15 March 2010
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
She now has a daughter of her own. She is 2 years old. She is developing the same symptoms that my daughter had. She is being treated for eczema, not helping much. She is in a day care, and some of the children had a stomach virus.... The next day she had severe diarrhea and blotchy rash. Any place the diarrhea touched her bottom, her bottom was red like a burn. From crying and rubbing her eyes, she had a blotch on her eyelid. She puts her fingers in her mouth, and her hands and fingers look terrible, sore looking and blotchy. And the rash itches terribly. As soon as the diarrhea cleared up so did her rash, not completely but 80% better. We've noticed that whenever she gets sick, she breaks out in a rash and it clears when she is better, but it is always underlying.
Dr. L passed away many years ago, and we haven't been able to get a doctor to believe this allergic reaction to her own germs thing. If she sucks her thumb, that gets sore and infected, runny nose, blotches on the face, etc.
Have you ever heard of this? If you have, what is the medical term for it?
Thank you so much for listening.........
-DF
Dear DF: The allergic response is actually mediated by the same immune system that fights off infection. It is a different kind of immune response. Hives, which is an allergic manifestation, is a well known response to infections, so it is not at all far-fetched for a child to develop allergic rashes in response to infections; however, since you did not describe classic hives (urticaria), I am not sure what Dr. L's diagnosis was. And while some children experience hives in response to some infections, I've never had a patient who developed a rash with every illness. Finally, since there are no treatments which cure colds or viruses, it is difficult to know the significance of your daughter's rash clearing in response to cold medicines; however, many cold medicines have antihistamines which help to block the allergic response.
With regard to your granddaughter now having many of the same symptoms as her mother, sometimes it is difficult to separate allergy from other types of reactions. Many children with sensitive skin will get a diaper burn almost instantly from diarrhea, and rubbing their eyes or sucking their thumbs could easily affect the skin adversely without allergy playing a role. In any event, I'm not sure the issue of allergy is crucial to treating the rashes since viral infections cannot be cured and must run their course leaving only local skin treatment to resolve the rashes. I suppose an antihistamine might play a role if there is a definite allergic component, so besides consulting a dermatologist, you might consult an allergist.
Sincerely,
Dr. Warren
My doctor has done two urine tests, but not cultures. He sent my child for spinal X-rays (were normal) because he said the spine could be pushing on the bowels then bladder. He put him on Miralax, (I told him BM's were normal) I had to take him off because he was having diarrhea.
He wants to send him Friday for a bladder and kidney ultrasound and an EKG (to put him on Tofranil). He said if none of this helps or shows anything he wants him to have an MRI to check for tethered cord.
My child has none of the symptoms for tethered cord. Is all of this overkill? My insurance is terrible and I am a single working Mom trying to keep my head above water.
If my child needs anything, I will get if for him, but this all sounds kind of strange to me.
-(unsigned)
Dear Parent: It is always difficult for me to question the treatment or recommendations of another physician since he has seen the patient and I have not. Your choice of words, "My 4 year old boy is leaking urine almost everyday." rather than saying, he wets himself, or has accidents, suggests an anatomic abnormality which causes leakage. Of course, I may be over interpreting your choice of words.
A renal and bladder ultrasound is a reasonable test to be sure there is no obvious abnormality. The EKG is recommended before starting Tofranil since there may be some cardiac toxicity. Tofranil is no longer the first line treatment for bed wetting since it has more side effects than DDAVP; however, Tofranil cost less than DDAVP. I'm not sure that either medication would be helpful for daytime wetting.
Before proceeding with an MRI or medicating with Tofranil, I'd suggest consulting a pediatric urologist. Again, I'm reacting to your description of the problem, but I'd rather see you spend your money on an appropriate consultation than try medications which are not indicated for daytime wetting or go for an MRI (which is benign, but likely more expensive than the urology consultation and may not provide any answers).
