27 March 2000

1. Growth Hormone for Short Stature
2. Weepy Rash - ? Seborrhea
3. Vascular Ring
4. Obesity and Developmental Delay
5. Stool Color
6. Dealing with Weight Loss from Illness
7. Device to Calm Infants
8. Mystery Illness Once a Week
9. Disclaimer

• Read Questions & Answers in Another Column

Growth Hormone for Short Stature

-JS

Dear JS: The use of growth hormone for treatment of children who are not growth hormone deficient is still somewhat controversial. If a child needs growth hormone, the earlier treatment is started the better the results. Treatment involves daily injections of growth hormone which are continued until cessation of growth at the end of puberty. While there is no question that growth hormone can accelerate the growth rate, it still remains unknown whether or not treatment can affect the final height except in children who are growth hormone deficient. Children who are growth hormone deficient cannot grow to a normal height without growth hormone treatment.

Being short certainly can contribute to emotional difficulties during childhood, but if a child's growth rate is normal (the number of inches he grows each year, even if his height is at the low end of normal or slightly below normal, he may not be a good candidate for growth hormone therapy. In addition, the treatment is expensive and may not be covered by your insurance if it is not clearly medically justified.

You should consult a pediatric endocrinologist. A review of your son's growth and a number of blood tests will be required to determine if he should receive growth hormone.

Sincerely,
Dr. Warren

Thanks

-CS

Dear CS: Seborrhea is caused by increased scaling and inflammation of oil glands. This is very common in infancy because the oil glands are activated by exposure to hormones in the womb. Cradle cap is a form of seborrhea. Seborrhea is usually worst in early infancy, but amy persist many months. It usually responds well to treatment with 1% hydrocortisone cream (such as Cortaid or Cortizone 10).

The rash you describe may very well be seborrhea, but since it is inflamed enough to weep, it should be checked by a doctor. A 4 month old should have at least one pediatrician visit in 2 months just for routine care and immunizations anyway.

Sincerely,
Dr. Warren

Sincerely,
-SH

Dear SH: The condition you are referring to is a vascular ring. The aortic arch is only part of the ring Nelson's Textbook of Pediatrics say the following:

Vascular Rings. Congenital abnormalities of the aortic arch and its major branches result in the formation of vascular rings around the trachea and esophagus with varying degrees of compression on them. The following are the more common anomalies: (1) double aortic arch, (2) right aortic arch with left ligamentum arteriosum, (3) anomalous right subclavian artery arising as the last major thoracic branch of a normally placed aorta, (4) anomalous innominate artery arising further to the left on the arch than usual, (5) anomalous left carotid artery arising further to the right than usual and passing anterior to the trachea, and (6) anomalous left pulmonary artery (vascular sling). This abnormal vessel arises from an elongated main pulmonary artery or from the right pulmonary artery. It courses between and compresses the trachea and esophagus.

The clinical patterns are extremely variable. In some instances, especially with anomalous right subclavian artery, the condition is asymptomatic. If the vascular ring produces compression of the trachea and esophagus, symptoms are frequently present during infancy. Respirations are wheezing and are aggravated by crying, feeding, and flexion of the neck. Extension of the neck tends to relieve the noisy respiration. Vomiting is frequent. There may be a brassy cough, and pneumonia is common. Radiographic examination of the barium-filled esophagus and aortography identify the anomaly.

Surgery is advised for symptomatic patients who have radiographic evidence of tracheal or esophageal compression. The appropriate vessel is divided in patients with double aortic arch. Compression produced by a right aortic arch and left ligamentum arteriosum is relieved by division of the latter. An anomalous right subclavian artery is divided at its origin from the aorta. Anomalous innominate or carotid arteries cannot be divided; the tracheal compression is relieved by attaching the adventitia of these vessels to the sternum. Anomalous left pulmonary artery is corrected during cardiopulmonary bypass by division at its origin and reanastomosis to the main pulmonary artery after it has been brought in front of the trachea.

