28 February 2000

1. Cyanosis (Turning Blue)
2. ?Allergic Shiners?
3. Cat Scratch Disease
4. Persistent Cough
5. Divorce and Custody Issues
6. Baby Looks Yellow
7. Preparing a Child for Surgery
8. Legalizing Marijuana ~ Comparison to Alcohol as a Debate Tactic
9. Disclaimer

• Read Questions & Answers in Another Column

Cyanosis (Turning Blue)

2nd episode Feb.14, both arms blue, almost to shoulder..after 7 hrs. sleep...better after rubbing.

3rd episode Feb.27, both hands greyish-blue upon waking from nap.

Baby boy presents no other symptoms, exibits no distress w/ episodes

Mother reports to have observed baby at sleep to see he is not sleeping on hands.

-F

Dear F: If the child just had acrocyanosis (blue hands and feet) one would have to consider the possibility that the baby was cold. Blueness of just the hands and feet is considered peripheral cyanosis, but blueness up to the shoulders cannot be considered peripheral. Since the cyanosis described was the most obvious, the first question is were the lips observed for cyanosis? Any large degree of cyanosis during sleep deserves further evaluation since the possibilities include heart disease, respiratory disease, sleep apnea, and seizures.

Sincerely,
Dr. Warren

-E

Dear E: Allergies may cause dark circles around the eyes, but for some children, dark circles may simply be normal. Evaluation for allergies can be done by an allergist. Testing may include blood tests or scratch tests. Scratch tests are done by placing a drop of allergen on the skin, gently pricking the skin in the area, and then observing for a reaction.

Sincerely,
Dr. Warren

Finally, my question. What could this have been? Was this handled the right way, or should it have been treated more aggressively in the beginning? I have been told that with cat scratch fever (if that is what it was), the area might have to be cut out. Is this true?

-CR

Dear CR: The main sign of cat scratch disease is swollen, tender lymph nodes in the area near the scratch. These lymph nodes may be preceded by some bumps at the site of the scratch. Treatment is generally aimed at symptomatic relief since the disease is usually self-limited and resolves in 2 to 4 months. If necessary, the enlarged nodes can be drained with a needle. Surgery is rarely necessary. No controlled studies have demonstrated which antibiotics are effective for treatment but some reports have suggested that rifampin and trimethoprim-sufamethoxazole may be effective. Trimethoprim-sulfamethoxazole is a sulfonomide and may be the antibiotic your doctor prescribed initially. It is certainly possible that your daughter had cat scratch disease. The only thing missing from the story is a description of some unusual swollen glands.

Sincerely,
Dr. Warren

Thanks

-Sonia

Dear Sonia: There are a number of causes for persistent cough including asthma, allergies, and sinus infection. If your son had wheezing, asthma is a the most likely cause. Since eating generally does not increase coughing, the possibility of an allergic reaction to food or gastroesophageal reflux must be considered.

Cough medicine provides only symptomatic relief and does not cure coughs. If your son has asthma, he needs medication that will control his wheezing. If he does not have asthma, he needs further evaluation. Therefore, your son needs to see his doctor again.

Sincerely,
Dr. Warren

In addition, if you know a child psychologist I can email for information please let me know.

Thanks.

-MB

Dear MB: There is no question that it is best for children to have an ongoing, good, predictable, and secure relationship with both parents. It is equally important when there is a divorce for the children to not become pawns in the parents' unresolved conflicts. It would be best for the child to have a home at both parents' houses which includes a life with friends as well as rules and consistent discipline.

That being said, it does not necessarily mean that the time spent in both homes should be equal, even if the custody is joint. Even though my wife and I are married and live together in the same house, my work schedule didn't allow me to be with my children as much as my wife was. On the other hand, I was always available to meet my children's needs.

At a young age, the 50/50 visiting schedule may be the best to be sure that a comfortable relationship develops and is maintained with both parents. When children start school, unless both parents live in the same general area, it may be necessary to arrange visitation so as to not be disruptive to the child's life outside the home.

Sincerely,
Dr. Warren

I'm appreciated for your help.

-Lei

Dear Lei: Many babies look yellow from carotenemia, an elevated level of carotene in the blood caused by eating a lot of yellow vegetables like squash and sweet potatoes. Carotenemia is harmless. If your baby is jaundiced, his eyes will look yellow as well. There are many causes of jaundice besides hepatitis. If you think your baby may be jaundiced, you should have him checked by his pediatrician. If he is jaundiced, some blood work will be necessary to determine how jaundiced and what the cause is.

Sincerely,
Dr. Warren

My questions are... What should Steph be told about prior to the surgery? How should her mom go about explaining to her what is going to happen to her? Are there videos, books or audio tapes to help explain to a very smart six year old what is going to happen to her and not to worry? Also is there something out there for the adults in her life not to be more afraid than she is about this? What should our concerns be and what are the risks?

-Worried Sick

Dear Worried Sick: Steph should be prepared for the surgery by being told everything that will happen to her, but this should be done on her level, and you will need the help of a professional. While you might be thinking about the complicated nature of Steph's medical condition, the complicated nature of the surgery, the risks, and the things that could go wrong, what Steph needs to know is what she will actually experience.