Sincerely,
Dr. Warren
y child visited a pediatric urologist on Friday. He did a ultrasound of the bladder right in his office and said everything looked great. He told me to get rid of the diapers at night; that I was allowing way to much liquid and assured me that the leaking was not an uncommon problem. For two nights my child has not leaked or wet the bed for the very first time. It all cost me $30.00. Thank you so much.
In a world where nothing is free you are such a generous doctor to give so freely of your time. God bless you!
-(unsigned)
Thank you for your time.
-Deirdre
Dear Deirdre: I have never heard of a lazy palate, but it is true that if we wait long beyond the optimal time to introduce new things to infants and toddlers, they may become set in their ways. Some kids are more resistant to change than others. You might consider consulting a speech therapist (speech pathologist) to evaluate her oral mechanism (musculature of the mouth and jaw) to be sure that your daughter is capable of handling real food. If she is, I suggest you start making it available to her in the form of finger food which she can pick up and feed herself. Start off with soft items like cut up ripe banana, Cheerios in milk, cheese, or well cooked pasta. Place them on her tray and let her eat what she wants. Do NOT pressure her to eat. If provided the opportunity to eat real food regularly, most children will find something they like. It is certainly more palatable than jarred food. In the meanwhile, if she eats it, it is perfectly okay to continue giving her stage 1 foods.
32 ounces of milk a day should meet your daughter's basic nutritional needs, although it will not provide all the necessary vitamins and minerals like formula does, and it lacks fiber which is an important ingredient in a mature diet. Unfortunately, 32 ounces of milk a day may be enough to satisfy her hunger and eliminate any urge to eat. You then may have a child who's developed the habit of living on bottles and eating no food at all. Therefore, it may be necessary to cut down on your daughter's milk intake and let her experience hunger in order to make any headway with solid food.
Although the article does not deal with your daughter's type of feeding problem, I'd suggest you read my article, Nutrition Without Tears, for the principles of nutrition and general advice it contains.
Sincerely,
Dr. Warren
Thank you.
-Nayela
Dear Nayela: I have never heard of "Devil Spots." I suspect it is a layman's (nonmedical) name for some condition which is seen in Egypt. It may even be a term for a condition known in the United States, but the term is not used here. You need to ask your doctor to explain exactly what your daughter's condition is - the exact medical diagnosis (correct medical terminology), the risks to her, the natural course, anything you should be watching for, any treatment necessary, what monitoring is necessary, and at what point further intervention is necessary. I cannot give you any reassurance based on a normal CBC with a hemoglobin of 10. Your daughter is anemic and your doctor is obliged to find out why. If it is related to abnormal blood loss due to bruising, then further evaluation for the cause of that is necessary. I would advise consulting a hematologist.
Sincerely,
Dr. Warren
I'm worried, well very worried about my 6 year old daughter. She is passing blood in her stools. I only found out as I went to the toilet after she had been after a few hours and there was still blood sitting in the bottom of the toilet bowl (after it had been flushed). When talking to her she said she had been bleeding anally for a while. She eats vegetables and fruit on a daily basis so I don't think it can be constipation. She isn't overweight and is an active child, and normally a very happy child but of late hasn't been herself. I put this down to her growing up, but I have to say I'm worried... but before I worry her and take her to the doctor which she has seen rarely since birth, I would like a basic opinion whether I need to increase her dietary intake or can help her before I scare her.
Thank you for your time.
-YS
Dear YS: It is not necessarily frightening for a child to see a doctor for an illness. In any event, I cannot recommend dietary changes as a means to deal with rectal bleeding without a diagnosis. If you are seeing bright red blood in the toilet, the most likely cause would be an anal fissure or hemorrhoid; however, both are often related to constipation. Your description of finding blood in the bowl after it had been flushed (you didn't mention stool) concerns me because it suggests a large blood loss. Further, your statement that "of late she (your daughter) hasn't been herself," adds to my concern that your daughter may be having significant blood loss. The cause doesn't have to be serious. It could be juvenile polyps or a Meckel's diverticulum neither of which is deadly, but both of which require treatment, sometimes urgent. Get your daughter to a doctor without delay.
