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1. R.R., Dubai

*My 18 months old baby has the problem of hernia. The doctor  here has informed that normally there  will not be serious problem in such type of the cases. But at the same time he told that the child will need immediate treatment incase he starts vomiting or feels pain. We are to visit India in the next April.  Kindly  advise us if this surgery required immediately or we can get it done during  our visit. Please also suggest us what are the indications of this  particular hernia so that we can keep watch on the above. Please confirm us what  is hernia?  What are the precautions we can take ?  Your earliest reply shall be highly appreciated.

* A hernia occurs when a portion of an organ within the abdomen, such as the intestines, protrudes through a weakness in the muscles of the abdomen. A soft bulge is seen underneath the skin where the hernia is located. A hernia that occurs in the groin (inguinal) area is called an inguinal hernia.

Between 12 to 14 weeks of fetal development, the testicles or ovaries form in the abdomen near the kidneys. They gradually move down into the lower part of the abdomen as the baby continues to develop. As they move down, a portion of the peritoneum (a thin layer of tissue that lines the inside of the abdomen) that attaches to the testicle is drawn with it into the scrotum, forming a pouch or sac. A similar process occurs in girls as the round ligament of the uterus descends into the groin at the labia. This sac is known as the processes vaginalis and normally closes shortly after birth. This eliminates any connection between the abdominal cavity and the scrotum or groin.

When closure of the processes vaginalis is delayed or incomplete, it may stretch and eventually become a hernia. The stretching of the processes vaginalis creates an inguinal sac, allowing organs to extend from the abdomen and enter the sac. If fluid, rather than organs, builds up and remains in the sac, the child has a hydrocele.

Approximately 80% to 90% of inguinal hernias appear in boys. They are more common on the right side, but in about 10% of cases, they occur on both sides (bilaterally).An inguinal hernia can occur at any age, but one-third of hernias in children appear in the first six months of life.

Hernia usually manifests as a swelling or a bulge in the groin or scrotum which may be seen during crying or straining, and it may get smaller or go away when the baby relaxes. The smooth mass is usually not painful to touch.

If the bulge can be gently pressed back into the abdomen, the hernia is termed reducible. If it cannot be pressed back into the abdomen, the hernia is known as incarcerated (irreducible). When a hernia becomes incarcerated, infants or children will show signs of irritability and may vomit. They may also have loss of appetite, abnormal bowel patterns, and / or tenderness of the groin area and swelling of the abdomen. The doctor on examination will be able to pin point the problem to irreducible hernia. However incarceration is not very common problem. 

With a prolonged period of incarceration, the blood supply to the intestine could be cut off, causing it to die. This is referred to as a strangulated hernia and this requires urgent surgical attention.

Inguinal hernias require an operation, and to avoid the risk of abdominal organs becoming incarcerated, this is generally done as early as possible. In premature infants, surgery may be postponed for two to three months after birth to ensure that the lungs are functioning properly.

Surgery is carried out under general anesthesia. A small incision is made in the groin. The hernia sac is identified and repaired. The incision is closed with dissolving stitches Most children who undergo hernia repairs go home the same day after a short stay in recovery; however, premature infants may require an overnight stay. Most children are able to return to normal activities, even out-door games with no restrictions within a few days. The length of time sports activities are restricted depends on the age of the child and the sports activity.

In cases where a large inguinal hernia extends down into the scrotum, the scrotum may swell after surgery. It may appear as though the hernia has come back. This swelling is normal and will go away on its own within several weeks to months.

After surgery, the risk of the hernia returning is extremely low. However, the risk is known to be higher in premature infants and in children with hydrocephalus, connective tissue disorders, chronic lung disease and chronic renal failure.

Though it is advisable to treat hernia at the earliest, you may wait till your visit to India. Complications are not very common and hernia is rarely treated as an emergency for irreducibility.  Vomiting and excessive cry is common in children and even in children with untreated hernia, this need not be due to irreducible hernia. A doctor can relate these symptoms to the signs of irreducibility by examining the child.

Hernia surgery in children is a simple surgical procedure and the cost of the surgery is generally moderate. The cost of the surgery depends on the surgeon and the institution. 

2. A. M., Mangalore

*My daughter is 3 years old and her weight is only 11 kg. She is very poor in eating. Earlier she used to drink milk now she doesn't like milk also. She is physically good and active, like all her age children. Any solution for this?

