Primary Complex Thread 3

[fionnah325]

^Dra.leletmd thanks god at negative po yong ppd ni baby nong binalik ko siya sa pedia niya nong monday..hindi namaga yong ginawang skin test sa kanya...pag namaga daw po positive mabuti at hindi taz sabi ng pedia niya kailangan niya pa din makita yong xray  baka daw kasi sa xray positive siya at nong nakita namin ang result normal lang ang xray niya...Ngayon si baby kasi eh hindi talaga siya nataba iwan ko ba kulang nga siya ng 2 pounds sabi ng pedia niya nan hw3 gatas niya..taz vitamins niya ceelin plus,nutrillin at growee..Minsan naman pag umaga may gana kumain pero pag tanghali at gabi na hindi na madami ang kinakain....May sipon siya till now hindi pa din nawala...Nagkakulani siya sa may neck sabi ng pedia niya mawawala lang daw yon...Im so happy kasi atleast negative ang result ng ppd ant xray ni bab...Dra.ano kaya ang kailangan kung gawin upang tumaba si baby ko?

hindi ko pa din confirm ngayon na pregnant ako kaya hindi nalang muna ako nagpa xray pati kapatid ko na kasama namin sa bahay...doc thank you so much po sa advise....

[mom_of_ryelee]

Hi po dra. Lelet. My son po is 2yrs and 5months now and 20kls prior sa pagkakaron nya ng tonsillitis. Now po 18 to 18.5kls nlang po sya dahil hirap kumain ng ilang araw. Nakwento ko po sa pedia nya na nadiagnose uncle ko na may PTB based on sputum pero negative sa xray. Nasa 5th month na sya ng paggagamot.

Di ko na po nakwento dati kay pedia dahil consistent naman pagtaas ng timbang ng son ko except recently kaya naalarm din po ako. Pina skin test and xray po sya and both are negative. Pero binigyan pa rin sya ng Isoniazid Comprilex 5ml daily for 9months. Eto po mga concern ko.

1. Sabi ni pedia anytime of the day pwede inumin pero nabasa ko po sa post nyo dapat 1st thing in the morning w/ empty stomach.

2. Bakit po aabot ng 9months? Sabi po negative naman mga test kelangan ba talaga magtake ng ganon katagal?

3. Tama naman po ba yung 5ml dosage na binigay? Parang nadadamihan po ako.

Thank you in advance.

[leletmd]

@ fionnah325:
Malakas pa ba siya magmilk? At his age kasi, dapat ang priority is solid food rather than milk. Try to make a feeding diary (list down all his food and milk intake as well as quantity for a period of 1 week) and show it to your pedia. The feeding diary will help you pinpoint what the problem is. Most of the time, hindi ang gatas or vitamins ang sagot sa pag increase ng appetite kundi ang pagbago ng feeding habits.

@mom_of_rylee:
Does your son interact regularly with your uncle? If he is a close contact of your son, that constitutes exposure to someone with PTB already so your son really needs to be given Isoniazid prophylaxis even though his xray and PPD were both negative. The Isoniazid is given to prevent him from getting infected due to his exposure to your uncle.
Tama ang dose (computed kasi yan based on weight and preparation) and tama din na 9 months ang bigayan ng Isoniazid prophylaxis. Isoniazid is best given 30 minutes to 1 hour before breakfast for better absorption.

[fionnah325]

^Doc leletmd malakas naman po siya doc sa milk 4 onz lang ang mauubos niya eh pero for one day makakaubos siya ng 16 onz....siguro po sa mga binibigay ko sa kanya na pagkain kasi iba iba din kasi ang pinapakain ko eh....thank you doc leletmd gagawin ko po yong advise mo gagawa nalang ako ang feeding diary para din hindi ako mahihirapan..thanks po again

[ysuran]

Doc leletmd. salamat po ng marami sa mga inputs na binigay mo regarding po sa case ng baby ko. pinabasa ko din po sa asawa ko yung payo mo po. Very grateful po kami sa tulong mo. Anyway, we will make an appointment dun sa nirefer nyang pedia-endocrinologist..

Yung sa meds nya po regarding sa primary, inumpisahan na po namin yung isonazid only last week, and will last for six months of medication. next meet namin nung pedia is after 3 months pa po.

yung low urine gravity po (which is caused either by diabetes insipidus or kidney problem) how serious is that disease po doc? madali lang po ba ang gamutan dun?

Thank you for giving us peace of mind. God Bless you!