Yes she needs to know that she has a hole in her heart and a surgeon is going to fix it, but unless she has more questions about that, she doesn't need any more details about it. Of course, if she does have questions, they should be answered as honestly and simply as possible. But what Steph really needs to know about are things like having IV's started, having a mask over her face for anesthesia, waking up with tubes in her, when she will see Mom and Dad, what pain she might have, and how it will be taken care of. Telling her that nothing will hurt would be a disaster since she wouldn't be able to trust anything she was told when she finds out things hurt.

I said previously that you would need the help of a professional. Most pediatric hospitals offer tours to their young patients before surgery to acquaint them with the operating room. Many of these programs include demonstrations with dolls. If your hospital does not have such a program, perhaps the cardiac surgeon or his nurse can provide a little help preparing Steph or preparing you for what you need to tell Steph.

If you have Web access, please look at the section of Band-Aides and Blackboards devoted to hospitalization. There is material to help the adults and the children. You should explore the rest of the site as well to gain some insights into how children deal with illness.

Finally, ask your local librarian. Most libraries have videos now as well as books. While I am not knowledgeable on the matter of what materials are out there to help you, your librarian will be.

Sincerely,
Dr. Warren

-SB

Dear SB: You don't say what age group your students are. While many of the arguments may be the same for any age group, I think it's essential for kids under or near the legal age to be aware that alcohol is a dangerous drug, legal or not.

The illegality of the drug plays a significant role in its negative effects. Although many high school students will tell you that it's easy enough to get drugs or alcohol at the school, the fact that it's illegal plays a big role in the social milieu of the users. Since alcohol is illegal for minors and marijuana will likely remain illegal for minors, in order to use those drugs regularly, the users have to be willing to consort with risk takers and possibly suppliers. That tends to spawn a drug subculture which is separate and distinct from the mainstream. While some kids may easily participate in both groups, many will find that they form a specific alliance with the drug users which will contribute to their general attitudes and problems both at home and in school. Unfortunately, hanging around with users increases the likelihood of exposure to hard drugs, and the likelihood of having a positive attitude toward trying hard drugs. This contributes in large part to the fact that alcohol, marijuana, and even cigarettes are gateway drugs toward harder drug use.

As regards your question about negative health effects, I think that the health profession has a great deal more experience with the ill effects of alcohol. Should the use of marijuana increase significantly in our population, we may develop statistics about previously unrecognized ill effects of marijuana. But at the current time, I suspect that the evidence favors alcohol as being more destructive to the body. Alcoholism can lead to liver damage, cirrhosis, and a huge number of complications from cirrhosis. It can also cause permanent neurological damage.

If somebody drinks enough, I'm sure that these complications could occur at an early age, but these are the ill effects of long term drinking. There have been several case reports in the news of acute alcohol intoxication leading to death in high school and college students. I haven't heard anything similar with regard to marijuana. But if you are discussing the health effects from the point of view of the students, I think you should consider the following:

Automobile accidents and violence are among the leading causes of death in teens and young adults. Drugs and alcohol play a major role in both. If marijuana becomes legal, I'm sure it will equal, if not exceed alcohol as a major cause of DUI. The slaughter on our roads far exceeds the morbidity and mortality from the ravages of alcohol on the body. The vast majority of the drinkers involved in DUI are young men who cut their own promising lives short. It should be a preventable tragedy. And it's a double tragedy, because they often kill others, young and old. You can be sure that marijuana will not have any less of a disastrous effect behind the wheel of a car.

Alcohol is an addictive drug. Some of the proponents of legalizing marijuana have argued that marijuana is not. While not everyone who uses marijuana becomes addicted, when a user begins to feel that he or she needs to take the drug to feel well, that person is said to be dependent on the drug or addicted to it. In 1993, over 100,000 people entering drug treatment programs reported marijuana as their primary drug of abuse, showing they need help to stop using. Some heavy users of marijuana show signs of dependence because when they do not use the drug, they develop withdrawal symptoms. Some subjects in an experiment on marijuana withdrawal had such symptoms as restlessness, loss of appetite, trouble with sleeping, weight loss, and shaky hands.

While I understand the reasons for comparing alcohol and marijuana in any discussion of the merits of legalizing marijuana, the fact is that as a society, we have accepted alcohol. Marijuana has not been elevated to that status. We also saw that we paid a high price during Prohibition when we tried to make alcohol illegal. Marijuana is not part of the mainstream of society. In arguing for legalization based on a comparison to alcohol, we as a society, need to consider the ramifications of allowing another problematic drug join the mainstream.

For some reliable information on the Web, please check the following sites:

• Basic Facts About Drugs presented by the American Council for Drug Education.
• Signs and Symptoms of Drug Abuse presented by the American Council for Drug Education.
• Basic Facts About Drugs: Marijuana.
  Arm yourself with accurate information from the American Council for Drug Education.
• Marijuana - Facts Parents Need to Know - From the National Institute on Drug Abuse.

Sincerely,
Dr. Warren

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