening test for autism such as Checklist for autism in toddlers.

What are the managements?

• There is no cure for this disease. 
• But, it can be managed with the help of medications and specialist education. 
• Early intervention services can help in child's improvement. 
• These helps child talk, walk and interact with others. 
• Therefore, it is important to meet and talk to child's doctor as soon as possible.

References:

1. https://www.nhp.gov.in/disease/neurological/autism
2. https://www.nhp.gov.in/world-autism-awareness-day2021_pg#:~:text=World%20Autism%20Awareness%20Day%20(WAAD,raise%20public%20awareness%20of%20autism.
3. https://www.un.org/en/observances/autism-day
4. https://www.autismspeaks.org/world-autism-awareness-day
5. https://nationaltoday.com/world-autism-awareness-day/

Weaning/Complementary foods for babies

What is it?

Exclusive breastfeeding (Feeding only breast milk) is adequate for baby till 6 months of life. After 6 months, breastfeeding alone is no longer enough for optimal growth and development of the child. Hence, along with breast milk, it is necessary to start complementary feeding (CF)/ Weaning i.e., the process of introduction of suitable semi-solid food at the right age. An infant of this age is also developmentally ready for other foods.

Problem statement:

Undernutrition is associated with 45% of child deaths. Less than a fourth of infants aged 6–23 months have age-appropriate dietary diversity. Globally, 144 million children under 5 yrs of age are too short for their age (stunted).

What happens when not given?

If complementary foods are not introduced around the age of 6 months, or if they are given inappropriately, an infant’s growth may falter. 6 months is the ideal time or “sensitive period”. If CFs is delayed, then child may enter “critical period” after which the infant may always be a poor chewer and may be poor in eating solids later. 

How it should be given?

Caregivers should take active care in the feeding of infants by being responsive to the child’s clues for hunger and also encouraging the child to eat. 

• Timely – CFs are introduced when the need for energy and nutrients exceeds what can be provided through exclusive breastfeeding.
• Adequate – CFs provide sufficient energy, protein and micronutrients to meet a growing child’s nutritional needs.
• Safe – CFs are hygienically stored and prepared, and fed with clean hands using clean utensils and not bottles and teats.
• Properly fed – CFs are given consistent with a child’s signals of appetite and satiety, and that meal frequency and feeding are suitable for age.

When to start?

Weaning must begin soon after completing 6 months of age as the biting movement of jaw appears around 5 months. Around 6–7 months, swallowing of solid foods occurs and the side-to-side movement of tongue develops by 8–12 months. The other reasons for complementary feeding at 6 months of age are: 

1. Child develops neck/head control and hand-to-mouth coordination. 
2. Child starts enjoying mouthing and biting. 
3. The intestines are mature and ready to digest pulses and cereals. 
4. Baby likes chewing and gumming semisolids as there is hardening of gums and eruption of teeth. 
5. Tendency to push solids out of mouth decreases.

Which foods should be used?

Prefer the regular family food that is locally available and culturally acceptable rather than cooking special foods. The recent concept is of “Baby-led Weaning”, i.e., feed as per baby’s choice shall be practiced. Food should be easily digestible and nourishing . Taste and palatability of food should be good for the infant. It should be

Appropriate to give:

• Combination of cereals and pulses (Khichdi, Dalrice, etc.), locally available staple foods such as idli, dosa, dhokla, ragi, chapati, roti, paratha with oil/ ghee, and some amount of sugar. 
• Mashed banana, other pulpy fruits (e.g., mango, papaya), sweet potato, and potato
• Sprouts, pulses, legumes, groundnuts, almonds, cashewnuts, raisins (Note: Any nut should be well grinded and mixed with food as solid pieces may cause choking in young children)

Avoidable:

• *Biscuits, breads, pastry, chocolates, cheese, softy, ice cream, doughnuts, cakes, etc. 
• # Tinned foods, packaged or stored foods, artificially cooked foods with preservatives or chemicals 
• *Commercial breakfast cereals {*These foods should not form the main bulk of complementary foods and may be offered only occasionally.}
• # Fruit juices and fruit drinks Milk-based cereals preparations 
• # Repeatedly fried foods containing trans-fatty acids (which predispose to obesity, diabetes, atherosclerosis, cardiac, and neurological problems in future) { #These foods should be avoided altogether in children below 2 years of age. }

What precautions are needed:

1. Follow proper hand washing with soap before preparing and eating the food. 
2. The foods shall be stored safely and served fresh after preparation. 
3. Use clean utensils for preparing and serving the food. 
4. Spoon, cups, and bowls used for feeding the children shall be clean. 
5. Avoid using feeding bottle as it is difficult to clean and maintain the hygiene. “Bottle feeding is injurious to health of the child.” Diarrhea, dehydration, and malnutrition are usually the results of unsafe bottle-feeding.

Quantity, frequency, and texture of complementary foods:

Principles to be followed for complementary feeding:

• Start complementary feeds after completion of 180 days. 
• Continue breastfeeding up to 2 years of age along with appropriate complementary feeding. 
• Give semi-solid food (Avoid watery food such as soups, fruit juices, and animal milk) 
• Prefer home-made food (clean, fresh, cheap, and easily available) 
• Prefer balanced food (Cereal + pulse + vegetables) using locally available ingredients preparations. 
• Introduce one food at one time; once child starts accepting it, introduce another preparation. 
• Addition of ghee, oil, oil-seed powder, fats adds to energy, and palatability of food (except in children who are overweight or obese) 
• Child’s choice and preferences shall be respected. Avoid force feeding. 
• Give as much as child consumes. Monitor weight of the child.

