17 January 2000

1. Aspirin for Kawasaki
2. Fever (or Not), Asthma
3. Asthma vs. Croup
4. Persistent Abdominal Pain
5. No Longer Potty Trained
6. Henoch Schonlein Purpura (HSP)
7. Penile Rash After Intercourse
8. Dangers from Pesticides on Apples?
9. Disclaimer

• Read Questions & Answers in Another Column

Aspirin for Kawasaki

-FC

Dear FC: If your nephew took 5 aspirins every 4 hours, even if he took them in the middle of the night, his maximum daily dose would come to 30 aspirins. The correct dose depends on the child's weight, but since children with Kawasaki syndrome sometimes require higher doses of aspirin to keep the salicylate level in the therapeutic range, the best way to determine if he is receiving the correct dose is to measure his salicylate level.

The initial management of Kawasaki syndrome includes IV gamma globulin to prevent coronary artery complications. Initially, high doses of aspirin are required during the acute symptoms. After that, lower doses are required for at least 8 weeks, or until the platelet count and sedimentation rate are normal. Management must include a cardiology consult and cardiology follow up with echocardiograms to check the coronary arteries.

Sincerely,
Dr. Warren

Thank you for your web page.

-TG

Dear TG: A temperature of 99.1 is entirely normal and need not cause you any concern.

You might wish to review the use of albuterol with your physician. Albuterol controls, but doesn't cure wheezing. If your son has ongoing wheezing, giving the medication once a day may not control it since the duration of action is 6-8 hours. If the albuterol makes your son hyper, you may need to discuss other treatment options with your doctor. If your son is taking the syrup, switching him to the spray may provide better treatment with less side effects.

Sincerely,
Dr. Warren

Thank you.

regards

-AN

Dear AN: Wheezing occurs when there is constriction of the bronchial tree, either as a result of bronchospasm (spasm of the smooth muscles which control bronchial diameter), or as a result of mucus or inflammation in the bronchial tree narrowing the airways. Breathing in expands the chest and the bronchial tree. Breathing out collapses the chest and the bronchial tree. As a result, when the airways are narrowed it becomes more difficult to force air out. The air exiting through the narrowed airways causes a whistling sound known as a wheeze. Wheezing may be associated with bronchitis, accidentally inhaling an object into the lungs, bronchiolitis, cystic fibrosis, asthma, etc. Asthma is by far the most common cause of wheezing. Asthma is an inflammatory condition of the lungs which results in recurrent episodes of wheezing. For more information read my five part series of articles about asthma. The links to these articles and many others can be found on my Web site at http://www.askdrwarren.com/articles.htm.

The bronchial tree, which is the lower airway, is entirely in the chest. The trachea (windpipe), which is the upper airway, is in the neck, outside the chest. The physiology of upper airway obstruction is the opposite of lower airway obstruction. When air is forced out from the lungs through the trachea, the trachea expands somewhat to accommodate the airflow; however, when the trachea is narrowed by inflammation, the suction from air being pulled into the lungs collapses the trachea making it is more difficult to breathe in. This can result in a crowing noise during breathing in. This is called stridor and sound quite different from a wheeze. The most common cause of stridor is croup, which is a viral infection that causes inflammation in the trachea. Children with croup develop a barking cough and noisy, sometimes labored, breathing. For more information about croup, read my article Croup.

Neither croup nor asthma are "do it yourself" treat at home projects if a child is having difficulty breathing. Mild croup can be treated at home with steam, but difficulty breathing which doesn't respond quickly to steam requires immediate medical attention. Both croup and asthma have the potential to be serious emergencies. Therefore, if you don't know what your child has, you must call the doctor. Asthma requires prescription medicines, and since it is a chronic disease, parents must become educated in its management and work out a treatment program with the doctor. As asthma symptoms change, the treatment must be adjusted with the advice of the physician. Any severe symptoms should be reported immediately. While medications shouldn't be delayed awaiting the doctor's call, parents shouldn't undertake treatment of symptoms whose severity is greater than their experience without contacting the doctor.

Sincerely,
Dr. Warren

The doctor checked him out and said maybe he had hard stools and was tearing when he had a bowl movement. We gave him more water, fruits, vegetables and psyllium husks in his cereal, also aloe vera juice before meals to help with digestion. There is no more blood in his stool but he is always burping and one day he threw up just a little bit four times. And last night he had pain about one inch diameter around his navel he said it felt like someone squeezing your arm only in his stomach, then like needles going in. It lasted for about 2 minutes. We are very concerned.

Thank you in advance.