** Eating problems of children seem to be a major concern of many affluent parents. Most of the children refuse to eat because of faulty dietary habits. One must remember and appreciate that appetite is a built in mechanism. A child will eat as much as his body needs. There would be days when he eat more and other days when he hardly eat anything. This is physiological loss of appetite. Most of the parents out of ignorance start forcing the food down the throat of the child. Various means- threats, flattery, pampering- are tried. Such attempts often lead to what is known as psychological loss of appetite. Added to this some of the parents tend to make this a big issue and discuss this with others in front of the child. This can lead to an attention seeking matter for the child and child unconsciously keeps the issue alive. Majority of such parents tend to substitute the regular food by chocolates, fruit juices etc and at the dining table pressurize the child to eat. Most of these children who refuse to eat regular food remain healthy and grow normally. They do not eat regular food because they are fed with other things in between.  Feeding also should be disciplined. (There are many other issues influencing feeding habits of the children. I have written in detail about this in my book on child care)

Some children may grow lean and look weak. It can be constitution of the child and can be normal. For example Punjabi children grow fat and other children may look weak compared to them.  If your child is weak, anemic and underweight then you may have to consult a child specialist to know if there are any other problems If you have already consulted one, then second opinion may be required. Refusal to eat itself may not be the cause of the problem. It is probably secondary to some other cause then it may be set right.

Here are few tips in general for parents of small children:

* Do not feed the child when it is able eat; allow her to eat.  Do not serve her; instead encourage her to take as little as she wants. If the child is healthy and has put on enough weight compared to the children of her age, then there is nothing to worry about. It means that the child is getting enough nutrition in spite of her bad feeding habits.

*Do not feed in between the feeds. Most of the parents allow the children to eat chocolates, sweets, fruits etc. in between the meals and on the dining table they force them to eat the full meal. Feeding in between two meals may be because parents feel that the child has not eaten properly during meals and allow the child to go for sweets etc. This kills the appetite and the child will refuse the next meal.

*Children also have taste preferences. Ask your child what she wants to eat, prepare it and allow her to eat that.

*If the child does not eat a particular meal, just do not force. Do not curse. Allow her to go out without proper meals. She will feel hungry and eat the next meal properly. Most of the children do not feel hungry because parents keep their stomach always fed! Let her starve once or twice, nothing bad will happen.

*Forcing or cursing will never solve the problem. Few children use this as an ‘attention seeking’ and will repeat as long as you force or curse. Do you know that the children also have feelings and at times unknowingly they seek the attention of their parent?

*Just allow the child to have freedom on the dining table. You may feel that this advice is just impossible to follow, but remember nothing else you can do. No medicines are available to enhance the appetite in children.

3. V.M., Mangalore

*I am 21 years  of age and I am having only one testis. I am worried about this. I am feeling shy to speak about this to anyone. I masturbate daily and there is no wrong with sperm production.

**Single testes is sufficient for normal hormonal and related sexual function. As you have grown normally, have normal sexual response like masturbation, you may not have any other sexual problem related to absent testes. 

The testis normally grow inside the abdomen when the baby boy is still in mother’s womb. They descend down to scrotal sac sometime near to birth. In some  of the babies one or both testis may get stuck on the way to scrotal sac and may be one of the reasons for absent testes. This is known as undescended testes. In some individuals  the undescended testes that was stuck can cause certain problems. In few individuals there may be only one testes from the beginning and another may be totally absent. This can be diagnosed by ultrasound scanning. Therefore it is better to consult an urologist and to be sure that there are no issues related to undescended testes. You can go to any institution where there is urology department and consult the specialists.

4. J.R., Kuwait

*I am 48 years of age. I have the habit of biting tongue during sleep and due to this I experience terrible pain on my tongue which disturb my sleep for long hours and the pain continues weeks together.

** Biting in tongue in sleep could be caused by  two important causes nocturnal seizures or sleep bruxism. Having seizures during the night is often associated with tongue biting at night or while sleeping especially if someone has the tonic-clonic seizure where a person loses consciousness, muscles stiffen, and jerking movements are seen. Some seizures such as the frontal lobe epilepsy might be quite calm. Sleep bruxism is a condition in which people grind, gnash or clench their teeth. People with bruxism, may unconsciously clench their teeth together during the day, or clench or grind them at night (sleep bruxism. Most people who have this problem also tend to have the problem of biting tongue while asleep. 

Initially you may consult a neurologist to know whether you have any problem of  nocturnal seizures. If he finds you normal, he might refer you to other appropriate specialist.

5. R.D., Mangalore

*I am 28 years of age. I am fair and beautiful, but my bikini area is very dark. My whole body is fair, only that part is very dark. Anything can be done?

**Though it is not easy, you may consult a skin specialist and use certain creams that may help to lighten the pigmentation of the skin.