[mom_of_ryelee]

Thank you Dra. Lelet for the insight. There is a regular interactions with my uncle because we live in a compound. My husband and I were hesitant to give the Isoniazid baka po kasi may side effect. Now, we are enlightened and I'll start first thing in the morning. 😊

[leletmd]

^ You're welcome. Ideally, all household contacts who are not infected yet should receive INH prophylaxis. I suggest you ask na lang your family doctor if there is a need for the adults in your family to be tested and given prophylaxis, too.

@ysuran:
You're welcome.
Low specific gravity may also be caused by excessive water intake. If sobrang lakas uminom ng tubig, nagkakaproblem din sa kidneys dahil sa water load. Were you able to repeat the urinalysis already? If low pa rin ang specific gravity, best to have her evaluated by the pedia endo. Severity and treatment kasi would depend on the cause.

@fionnah325:
You're welcome. Tama lang ang 16 oz a day of milk for his age. Dapat more on solids ang focus kasi kapag 1 year old and above.

[abyquitz]

hi dra. leletmd, ok lang po ba ang ethambutol sa young children?
Ibinibigay din po ba ito kasama ng 3 anti-tb meds?

thanks po.

[leletmd]

^ The first line medications for TB are isoniazid, rifampicin and pyranizamide. Ethambutol may be given as a second line medication or as an alternative to any of the 3 drugs I earlier mentioned if hindi pwede ibigay ang 1 sa 3 first line medications. Kailangan lang meron baseline screening for vision and monitoring while on ethambutol. Before kasi hindi binibigay ang ethambutol sa kids less than 7 years of age due to possible vision problems, but since 2006, nirevise ng WHO ang recommendations nila regarding this based on evidence na lesser ang chance ng side effects in kids compared to adults.

[dropdeaad]

Hi po, ewan ko kung may PC si LO kasi almost 7kgs lang siya for 11 months malakas naman apetite niya more on solids siya saka nagkaubo siya recently kaya pinacheck namin kung may PC siya result sa xray nodular opacities nakita saka may kulani kaya there's a big chance na may PPD siya tapos ngayong gabi hindi ganoon namula skin niya at namaga parang pag hindi mo tinitigan wala makikita positive na kaya siya sa PC non?

[radiant15]

Hello @docleletmd

My 2 kids were diagnosed last year Novemeber of Primary Complex but my question is for my youngest lang. So we started treatment right away. It's kind of a long story but i'll try my best to summarize. So his skin test was positive and xray was negative but then, our 1st pedia pulmo gave him all the 3 medicines right away kahit wala pa noon na xray results kasi nga close ang contact ng source which was the caregiver. Pero napauwi namin agad si yaya after 2 weeks of contact kaya lang since my son was just 3 months old then, he said kelangan aggressive. So we gave him the kidzkit forte 3 for a month but we were not comfortable giving him 3 medicines so we sought for a 2nd opinion given the facts read online so tama nga dapat pala 2 lang tapos yung isoniazid on the last 4 months. However, we ended the 6 months treatment last may 7 this year kaya lang super poor weight gain pa rin pero magana naman kumain (weighs 7.8 at almost 1 year, may mga nakakapa pa din kulani. So our pedia pulmo referred us to hematology oncologist just to make sure everything's okay before treating again. We did CBC and LDH. May mga lumagpas sa range but hematology oncologist said okay pa sakanya computation so he referred us back to our pedia. Pero nung nakita niya CBC sabe niya muka nga may infection so she decided to treat again.

Question is, okay ba na magtreat ulit for 6 months again? Kasi ang haba na naman. Ang naririnig lang namin naeextend hanggang 9 months. By the way here are the tests na lumagpas sa range:

LDH -346

Hemoglobin-11
Hematocrit-33.9
RBC-4.55
WBC-13, 630
Neutrophil- 16
Lymphocyte-76
MCH-24
RDW-14.3

Parang halos lahat lagpas. Bakit po ganoon? Nagworry talaga kami. 2 weeks na since the doctor prescribed primary complex medicines pero parang hesitant po kami at ang tagal na naman so takot po kami sa mga effects sa son namin. Sabe ng pedia eto daw ang nagpadecide sakanya to treat again kasi nung una yung poor weight gain and kulani hindi pa siya sold na magtreat ulit. Pero when he saw the blood works, sabe niya treat na lang daw ulit. What should we do?

[leletmd]

@dropdeaad:
You need to fulfill 3 out of 5 criteria in order to diagnose PC so even if negative ang PPD pero meron pang 3 other criteria na nafulfill then pwede pa rin madiagnose for PC. Best to ask your pedia the basis for diagnosis.

