18 August 2008
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
-Julie
Dear Julie: The Harriet Lane Handbook lists the average heart rate for a 5-7 year old as 100 beats per minute with 133 being at the 98th percentile. This would place your daughter's heart rate within the normal range for her age.
Sincerely,
Dr. Warren
The older daughter (9) seems to be fine now with the digestive enzymes and only complains of gas like pains occasionally that are relieved with a bowel movement. My 5 year old is still complaining although there are no more tears or sleepless nights. She complains of "Oh, my tummy aches like I swallowed a giant cake. Give me something to eat!" kind of pains about 8 times a day. She eats constantly but only tiny amounts (a bite or two). When the pain is too bad, I give her a pain med and she asks for Mylanta after almost every meal. The pain doesn't seem to last too long but does come before and after meals which are constant.
The doctor wants to have further testing by a pediatric GI specialist. He is concerned about the lack of weight gain. My husband is not convinced that the pain is bad enough to warrant the testing. Is it possible that this is just digestive? What will the specialist be looking for? Wouldn't someone who was very sick act sick? Is a lack of a gain over a 6 week period serious in a 5 year old girl?
Thanks so much.
-Jennifer
Dear Jennifer: Weight gain in a 5 year old can be so slow, that a lack of weight gain in 6 weeks may not be significant; however, after recovery from an illness, most children should regain what they've lost fairly quickly.
When you ask whether or not the problem could be "just digestive" I'm not entirely sure what you mean. That both girls benefit from enzymes to aid digestion after an illness does not surprise me, but the idea that they could both suddenly develop a need for these enzymes with no underlying cause strikes me as a bit unusual.
How bad does the pain have to be to warrant further evaluation? How sick does the child have to act for her continuing symptoms to merit further evaluation? The role of the specialist is to bring his expertise to bear on a problem that the generalist (pediatrician, family practitioner, internist) feels warrants further evaluation. Your pediatrician does not feel satisfied that the problem has been solved or that it is okay to just let it run its course. I would respect his judgment on this matter. Based on the specialist's experience, he may give you peace of mind with no further testing. If he does feel that further intervention is necessary, it does not mean that it has to be something serious. Why should your child not get help that can hasten her recovery just because the problem isn't necessarily serious?
Sincerely,
Dr. Warren
I recently found out that I may have not been takin enough Prilosec for me. I wanted your opinion on this if you don't mind. Oh and by the way , I've taken zantac for a year with about a 65% cure of my sore throat. So I know acid reflux is my problem.
I also don't eat or drink caffeine, chocolate, milk, tomato sauce, pizza, spaghetti, etc. and I have the head of my bed tilted slightly with bricks. All this has helped but (all this) hasn't cured me of my illness.
I want to know what the max dose is for Prilosec so I can start taking it. I think I need to take 20mgs or maybe even 30mgs twice a day before meals.
What do you think?
Thank you.
-Matt
Dear Matt: The usual dose of Prilosec is 20-40 mg. taken once daily. Since its action is not immediate, taking it just before meals does not provide any specific benefit. To be effective, once you start taking Prilosec, you must stay on it for a while in order for it to keep acid production down.
Sincerely,
Dr. Warren
My son complains of reduced hearing almost once in 6 months & is ok after being treated with antibiotics. He does not complain of ear pain, or has cold before this happens.
I wanted to know what could be the reason for him to have fluid in the ear. He is generally healthy & does not have frequent cold or throat infections. He goes to swimming almost 3 to 4 times a week.
You answer would be greatly appreciated. Thanks in advance.
-KSK
Dear KSK: Even though dysfunction of the Eustachian tube caused either by congestion, inflammation or enlargement of the adenoids is the most common cause of middle ear fluid and ear infections, there must be other mechanisms leading to ear infection. If there weren't, it would not be possible for children who have myringotomy tubes placed to develop ear infections. The purpose of the myringotomy tube is to aerate the middle ear, bypassing the malfunctioning Eustachian tube. Some children continue to get ear infections with tubes in place. I have never read a satisfactory explanation as to the cause.
It is possible, that even though your son does not have an obvious cold, there may be inflammation or congestion of his Eustachian tube from a viral infection or allergy resulting in your son's problem. But as illustrated above, for reasons I can't explain, ear infections can occur even when the middle ear is aerated.
Sincerely,
Dr. Warren
-A
Dear A: Unfortunately, I'm not familiar with any resources relating to physical therapy. You might find some help on that using a search engine like Lycos or Google with the query +"physical therapy" +children.
As regards my opinion, the challenge in all fields of medicine is to remember that children are not little adults. They cannot or will not follow instructions in the same manner. While a gentle hand is effective with adults as well as children, a frightened adult will respond to explanations of what to expect whereas working with a frightened child will depends on your ability to distract and amuse him and calm him. Even a cooperative child will respond better to exercises that can be made into a game. If you expect the child to do exercises on his own at home, it had better be fun.