Sincerely,
Dr. Warren
Thank you for you time and consideration.
-AA
Dear AA: You are on the right track in dealing with your son's hitting behavior; however, you need to have realistic expectations about what you can accomplish and what time frame will be required to accomplish your goal. Unfortunately, there is no behavioral management technique which causes instant results at any age. At 17 months you're dealing with a child who doesn't understand cause and effect or consequences. In addition he lacks the self control to refrain from acting on his urges. The most you can expect to accomplish at 17 months is to consistently respond to his behavior so that he learns what to expect as a response. In time, you will accomplish your goal. At this point you must do the following:
Remove him from any situation in which he is hitting other children. Do not permit him to return to the activity until it is clear that he has calmed down or has been sufficiently distracted as to redirect his behavior. While this is not an immediate solution, it is what is expected of you socially and it will eventually teach him that he will be removed from all social situations in which he lashes out by hitting. There are no gray zones on this matter. Violence is not an acceptable behavior to express frustration or deal with problems, even if it appears that your child's response has been provoked; however, if it has been provoked, he needs your clear and decisive intervention to deal with the problem he can't solve. He must also learn acceptable ways to deal with his frustration, and it is up to you to help him find these ways. At 17 months he won't be verbal enough to express frustration with language or resourceful enough to find solutions to his frustration, but he will learn by your responses and solutions to do things such as finding another toy he can enjoy when he can't have the one he wants, or go off by himself to calm down when he can't deal with a difficult person.
Make time out and restriction of his hands quick enough in response to his hitting for him to associate it with his behavior. Make it brief enough to fit the attention span of a 17 month old so that it doesn't become the source of additional frustration.
Don't give him his way to avoid situations where he hits or because he is hitting, but don't forget that your goal is to change his behavior, not to punish or respond to your own frustration. While you want to avoid rewarding this behavior, there's nothing wrong with distracting him from it and trying to redirect his attention to something else. In fact, that is what you want to teach him to do himself.
Make sure you are providing him with attention and dealing with potential problems when he is not hitting so that he doesn't learn to use that as a means to get your attention.
Children don't have to be taught to hit. They come to this naturally as a means to express frustration and defend themselves. To a 17 month old, not getting his way is something he has to defend himself against. With patience and consistency, you will teach him otherwise.
Please read my article, Managing the Difficult Child: Toddlers.
Sincerely,
Dr. Warren
-S
Dear S: You're describing a skin condition of the head of your penis, essentially a rash. It's hard to diagnose and treat rashes without seeing them. If you know for sure that it's not an STD you have to consider the following: could it be a result of the yeast infection, or a reaction to the medication for the yeast infection, or a reaction to your condoms or any birth control method you are using? Since you describe the rash as dry, rubbing in a moisturizer daily after your shower may help. If not, you'll have to show it to a doctor for diagnosis and treatment.
Sincerely,
Dr. Warren
My question is: Several times after having intercourse with my husband I have some bleeding. I had a hysterectomy when I was 28 and now am 45. I finally got a mirror to find out where the bleeding was from and found knife like cuts between the vagina and anus area. I guess that's the perineum. Anyway, we have no rough sex but I'm wondering if the tissue is thin and tears which looks like cut marks up and down.
Please help me with this. Thank you.
-Sharon
Dear Sharon: If your perineal area is raw and cut up, it does not require rough sex in order to bleed; however, if the bleeding occurs every time you have intercourse and only when you have intercourse, it stands to reason that you may need to abstain from intercourse long enough for it to heal and reevaluate your sexual practices to see if anything about your position during intercourse or your foreplay is causing injury. You also need to adopt some skin care measures to speed healing. While I could suggest sitz baths (warm soaks) and a bland ointment like A&D, my best advice would be to have your doctor (GP, internist, or gynecologist) or a dermatologist look at the area.
Sincerely,
Dr. Warren
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