3 January 2000

1. Prolonged Separation from a Parent
2. Child Started Falling a Lot
3. Babylax to Induce BM
4. Osgood Schlatter Disease
5. Questions About Ear Tubes
6. Sedation for CT Scan for Evaluation of Large Head
7. The Child Who Gets Teased
8. Big Tonsils
9. Disclaimer

• Read Questions & Answers in Another Column

Prolonged Separation from a Parent

-Allison

Dear Allison: Unfortunately, under the best of circumstances, some children handle separation badly, but it is a fact of military life, and so it should be handled without any guilt or recriminations. You should start talking to your son about the upcoming separation. Even though he may not fully understand, it will prepare him. You can help your son understand the temporary nature of separation by comparing it to Dad's coming an going now, but you must realize that at such a young age, the concept of 6 weeks or 1 year is beyond him. The 6 week separation can serve as a good experience to help your son deal with the longer separation. You can set up a calendar and let your son mark the days with you so that he can see each day passing and see when Dad will return. Plan telephone contact or other contact to come at predictable intervals so that your son can anticipate his father's "visits." Watch home movies of your son and Dad to help him maintain a sense of continuity. A few well planned gifts that your son can hold onto as symbols of Dad's love during the year away might be useful (well planned meaning something that can be cherished and have some special meaning for the father-son bond rather than something expensive).

Sincerely,
Dr. Warren

Now I know we can expect some clumsiness out of a toddler, but it seems as if he has suddenly moved backwards...he was so "steady on his feet" before and now all these falls.

Is this normal or cause for alarm?

-JM

Dear JM: One common reason for a child who walks well to start falling is that the child, who is now secure in his walking skills, starts walking faster or running, or pays attention to other things while he is walking. If that is the case, there is no reason for concern. But if your child's walking hasn't changed and there is no problem with his shoes, then a sudden increase in falling could require evaluation. There are some worrisome medical conditions which may affect balance, but some children may develop balance problems from something as common as an ear infection.

Sincerely,
Dr. Warren

-DH

Dear DH: Many healthy breastfed infants have bowel movements as infrequently as every 4 to 5 days. As long as the bowel movements remain soft and the child is not distressed, you should not set an arbitrary limit of 2 to 3 days and then induce a bowel movement. You must allow your child to develop her own natural rhythm. As long as you continue to intervene every few days, she will never develop enough of an urge to push on her own. Reserve the Babylax for desperate situations such as much longer intervals with associated abdominal pain, hard stool, and abdominal distention.

Sincerely,
Dr. Warren

-AM

Dear AM: Osgood Schlatter disease is an inflammation and partial separation of the tibial tubercle. The tibial tubercle is a bony prominence where one of the ligaments of the knee cap attaches to the bone. Generally activity only needs to be limited when there is pain. For most children, the pain will result in the necessary limitation of activity.

The pain is not generally continuous. It is unlikely that your nephew will have to take Tylenol 4 times every day for a year. Tylenol is a safe medicine when taken in proper doses. The recent reports of liver damage were a result of overdosage due to confusion of dosage forms. If your doctor said to take 2 Tylenol and he meant 325 mg tablets, and you gave 500 mg tablets, that would result in an overdose. Since the dose is based most accurately on weight rather than age, make sure you know just how many milligrams the doctor wants your nephew to receive.

For severe musculoskeletal pain, I recommend ibuprofen, but that is also metabolized in the liver and may be more irritating to the stomach than Tylenol. If you nephew's pain is severe and persistent, he may require more restriction of his activity, an orthopedic evaluation, and physical therapy.

Sincerely,
Dr. Warren

1.) At her age is it a wise decision to have the procedure done?

2.) With a 95% cure rate, why is this not recommended more often?

3.) Is it more prudent to just continue using a preventative antibiotic and hope that she grows out of it?

4.) What can happen to her if the procedure is done and she gets water in her ears from a bath or a swimming pool?

-Worried Mom

Dear Worried Mom:

1. A child who has 4-5 ear infections in 2 months while on prophylactic antibiotics is certainly a candidate for tubes at any age, especially after 2 years of conservative medical management.
2. Many parents who've had tubes put in their children's ears have been so impressed with the results, that they wished they'd done it sooner. But the smaller number, whose children continued to have ear infections after the surgery or whose ear problems got worse, wondered why they bothered to put their kids through surgery. Surgery is not a panacea, and while the risks of general anesthesia are small, they are real. True, antibiotic therapy has its risks as well. But surgery is a major event for both parent and child. One shouldn't embark on surgical management of a medical problem without a reasonable trial of medical therapy.
3. See the answer to question #1. I think you've already given medical therapy a reasonable trial. For your comfort, you might like to get a second opinion from another specialist.
4. An accidental splash of water in the ear of a child with tubes is not likely to cause a problem, but children with tubes cannot immerse their heads in water without watertight earplugs. Water which gets into the middle ear may cause pain and an infection.

Sincerely,
Dr. Warren

-EG

Dear EG: A head circumference of 48 cm. at 9 months is above the 97th percentile and therefore, larger than the normal range. If your daughter's head circumference has increased rapidly in a short time causing her percentile to increase she needs to be evaluated for hydrocephalus (fluid on the brain). Hydrocephalus can cause brain damage, but with early detection and treatment, the damage can be prevented. A CAT scan is an excellent way to check for hydrocephalus. Based on what you have told me, it sounds like the test should be done. If you are anxious about the sedation, you could inquire about doing an ultrasound study, but the CAT scan is probably a more definitive test.

Sincerely,
Dr. Warren

-JRG

Dear JRG: Many children with ADHD have difficulty getting along with others. It isn't that they aren't nice kids, but they can be annoying to others and can stand out as being different. As much as I adore children, I must tell you honestly that they can be cruel. Once a group of children have picked an outcast, even the nicer children are likely to join the bandwagon, since at least that way they're not the one's being picked on.

As parents, we all want to protect our kids. If there is any risk of injury, it is wise to discuss it with the teacher. But be careful about becoming overzealous about protecting your son. Excessive parental intervention does not do anything to increase a kid's popularity.

The most useful thing you can do for your son is to help him find strategies for coping. First, your son needs some allies. If he's isolated from most of the rest of the class, he's an easy target. If he can somehow win over the ringleader or instigator of the teasing, that's great, but if he can't, having a few kids who'll stay by his side will make it easier for him and make him a less likely target. You may be able to help him cultivate some friendships through after school activities and play dates.

Your son can also increase his standing among class members and increase his own self esteem by capitalizing on his strengths to do something special. For this, you can enlist the help of the teacher. Whatever special talents your son has, the teacher can help create a project which will be useful to the class that would also let your son's special gifts shine. It might even be beneficial to your son and his class to do a presentation about ADHD.

Finally, 6th grade is an excellent time for the class to do a project on tolerance, getting along, and differences. However, such a project should focus on the big picture, and your son's plight should not be easily identifiable as the sole motivating factor for such a discussion.

Sincerely,
Dr. Warren

-Jose

Dear Jose: If your brother's tonsils are so enlarged that they are causing significant breathing problems, they should be removed. Antibiotics may help if there is chronic infection, but there is no medicine which shrinks tonsils. 5 years old is not too young to have surgery. I was 5 years old when I had my tonsils taken out 46 years ago.

Sincerely,
Dr. Warren

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