MMR and V (two visit), MMR+V (one visit) or MMRV (one visit)

My baby #3 turns 1 today. 

This means that he will be due for his Measles, Mumps and Rubella (MMR) vaccination in accordance to the Singapore National Child Immunisation Program. We can opt for this MMR vaccine or for added convenience MMR+V (MMR and Varicella in two separate injections) or MMRV (MMR and Varicella in one injection). Varicella is also commonly known as chicken pox.

We had made an appointment with the government polyclinic for the MMR vaccination not only because this is the free (fully subsidised) option but this option poses the least risk for fever and fever induced seizures (fits). We will do the Varicella vaccination 42 days later.

	MMR and Varicella Vaccines (Administered 42 days apart)	MMR and Varicella Vaccines (Administered at the same doctor visit)	MMRV Vaccine
Protection against measles, mumps, rubella and varicella	No protection for Varicella until after Varicella vaccine is given	Provides the same protection against the four diseases as the MMRV vaccine	Provides the same protection against the four diseases as the MMR and varicella vaccines
Number of shots	Two shots separated to two doctor visits	Two shots needed at the same doctor visit to provide protection against measles, mumps, rubella, and varicella	One shot needed to provide protection against measles, mumps, rubella, and varicella
Fever within 42 days being vaccinated	1 out of every 6; ; the highest risk for fever is during 6-14 days after vaccination	1 out of every 6; the highest risk for fever is during 5-12 days after vaccination)	1 out of every 4; the highest risk for fever is during 5-12 days after vaccination)
Febrile seizures(Seizures caused by fever 5 to 12 days after vaccination)	1 out of every 3500 for MMR; none known for Varicella	1 out of every 2500	1 out of every 1250

Source: US Centers For Disease Control and Prevention

For a doctor's visit

In order to help doctors make better diagnoses and / or treatment of our health condition, we need to provide as many relevant information as possible.

This is a checklist that I use for a doctor's visit; especially when my husband is bringing the children to see the doctor without me. 

Blood glucose monitoring

“Canola oil-enriched diet may benefit people with diabetes” and “Canola Oil Helps Fight Type 2 Diabetics: Study” – headlines like all headlines grabbed my attention. But when I read further, the study¹ compared two groups of participants - (1) a low-glycaemic index diet with a canola oil–enriched bread provided as a supplement (test) and 2) a high wheat-fibre diet emphasizing whole-wheat foods. Further details - the test diet included 4.5 slices of canola oil–enriched whole-wheat bread whereas the control diet included 7.5 slices of whole-wheat bread without canola oil per day. And so, it’s not just canola oil.

I was diagnosed as having gestational diabetes at week 32 of my pregnancy with my #3. Being on the lower end of glucose intolerance (my reading was 8.0 slightly above the cut-off 7.8mmol/L for 2-hour 75g OGTT), I only had to do some diet changes, no drugs, no injections. But that alone was so so so hard. I went through dietary counselling with a nutritionist and was taught on carbohydrate exchange. I had to monitor my blood glucose level to ensure that it is between 4.4 to 5.5 mmol/L before meals and 5.5 to 6.6 mmol/L 2 hours after meals, 7 times a day for 2 consecutive days a week. The blood glucose monitoring allowed me to tweak my diet, know what and how much I can eat.

Recently, my friend Lynn was diagnosed with gestational diabetes at week 25 of her pregnancy. Lynn, below is the blood glucose monitoring record that I had used.

• Record the readings in the ‘Pre’ and ‘Post’ columns. ‘Pre’ and ‘Post’ refer to before meals and 2 hours after completion of meals, respectively. The ‘Late night’ reading is the one taken at three hours after completion of dinner.
• Record the time upon completion of a meal in the ‘Time’ columns. The ‘’Time +2H’ is the time that the ‘Post’ reading should be taken and the ‘Time +3H’ refers to the time for “Late night’ reading.
• The yellow bars are for dietary recordings, in particular, foods that contain sugar or will breakdown to sugar in the body
• If a reading falls out of the target reading, alter your diet and monitor until you achieve target readings for two consecutive days. 