6. K.C., Bangalore

*I am 26 years old. My foreskin is tight and I am having a very painful sex. As advised I am pulling my foreskin skin back it has not lessened yet.

** You may require to undergo circumcision. Consult an urologist or a general surgeon and take their opinion. Circumcision is a simple surgery, rarely requires to be hospitalised.

7.R.D., Bantwal

*I am 39 years old. I have a dent on the top of my head. Though I feel no pain, I do worry about that. 

** You may consult a plastic surgeon and explore the treatment options to conceal the dent if it of cosmetic problem. If it is not giving you any problems and I if it s there from birth nothing may be required. If it  is not of cosmetic reason, but it bothers you, then consult a neurosurgeon for opinion.

8.A.R., Puttur

*I am 21 years of age. I used to masturbate since 10th standard and was masturbating almost twice a day. I recently had a physical experience with my girlfriend. But I was unable to hold an erection long enough for sexual intercourse. Am I impotent? Is there any natural remedy to overcome impotency if I have it?

** Many of the youngsters fail to perform during pre-marital encounters because of anxiety, stress and fear.  This is unlikely to continue in marriage. 

9.Y.A., Mumbai

* I am 50 years of age. I have got some pain in the right shoulder and arm since for the past two months. This I have shown it to doctor who gave some pain killers but no improvement; the pain is still there. Now the pain started in the right leg below knee region and above ankle. 

** You may consult an orthopaedic surgeon for proper evaluation. Physiotherapy and exercises may give you prolonged benefit rather than using pain killers. The pain relieving medicines may be used for a short duration when the pain is severe.

10. R.D., Qatar

* I am 28 years of age and married  for 1 year. We are planning for a baby and but during intercourse I do not get proper erection. What may be done?

** At your age the main cause for erectile dysfunction is stress. Some of the men, who are  otherwise healthy may get erectile dysfunction because of performance anxiety. When sex is to be performed for a particular purpose, like to have a baby  or to satisfy the partner the stress may lead to anxiety and in turn performance failure. Confidence building may solve the problem. However you may consult an urologist to know if there are any other causes. He might advise you certain medicines to solve the anxiety and perform properly.

11.A.S., Qatar

*I am 27 years of age. I am having tingling sensation on my thumb, index and middle fingers of my right hand for  the last 6 months now. I also  had pain in my neck and it went away.

** The problem may be either due to pressure on the nerve in the cervical spine or at the wrist. A neurologist may be able to pinpoint the cause. Many a times the problem on either regions can be managed without surgery, at times surgery may be needed.

12. M.P., Puttur

*I am 50 years of age, working in Gulf. During routine check up I had marginal raise in blood sugar levels. I nearly avoided sugar and sugar related foods  for the past two years. My mother was a diabetic patient. So please let me know what I have to do to prevent possible diabetes. I am using matta (kaje) rice thinking that is it better than other rice? 

** You may be gradually become one of  those with maturity onset or type 2 diabetes. About 90% to 95% of people with diabetes, have type 2 diabetes or maturity onset diabetes.(Type 1 is early onset or Insulin dependant diabetes is seen in about 5 to 10% people with diabetes) Diabetes cannot be prevented, because it is a progressive condition. When someone is first diagnosed with type 2 diabetes, the cornerstones of management are often, initially, is “diet and exercise,” or, more appropriately, “lifestyle changes.” In other words, a person in the early stages of type 2 diabetes may be able to control his blood glucose levels effectively by following a carbohydrate- and calorie-controlled meal plan, losing some weight (if necessary), and fitting regular physical activity into his or her schedule. At this stage, the body is still making enough insulin, and healthy eating and activity help the body use its own insulin quite efficiently. The quantity of rice is important and not the type; there is not much difference in the calorie content of boiled(kaje) or non-boiled rice.Over time, however, diabetes progresses, and lifestyle changes simply aren’t enough anymore to control blood glucose levels. At this point, a person with type 2 diabetes will likely need to start taking medicine in addition to continuing with those healthy lifestyle changes. Medicine is usually in the form of one or more diabetes pills. Many people with type 2 eventually go on to require insulin. 

People with diabetes often feel like they’ve failed because they have to go on diabetes drugs. The truth is that their pancreases have failed them. The natural course of type 2 diabetes is for it to progress to a point where, if the person lives long enough, he or she will have to take insulin. There’s evidence that incorporating healthy lifestyle behaviors may stave off the need to take medicine or insulin for a while, and it’s important for people with type 2 diabetes to work with their health-care teams on these behaviors. But the bottom line is that type 2 diabetes will eventually take its course. 