Working with children means working with parents. That means you have to educate the parents and enlist their cooperation on any activity you do with the child. I'm not sure that I consider that a challenge, but many people who love to work with children are not that anxious to work with parents. It's a big mistake to work in any pediatric field if you don't like dealing with parents.
Sincerely,
Dr. Warren
-R
Dear R: There are so many causes of abdominal pain from functional bowel problems like constipation, to psychological (stress or anxiety), to organic diseases such as reflux, ulcer, inflammatory bowel disease, to diseases outside the intestinal tract such as kidney or bladder problems, ovarian cysts, or rare problems like abdominal epilepsy.
You haven't told me what kind of evaluation your daughter has had, but there are many non-invasive tests that could be considered such as stool culture, stool for parasites, urinalysis, urine culture, abdominal ultrasound, abdominal CT scan. If all evaluations are negative, or your doctor is not sure that any such are warranted, then you should see a pediatric gastroenterologist for further evaluation.
Sincerely,
Dr. Warren
-Very Concerned Mom
Dear Very Concerned Mom: There are two separate issues to address: The best management of your son's asthma, and the repeated respiratory infections. In young asthmatics, respiratory infections are often the major trigger which causes their wheezing. Unfortunately there is little one can do to avoid catching colds; however, given your son's problem, it's worth a try. That means that everyone handling him should make an effort to stay away when they have respiratory infections, or at least wear a mask. That's true even if the person has very minor symptoms. The fact that their cold hardly bothers them does not mean it won't have a significant adverse effect on your son if he catches it. In addition, everyone involved with your son must wash his hands before every encounter.
Antibiotics have no role in treating colds. For more information, read my article, Upper Respiratory Infections (URIs). Even though viral URIs don't respond to antibiotics, sinus infections do, and sinus infections frequently trigger or aggravate asthma symptoms. Therefore, it is important to treat any sinus infections vigorously. A consult with an ENT to evaluate your son's sinuses and upper respiratory tract might be beneficial.
Based on what you've told me, your son most likely has asthma and not some other problem, but since he has had pneumonia twice, he should be evaluated for cystic fibrosis. This can be done with a sweat test or blood work for genetic testing. You might even want to consult a pediatric pulmonologist. Although infection is the major trigger in young asthmatics, allergy may also play a role. An allergy evaluation may be in order, especially if your son has eczema. A less likely possibility to consider is a congenital heart defect causing overcirculation to the lungs aggravating the asthma. If your son has a heart murmur, even if it sounds innocent, an evaluation might be in order.
There have been several articles written recently comparing the nebulizer to multiple sprays of albuterol using the aerochamber and mask in which the spray by aerochamber compared favorably to the nebulizer. I have not read the articles, so it is difficult for me to comment on them. I suspect the intent of the articles was to point out that, in an emergency, multiple doses of albuterol by spray can be used effectively to treat an asthma attack, even in babies. That has major implications in terms of convenience, expense, and portability of treatment. I doubt that the authors concluded that nebulizers should be eliminated as a mode of treatment because the effectiveness of aerochambers has made them unnecessary. Apparently your own experience in the emergency room has shown that the nebulizer has helped treat your son's asthma when you were not able to effectively treat it at home with the spray. It is true that the medicine is the same, but the delivery system is different. A child who is wheezing severely may not be able to get enough of the spray into his lungs to clear an attack.
What's more important in terms of whether or not your son would do better with the nebulizer or spray is the issue of his preventive therapy. The articles did not compare the effectiveness of inhaled steroids by aerochamber to Pulmicort by nebulizer. If your son's preventive medication isn't getting where he needs it in the dose intended, that's a serious flaw in his treatment. I'm not saying your son's Flovent treatment isn't as effective as nebulized Pulmicort. I can't know that. While I don't have the means to study these issues, my personal experience with several infants who did not do well with the aerochamber is that they did better with a nebulizer. I would certainly consider it worth trying your son on a daily dose of Pulmicort by nebulizer and let him have the benefit of nebulized albuterol when he is wheezing.
Sincerely,
Dr. Warren
-SG
Dear SG: It is so hard for me to comment when patients tell me they had blood work and x-rays and nothing could be found. After all, there are so may blood tests and imaging procedures, and I don't know which ones were done. As a result, I don't know if everything that can be done before seeing a specialist has been done. I also don't know the nature of the pain. Is it crampy, associated with nausea? Has your son's appetite been affected? What are his bowel habits? These kinds of questions, along with an examination, help a doctor determine what organs are likely involved and what tests should be done. Besides large intestine and small intestine, right sided pain could originate from a kidney, the liver, possibly the gall bladder, and even the chest.
A 4 month wait to see a specialist for severe pain sounds unreasonable to me. Is this the only specialist available in your area? If so, I would ask your doctor to prevail upon them to give you an earlier appointment or to review the case with him over the phone and advise him regarding additional evaluation he can do until they see your son.
Sincerely,
Dr. Warren
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