 For example:

Reference

1. Effect of lowering the glycemic load with canola oil on glycemic control and cardiovascular risk factors: a randomized controlled trial. Diabetes Care. 2014 Jul;37(7):1806-14

Ibuprofen dosage chart by weight

I don’t take ibuprofen, probably because paracetamol is good enough and works for all my fever and headaches. Ibuprofen belongs to the same class of drugs as aspirin, mefenamic acid, naproxen sodium and diclofenac – they are NSAIDS (pronounced as 'and-saids') – non-steroidal anti-inflammatory drugs. Since inflammation results in pain and/or fever, thus these drugs treat pain and fever by reducing inflammation. They are the second choice if paracetamol does not work well probably because these drugs may cause gastric discomfort (though newer generation NSAIDS have lesser risk of this). That’s why it is usually recommended to take after food or together with antacids.

My mom is allergic to paracetamol thus she takes mefenamic acid for all her fever and pain. My husband is allergic to diclofenac and avoids this but he had used diclofenac cream before (unknowingly once) and showed no signs of allergy.

I give my children ibuprofen syrup when their fever is not well controlled i.e. fever comes back before the next dose (6 hours later) or high fever (temperature more than 39°C. I am guilty of sometimes giving ibuprofen to my children because they refuse to take Paracetamol, the strawberry flavoured syrup is too bitter, they like the ‘orange colour’ ibuprofen syrup. The alternating ibuprofen-paracetamol dosing every 4 hourly is also a good way to control fever, this has been reported in a clinical trial¹ to be better than using either on its own.

There is a note of caution for ibuprofen - Do not use in infants less than 1 year old, unless advised by your doctor.

The oral dosage for fever is 5 to 10 mg/kg body weight. To be taken every 6 to 8 hours, not more than 4 doses a day. Like my earlier post on paracetamol dosage by weight, I too have a chart for ibuprofen dosage by weight.

If you’d wish to use this chart, here is a step-by-step guide.

1. Weigh your child, measurement should be in kilograms (kg). To convert from Pounds (lb), divide by 2.2.
2. Check the strength of your Ibuprofen syrup. Some clinic assistants do not label the strength, always ask. This syrup is most commonly available in the 100mg/5mL strength
3. Refer to the chart for the corresponding volume. You may give an amount between the lower and upper limit.
4. Shake the bottle to disperse the liquid and draw the correct volume using a syringe.

Common trade names for Ibuprofen are Brufen, Advil, Nurofen. If there are more, please leave a comment.

Reference

1. Paracetamol and ibuprofen for the treatment of fever in children: the PITCH randomised controlled trial. Health Technol Assess. 2009 May;13(27):iii-iv, ix-x, 1-163.

Paracetamol dosage chart by weight

Someone from the army once told me "Take Panadol (paracetamol), it will cure your illness if you are sick, if you are not sick, it will boost your health". That statement of course is not true but was probably meant as a cynical joke to how commonly prescribed this medicine is.

The adults in my home use it to treat fever and headache. Yes I have a policy that at the slightest headache, don't wait, don't sleep it off, it will not get better, just take two 500mg tablets, period.

I give my children paracetamol to treat fever, when temperature is more than 37.5°C. I would fumble with the phone calculator, checking to make sure that I give the correct volume according to the strength of the medication and the dose by body weight. After countless times doing this, with my third kid turning one soon, it just dawned on me that I should just make a chart and refer to it. So here it is and this gets printed, sealed in a plastic sheet and placed in the medicine cabinet. And my husband no longer needs to guess and estimate the right dose to give.

Why is the right dose important?

Too little and it will not be effective, the fever will not subside. Too much (this amount is very high) and it may cause harm to the liver.

The oral dosage for fever is 10 to 15 mg/kg body weight, not more than 3750 mg/day

To be taken every 4 to 6 hours, not more than 5 doses a day.

When my child develops fever before the 6 hours is up, I will then supplement with ibuprofen, more about this later.

At the correct dose, the fever should subside within 1.5 to 3 hours.

If you’d wish to use this chart, here is a step-by-step guide.

1. Weigh your child, measurement should be in kilograms (kg). To convert from Pounds (lb), divide by 2.2.
2. Check the strength of your Paracetamol syrup. Some clinic assistants do not label the strength, always ask. Common syrup strengths are 120mg/5mL and 250mg/5mL.
3. Refer to the chart for the corresponding volume. You may give an amount between the lower and upper limit.
4. Shake the bottle to disperse the liquid and draw the correct volume using a syringe.

Common trade names (brands) of Paracetamol are Panadol, Dhamol, Tylenol. If there are more, please leave a comment.