13.S.D., Bangalore

* I am having irritable, deadly itch on my inner thighs with rashes. It was pinkish at the beginning and now its turned very dark. I took flucanazole tab with candid cream; but it did not work. I consulted a gynecologist, she recommended canditrel tabs and canestan cream, even that did not work. I am feeling very miserable and devastated.

**All skin lesions need not be fungal infections. Consult skin specialist for proper evaluation.

14. N.S. Kuwait

*I am 42 years of age. Recently my doctor told me that I have hydrocele. What is hydrocele? How dangerous it is ? If it has to be treated surgically, how much time it will take ?

** A hydrocele   is a fluid-filled sac surrounding a testicle that causes swelling in the scrotum. Hydrocele is common in newborns and usually disappears without treatment during the first year of life. Older boys and adult men can develop a hydrocele due to inflammation or injury within the scrotum. A hydrocele requires treatment only if it gets large enough to cause discomfort or disfigurement. Then it might need to be surgically removed. There are no medicines or other forms of remedies for hydrocele.

15. L.D., Bangalore

* We are married for more than 7 years. No child. We both are 34 years of age. My husband's sperm count is low. We had consulted gynecologist and taking medicine. I want to know for low count, gynecologist medicine is enough or do we need to consult any other  specialist. Is there any way to find out the exact cause of low sperm count. 

**Ideally your husband should consult an urologist for proper treatment. He will be able to find out the causes of low sperm count and treat them effectively.

16. J. D’S. Mangalore

*I am 28 years old and married for 6 months. My wife is 26 years but she is underweight (44kgs.) I am scared to have sex as I feel my weight will be too much for her. And this feeling makes both of us uncomfortable. Moreover she is having fear that it will pain for the first time.  So far we have only attempted for intercourse but never succeeded. We have a plan to have a baby by this year end.

Please advise if being underweight will cause any problems in conceiving or during delivery. Will there be any effects for her or our baby. Will having mental fear be an obstacle in having successful love relationship.

What kind of food can she have to gain weight?

** Though your wife has less weight for her age, it need not be a hindrance for normal physical union. I hope you know, during physical union all the weight of the man is not put on the woman. You may adopt a position which will not thrust any weight on her.

Initially there can be mild to moderate pain during physical union. You will have to spend enough time in foreplay so that your wife reaches full arousal.  She may consult a gynecologist if the pain persists.

If your wife has thin constitution, it may not be possible to gain weight. Good diet and regular exercises like walking might help to some people to put on weight..

However, some lean individuals might gain weight by sincere efforts:

One has to look for a healthy weight gain, not just adding body fat. That means, instead of loading up on junk foods and high-fat nutritional nightmares like cookies and candies, treating oneself to nourishing foods that will help to add muscle and body mass. Here are a few tips:

Eating three meals every day: Yes, this means one need to get up in time for breakfast that he/she can't skip lunch, and that dinner actually needs to be prepared and eaten. 

Eating three snacks every day-midmorning, mid-afternoon and evening. In order to gain weight, one needs to fuel the body at regular times. The easiest way is to set up a schedule of three meals and three snacks. 

Stop drinking non-caloric beverages. That includes diet soda, and plain coffee or tea. Choose skim or 1 percent milk (To gain weight one needs healthy calories, not fat, so avoid milk with higher fat contents), 100 percent fruit juice or sports drinks. 

Choose calorie-dense foods. That means eating potatoes, corn or peas instead of celery and banana chips. Read food labels for the serving size and the calories, and make it a habit to routinely choose foods that are higher in calories. 

Expand the meals. Each meal should include some type of starchy food (rice, bread, potato, and cereal), fruits and vegetables, and a protein source (chicken, red meat, fish, legumes, eggs, cheese). Use two or three teaspoons of margarine or salad dressing with each meal to add moderate amounts of fat without going overboard. 

Exercise. Regular exercise and activity will help the body gain muscle and not unwanted fat. Thirty minutes of daily activity is plenty to get the system moving yet not so much that one is burning up tons of calories. If one is more active, he/she will need to increase the calorie intake. 

17. J. S. Udupi

I am 25 years of age. My first child is 2 years old and I still continue to breastfeed him. Now I am planning to have a second child and I wanted to know if can continue breastfeeding even after I am pregnant or will it have an effect on the unborn baby.

**There is nothing inherently wrong with breastfeeding till the child is three years or more and in most cultures children are breastfed much longer. It does not interfere with them in learning to use a cup or to be self sufficient. It is natural, beneficial, and can be a wonderful experience for both mother and child. It is our culture here that has made extended breast feeding something negative.