@radiant15:
Aside from the yaya, did the other adults in the household get worked up for TB? Two weeks lang ba nakasama ng baby mo ang yaya? If yes, then possible that there is another source for infection in your household.
What was the basis for stopping the meds last May?
Is the poor weight gain a new finding or did he already have poor weight gain during the time he was on the 2 meds for PC prophylaxis? How about the enlarged lymph nodes? How long na siya meron enlarged lymph nodes?
Was the chest xray repeated? The cbc shows long standing infection. Medyo low din ang hemoglobin so there is anemia possibly caused by a long standing infection or a chronic infection. One of the common causes of chronic infection in kids is PC. If you are not convinced with the PC diagnosis, you can try to get a second opinion from another pedia pulmo. If the PC diagnosis, however, is confirmed, I suggest you have all the adult household contacts worked up even if they had work up before because for your son to have PC, there must be another source of infection in your household. Kung two weeks lang kasi niya nakasama ang yaya, medyo short yun to get infected kahit na 3 month old lang siya noon at weak pa ang immune system. You need long term exposure in order to get infected with TB.

[radiant15]

@docleletmd

Doc, yup clear naman pong lahat ang buong household. We just consulted a pedia nearby and asked for a second opinion. We told her the history, showed all lab results and xray plates and readings. Brought our son with us too. According to her, huwag daw kami tumingin doon sa reference range at iba daw ang pang pediatrics. Para sakanya daw normal ang results at okay na okay si baby. We ended up the 6 months treatment last may po. We completed the treatment and while he was on isoniazid alone, talaga pong slow weight gain. Birth weight is 3.38kilos and now that he's almost 1 year old, he weighs 7.8kilos. Also, may i mention na hindi siya sakitin. Like ngayon 2 kami sa household na may colds and cough pero siya okay na okay pa din. He's exclusively breastfed plus solids. May time na lahat may sakit sa bahay pero siya ang last na magkakaroon. Sa kahapong pedia na pinuntahan namin ang sabe po isa sa mga signs is madalas magkasakit at kahit anong gamot parang ayaw matanggal. Except for the lymph nodes, slow weight gain and ito nga pong lab results, okay naman siya. So ngayon medyo napaisip po ako sa reading ninyo na parang may infection. Our original pedia pulmo considered treating again dahil nga po sa lab results.  Ano po yung sinasabi ng pedia na pinagconsultan namin kahapon na iba ang reference sa pediatrics?

[leletmd]

^ There is a different reference range for the pediatric age group. Kapag infants, mas mataas talaga ang wbc and lymphocytic predominance ito compared to older age groups. To clarify my earlier post, ang nakikita ko na possible reason ng pedia pulmo to consider treating it is because nasa high normal ang lymphocytes niya and the hemoglobin is nasa low normal range. All the rest is within the range for his age group. That points to a possible chronic infection kasi if you add up the persistently enlarged lymph nodes and the poor weight gain. The best thing to do, however, is to have your pedia pulmo explain to you what exactly in the cbc is her basis for treating again since she should be the one to offer her interpretation of the lab results.
Also, when interpreting lab results, it is best to correlate it with the history and the physical examination of the patient. Treatment kasi is not based solely on lab results.
If his birth weight is 3.8 kgs, at 11 months of age, his ideal weight should be 9.3 kgs. Are you able to empty your breast completely during your breastfeeding? Nakakakuha ba siya ng hind milk and not just the fore milk? Yung lymph nodes ba persistent na malaki ang size? Or may times na maliit? Hindi kasi mawawala ang lymph nodes. It will just decrease in size but it will always be there because it is part of the intact immune system.

[radiant15]

@docleletmd

Hi there doc! Thank you very much for a very quick response. Regarding lymphnodes, nakakapa namin 3 magkakadikit pero isa yung medyo malaki pero when the hematology oncologist tried to feel it, sabe niya for him daw hindi significant ang laki at walang 1cm. Tapos ang feel pa niya is parang namomove so hindi parang nakadikit and as what i've read online, mukang mas okay na nagmomove at hindi nakadikit? Tama po ba? Nahihiya po kasi ako bumalik sa pedia pulmo namin na nagconsider ulit ng treatment kasi i think she assumes na nagttreat na kami. Nahihiya po kasi ako bumalik to clarify kasi baka sabihin niya, after namin bumalik balik ilang balik talaga sakanya at lagi nga po akong worried sa weight gain at kulani, kung kelan siya pumayag na magtreat (when she saw the cbc and ldh results) saka naman kami naging hesitant na naman. Regarding milk consumption, it's another story. Mahina lang po siya uminom ng milk whenever he's with our caregiver. We do cupfeeding coz he has a history of lip and tongue ties which were released kaya may sucking problems po siya. But he is super malakas on solids. Super! My mom thought, payat ang built ko when i was a child so baka daw mana. So sa tingin ninyo po ba doc lelet, based sa blood results eh may kelangan iwork up sa son namin? Narelieve na nga po kami yesterday sa sinabi na our son seems fine. But your opinion is a good thing to take into consideration. Since nahihiya po ako sa pedia pulmo namin, do you think it's wise to seek for another opinion from
Another pedia pulmo?