-Phyllis

Dear Phyllis: It sounds like it's time for your son to be reevaluated by his doctor. There are so many causes of abdominal pain, I wouldn't even try to guess what your son has. Burping and nausea with abdominal pain are more characteristic of reflux, peptic ulcer disease, and food intolerance than constipation. In any event, persistent symptoms tell you there is a need for reevaluation and further diagnostic testing.

Sincerely,
Dr. Warren

I would appreciate any advice. Thanks.

-KB

Dear KB: If your daughter were wearing diapers again because of accidents, certainly the possibility of a UTI must be considered after a catheterization. But there is nothing about your daughter's refusal to use a toilet which would suggest UTI. Your daughter has been through a traumatic experience and is trying to reestablish control over her world. She may be finding a sense of comfort and security in regression. Even without a traumatic experience, regression in little ones is common. A few weeks of being potty trained is too short for her to have forgotten her sense of comfort at being a baby. Be patient. Encourage her to use the potty. Remind her how well she did and how proud of her you were. But try not to butt heads with her over this. If she comes into the bathroom or sits on the potty, praise her, but don't pressure her to succeed on the bowl. Eventually it will happen.

Sincerely,
Dr. Warren

Everything seems so vauge: Sometimes it last a few weeks, sometimes problems occur for years. One source says there is renal involvement in 80% of the cases, another source says 30%. We just don't know what to believe.

Our doctor seems to be taking it lightly, but from what I've read she should be monitored pretty closely (UA, BUN, Creatinine, etc).

Any thoughts you have would be appreciated.

Thanks

-Mr. & Mrs. BM

Dear Mr. & Mrs. BM: The cause of Henoch Schonlein Purpura is unknown, but the symptoms are caused by a vasculitis (inflammation of blood vessels) of small blood vessels. Allergy or drug sensitivity may play a role in some cases.

Many organ systems can be involved. Since the diagnosis requires the rash, by definition, skin involvement occurs in 100%. Arthritis occurs in 2/3 of affected children. Gastrointestinal symptoms, mostly abdominal pain, occur in 2/3 as well. Kidney involvement occurs in 25-50%, and is potentially the most serious manifestation. Other organs, including the central nervous system are rarely involved.

There is no specific treatment. Acute symptoms may sometimes benefit from corticosteroids. Later management depends on what specific symptoms are involved. Urines should be followed, and if abnormal, a kidney specialist should be consulted. A rheumatologist can advise on the management of joint symptoms.

If there are no serious problems during the acute stage most children recover completely within 4-6 weeks, but some have subsequent exacerbations and remissions or persistent symptoms for more than a year. Some may develop chronic kidney disease. About 25% with kidney involvement have persistently abnormal urinalyses but their final outcome cannot be predicted on that basis.

For more information about HSP consult the NORD database at http://www.rarediseases.org/.

Sincerely,
Dr. Warren

-Alex

Dear Alex: Several possibilities come to mind for your rash. Are you using condoms? I hope so, because even if your girlfriend has only been with two other guys, if these two guys were with other girls who had been with other guys, then essentially you've had sexual contact with every disease any of them had if they didn't use protection. Sex without protection is a dangerous crapshoot because any partner who has had only one or two sexual contacts without protection could actually have been exposed to the diseases of hundreds of partners.

Anyway, back to your rash. If you are using condoms, you could be having a reaction to something in the condom or to the latex. If you're not using condoms, you could be reacting to anything you are using such as spermicidal jelly, lubricant, foam, etc. If you're not using anything, you could be reacting to something your girlfriend uses for feminine hygiene. If your girlfriend has a vaginal yeast infection, you could be getting a yeast infection on your penis, but I can't imagine that causing immediate symptoms.

Since your symptoms sound like they're in the skin of your penis (a rash), perhaps next time you should see a dermatologist and see if you can get a more accurate diagnosis. If infection is suspected, a culture should be taken, and perhaps your girlfriend should be checked by her gynecologist.

Sincerely,
Dr. Warren

-DM

Dear DM: Several years ago there was a big fuss in the news about levels of Alar being too high in apple juice. Concerns centered around the fact that studies which determined acceptable limits might not have adequately controlled for the proportionately larger amount of apple juice per pound body weight consumed by infants as compared to adults. No studies ever indicated that any children were harmed by consuming the apple juice; however, the pressure on companies selling the juice was sufficiently high to result in a decreased use of Alar. I do not remember if there were any further restrictions placed on its use. I do not know if this is what your husband heard about.

Eating apples and drinking apple juice is perfectly safe for children. The American Academy of Pediatrics recommends moderation when it comes to juice consumption. Drinking large amounts of juice can result in diarrhea with malabsorption of other nutrients. In addition, children who fill up on large quantities of juice may limit there intake of other important foods.

Sincerely,
Dr. Warren

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