The child should be exclusively breast fed till the age of 6 months and can be breast fed till 12 months to 18 months. After 6 months of age a combination of solid foods and breast milk should be given until the baby is at least 1 year old. Some experts feel that there is nothing wrong with feeding a child breast milk until well into the toddler or even preschool years, as long as both the child and mother are comfortable with the situation. However, it's important to note that after 1 year, breast milk alone does not provide all the nutrients a growing child needs; solid foods must become a regular part of his diet.

As you are planning for a second child, it may be better to wean the present child from breast feeds. There is no harm in breast feeding the previous child even when the mother is pregnant for the next child.

18. E.S., Mangalore

*I am a lady aged 42 years; married for 13 years. My husband is 47 years of age. We live together. We have 2 kids. My husband has very low sex drive from beginning. We share a very good relationship as parents but sex life is killing me and gradually affecting badly my daily life. What may be done to increase the sex drive of my husband?

** As you are sharing good relationship with your husband, it may be better to discuss the issue of low sex drive in him and to consult an urologist. The specialist might advise certain tests and prescribe necessary drugs. Now there are effective medicines to overcome the problem if it is physical.

19. M. R., Mangalore

*I have received message from my friend as follows:


A 10 years old boy, had eaten panipuri about 15 days ago, and fell sick, from the day he had eaten, later when he had his health check done doctors diagnosed that he had AIDS, his parents couldn't believe it...? Then the entire family under went a checkup none of them was suffering from that. So the doctors checked with the boy if he had eaten out? And the boy said he had panipuri that evening. A group of doctors from the hospital went there to check. They found the panipuri seller had a cut on his finger while cutting the onions, his blood had spread in food, when they had his blood checked... the guy was suffering from AIDS but he himself was not aware. Unfortunately the boy is suffering from it."

Please clarify eating road side or hotel/restaurant will spread AIDS.

** No, one can not get AIDS through the food possibly mixed with HIV infected blood. AIDS is caused by HIV viruses. These viruses are very sensitive and do not thrive in the open atmosphere for more than few minutes. AIDS is infected by direct contacts where infected fluid from one person gets into the body of another. AIDS spreads mainly by sexual acts when one of the partners is already having the viruses in his body. Initially there were some incidences where HIV infected blood was transfused and the disease was spread to healthy recipients. Now there is strong legislation, and no blood or blood constituents can be transfused unless they are tested negative for disease causing agents like HIV viruses. Rarely HIV might be contacted through the needles pricked to the infected person. This is possible if such needle is pricked to others within few seconds. This is one of the common modes of transmission of the disease among intravenous drug abusers who share the same syringe and needle. 

AIDS does not spread through mere contacts like hugging, shaking hands, kissing on the cheeks etc. It does not spread by sharing utensils, food, water or linen. 

Even if a person without any oral sores swallows the infected blood, he is unlikely to get AIDS as the blood as well as viruses are destroyed in the stomach juices. But if an infected person bites a normal person and causes deep wounds, the normal person might get the disease.

While eating in the restaurants one need not worry about getting infection of HIV through food. (There are host of other diseases that might be contacted by eating food prepared and served in unhygienic conditions mainly in the road side food joints)

20. S. D. Dubai

* I am 35, I have been tested for low sperm count and doctors gave me some tablets one is which clome 25 (clomifene tablets IP). When I searched for information in net about this I found out that these tablets are linked to female fertility. I have some doubt about this. 

** Clomiphene citrate is commonly used to treat ovulatory problems in women; however it has been shown to be effective in some men with problems of infertility. Clomiphene belongs to class of medications known as anti-estrogens. As an anti-estrogen, clomiphene citrate interferes with a biochemical process called feedback that regulates the amount of gonadotropin releasing hormone (GnRh) that is released from the hypothalamus. Clomiphene citrate’s affect upon the hypothalamus leads to an increase in GnRH output. The pituitary gland responds to the GnRH by increasing the amount of follicle stimulating hormone (FSH) and luteinizing hormone (LH), which are responsible for stimulating testosterone and sperm production. In theory the net result is an increased sperm count. Clomiphene citrate is available in pill form and is taken for up to 6 months to see an improvement.  A daily dose of 25 to 50 mg is the current recommended dose.

Dr. Edward Nazareth

Dr. Edward Nazareth

Dr. Edward Nazareth: Born December 28, 1958. Dr.Nazareth holds medical degrees - M.B.B.S. (1982 Mysore Medical College, Mysore), D.Ortho (1986 Mysore Medical College, Mysore) M.S.(Ortho.) (1987 Mysore Medical College, Mysore).

At present Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Fr. Muller’s Medical College, Kankanady, Mangalore-575 002.

He is a resident of Kankanady.

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