Things to be avoided for complementary feeding:

• Avoid delay in starting complementary feeding. 
• Avoid outside, artificial, packaged, and commercial and Junk foods. 
• Avoid foods with excess of sugar, salt, and trans-fatty acids. 
• Avoid ultra-processed and refined foods. 
• Bottle-feeding has only disadvantages; avoid it. 
• Avoid feeding while watching television or mobile. 
• Do not force to feed. Feeding should not be an unpleasant experience. 
• Avoid overfeeding. 
• Avoid foods that may cause choking. 

Feeding your baby: 6–8 months old:

From 6–8 months old, feed your baby half a cup of soft food two to three times a day. Your baby can eat anything except honey, which she shouldn't eat until she is a year old. You can start to add a healthy snack, like mashed fruit, between meals. As your baby gets increasing amounts of solid foods, she should continue to get the same amount of breastmilk. 

Begin to feed at 6 months :

Type of food: Soft porridge, well mashed food 

How often: 2 to 3 times each day 

How much: 2 to 3 tablespoons at each meal 

From 6 up to 9 months:

Type of food: Mashed food 

How often: 2 to 3 times each day and 1 to 2 snacks 

How much: 2 to 3 tablespoons up to one-half (1/2) cup at each meal

From 9–11 months old:

Now baby can take half a cup of food three to four times a day, plus a healthy snack. Now you can start to chop up soft food into small pieces instead of mashing it. Your baby may even start to eat food herself with her fingers. Continue to breastfeed whenever your baby is hungry.

If your baby refuses a new food or spits it out, don’t force it. Try again a few days later. You can also try mixing it with another food that your baby likes or squeezing a little breastmilk on top.

How often: 3 to 4 times each day and 1 to 2 snacks 

How much: At least one half (1/2) cup at each meal

From 12 up to 24 months:

Type of food: Family foods, chopped or mashed if necessary 

How often: 3 to 4 times each day and 1 to 2 snacks How much: Three-quarters (3/4) up to 1 full cup at each meal

* A snack is extra food between meals ** A cup is 250 ml 

Feeding non-breastfed babies:

If you're not breastfeeding your baby, she’ll need to eat more often. She'll also need to rely on other foods, including milk products, to get all the nutrition to her body needs.

• Start to give your baby solid foods at 6 months of age, just as a breastfed baby would need. 
• Begin with 2 to 3 spoonful of soft and mashed food 4 times a day, which will give her the nutrients she needs without breastmilk.
• From 6–8 months old, she’ll need half a cup of soft food 4 times a day, plus a healthy snack. 
• From 9–11 months old, she’ll need half a cup of food 4 to 5 times a day, plus 2 healthy snacks.

Living with HIV:

If you are living with HIV, introduce your baby to his first solid foods at 6 months and continue to breastfeed him while taking your ARV medicines and following your treatment plan.

First food for the baby:

• The staple cereal of the family should be used to make the first food for an infant. 
• Porridge can be made with suji (semolina), broken wheat, atta (wheat flour) ground rice, ragi, millet etc, by using a little water or milk, if available. 
• Roasted flour of any cereal can be mixed with boiled water, sugar and a little fat to make the first complementary food for the baby.
• Adding sugar or jaggery and ghee or oil is important as it increases the energy value of the food. 
• In the beginning the porridge could be made a little thinner but as the child grows older the consistency has to be thicker. 
• A thick porridge is more nutritious than a thin one. 
• In case a family can not prepare the porridge for the infant separately, pieces of half chapatti could be soaked in half a cup of milk or boiled water, mashed properly and fed to the baby after adding sugar and fat. 
• Soaked and mashed chapatti could be passed through a sieve so as to get a soft semi-solid food for the infant.
• Fruits like banana, papaya, chikoo, mango etc. could be given at this age in a mashed form. 

References:

1. https://www.who.int/health-topics/complementary-feeding#tab=tab_1
2. https://iapindia.org/pdf/Ch-040-IAP-Parental-Guideline-Complementary-Feeding.pdf
3. https://www.cdc.gov/nutrition/infantandtoddlernutrition/foods-and-drinks/index.html
4. https://www.unicef.org/parenting/food-nutrition/feeding-your-baby-6-12-months
5. https://motherchildnutrition.org/india/complementary-feeding-guidelines.html
6. https://www.unicef.org/parenting/food-nutrition/feeding-your-baby-when-to-start-solid-foods
7. https://www.unicef.org/parenting/food-and-nutrition/first-foods-for-baby
8. https://www.unicef.org/uganda/media/3416/file/UGDA%20children%20feeding%20flyer.pdf
9. https://www.unicef.org/media/108431/file/Brochure%20Feeding%20After%206%20Months.pdf
10. https://data.unicef.org/topic/nutrition/infant-and-young-child-feeding/
11. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding
12. https://nhm.gov.in/New_Updates_2018/NHM_Components/Immunization/Guildelines_for_immunization/MCP_Guide_Book.pdf
13. https://nhm.assam.gov.in/sites/default/files/swf_utility_folder/departments/nhm_lipl_in_oid_6/menu/document/mcp_card_english.pdf
14. https://www.nhmmizoram.org/upload/mcpcard/MCP%20Card%20Revised.pdf