So sainyo po, kung pagbabasehan ang cbc niya, mukang may infection? Kasi sa pagkakatanda ko, nung nakita ng pedia pulmo namin ang results, she said na parang may infection nga daw although ang namiss namin gawin is paexplaim further at idetalye ang resulta.

[leletmd]

^ How many hours siya with the caregiver compared to direct breastfeeding? Hindi ba naconsider na possible cause ng poor weight gain niya ang sucking problem niya? At 6 to 11 months of age, dapat milk pa rin kasi ang primary source of nutrition and ang solid food is complementary pa lang. Pagdating ng 12 months of age, lesser na ang milk intake and dapat more on solids na talaga.
Regarding the lymph nodes, if it is mobile and small, then it could be still normal. As I've mentioned in this thread several times, it is not always bad to have palpable lymph nodes. Marami kasing reason as to why lymph nodes increase in size and become palpable and hindi lang PC ang dahilan ng paglaki nito.
I cannot base my answer to treat or not to treat based on the cbc alone since we do not treat lab results. Everything has to be taken into consideration: history, pe and lab results all together which is why I said in my first post to get a 2nd opinion if you are not convinced regarding the earlier diagnosis.
If I take into consideration all the information you've shared so far (breastfed healthy infant with poor weight gain, palpable lymph nodes, with sucking problem due to tongue and lip ties, only 2 week exposure to the yaya with TB, had previous PC prophylaxis) then there "might" be no need to treat again. Actually, the fact that he had only 2 weeks contact with the positive yaya and there is no other source of possible infection in your household, medyo too short for him to get infected. For a 3 month old to get TB kasi (based on the 1st time there was a decision to treat him), he should have been exposed even while you were pregnant pa lang with him.
I am saying "might" because I do not know the full history of your son and I am basing my opinion based on the information you've shared.

[hun_nie08]

Hi there, nakakatuwa naman kayo doc dahil you answered as much as you can. Pero ako kasi medyo depressed nung nalaman ko na may Primary ang 11-month old baby ko. This July lang sya nagkasakit tapos malala pa..:-( nakita lang sya sa xray - sa thursday pa ang skin test schedule nya. Gaano po kaya katagal bago mahawa yun? Fault namin na di pina-xray ang yaya nya e. Pero papagawa ko na yun sa weekend. Possible din po sa labas nya nakuha yun kasi lagi sya nilalabas ng yaya nya e. Ang lose na nga ng weight ang baby ko e. Tapos parang may asthma pa sya..

[leletmd]

@hun_nie08:
It takes several months of constant exposure for TB to develop so ang first suspects talaga ay ang mga kasama sa loob ng bahay at ang mga nag-aalaga sa bata. At 6 months to 2 years of age, humihina ang immune system ng bata kasi nababawasan at unti unting nawawala ang antibodies na nakuha niya during pregnancy so mas madali talagang tamaan ng sakit at that time. This is one of the reasons why dapat naibigay on schedule ang mga primary immunization doses nila para at least may protection sila sa mga sakit na kayang iprevent with vaccination.

[hun_nie08]

Thanks doc. Waiting for result ng PPD nya on Sat. In case mag negative dun pero positive sa xray mas ok po ba na mag 2nd opinion kami?

[leletmd]

^ What were the chest xray findings (description and assessment)?
You don't necessarily have to go for a 2nd opinion if the PPD is negative. The PPD kasi is just one of the 5 criteria and there is a tendency for false negatives especially if payat ang bata. Also, the ppd only shows exposure to disease and it doesn't correlate with actual infection.
What is important is that all the symptoms and laboratory procedures are taken into consideration when making a decision whether to treat or not. If your child has been proven to have PC, everyone in the household should get a chest xray. Hindi lang ang yaya.