Sincerely,
Dr. Warren

My son (on the advice of a nutritionist) only consumes 660 calories a day.I am only a hundred pounds and my eight year old has had none of the above problems.(he only weighs sixty pounds) The doctors seem to be at a loss and unable to provide any answers.I have poured over every medical book I can find and cannot find any similar cases. I know that there is something that we're missing and I was hoping you could help. Oh, I almost forgot! He has also been hospitalized for asthma three times.

I know that you usually answer the basic everyday concerns but please if you can, just let me know if you have ANY IDEAS at all!!!

Thank-You So Much!!!!!!

-VB

Dear VB: If a variety of tests, including metabolic tests, have come out normal, your son may have a genetic syndrome associated with obesity. For further evaluation, you should consult a geneticist or a specialist who deals with syndromes. These specialists can generally be found at children's' hospitals in university centers.

There are several rare syndromes associated with obesity, but the one that comes most immediately to my mind is Prader-Willi Syndrome. Of course, I cannot make a diagnosis without seeing your child. Smith's "Recognizable Patterns of Human Malformation" gives the following information about Prader-Willi Syndrome:

Prader, Labhart, and Willi reported this pattern of abnormality in nine children in 1956, and subsequently over 200 cases have been recorded.

ABNORMALITIES

• Small Stature. May be small at birth, occasionally normal stature until later childhood.
• Obesity. Onset from infancy to six years.
• Craniofacial. Almond-shaped appearance to palpebral fissures which may be upslanting. Narrow bifrontal diameter. Strabismus.
• Mental Deficiency. Intelligence quotient 20 to 80, most commonly 40 to 60.
• Hypotonia. Severe in early infancy.
• Small Hands and Feet, Slowing in growth of hands and/or feet, usually becoming evident in midchildhood. One patient wore size 3 shoes at 23 years.
• Small Penis and Cryptorchidism. Frequent hypogonadism, secondary to hypogonadotropism.

OCCASIONAL ABNORMALITIES. Poor fine and gross motor coordination. Upsweep of frontal scalp. Microcephaly, seizures, clinodactyly, syndactyly, hypoplasia of auricular cartilage. Diabetes mellitus. Scoliosis.

NATURAL HISTORY. The mother may have noted feeble fetal activity, and the baby is often born in the breech position. The hypotonia is most severe in early infancy when there may be respiratory and feeding problems, not uncommonly necessitating tube feeding. The degree of mental deficiency may appear to be greater in infancy than at a later age because of the severity of the hypotonia hindering developmental performance. Regarding behavior, these patients have been noted to be cheerful and good natured. However, behavioral problems, including stubborness and rage-type responses, tend to become more frequent in later childhood. Birth weight tends to be low, and failure to thrive is frequent in early infancy with obesity presenting at one to three years of age, especially over the lower abdomen, buttocks, and thighs. The obesity paradoxically develops at a time when the hypotonia is improving. The caloric intake is less than usual for height (about 80 per cent). The caloric intake must be dropped to about 60 per cent of usual for height in order to control the progressive obesity. The presence of a diabetic-type of glucose tolerance curve relates to the severity of the obesity and only an occasional patient develops diabetes mellitus during childhood.

Early short-term testosterone therapy has resulted in enlargement of the micropenis to normal size for age. Any boy who is doing reasonably well at the age of adolescence should be considered for full testosterone replacement therapy, since his own production is usually inadequate.

ETIOLOGY. Unknown. Usually sporadic, with occasional instances of recurrence. Empiric recurrence risk about 1 to 3 per cent. Possibly the syndrome represents the consequence of a single localized defect in early hypothalamic and/or midbrain development.

Sincerely,
Dr. Warren

My 5-year old son, who's always been a frugal eater, has had the strangest bowel movements in the past two weeks.

His stool color is bright green. Not greenish-brown, but flat out lime green.

What could this indicate? His diet hasn't changed. Is this serious enough to warrant a visit to his doctor?

Thanks so much!

-SW

Dear SW: Stool gets its color from waste products and bile. Bile is green. Any shade of yellow, green, or brown is an acceptable color for stool. When children have diarrhea the stool is often green, but the green color does not mean anything is wrong if the stool is formed and the child is asymptomatic (has no symptoms). Therefore, you don't have to be concerned that your son's stool is green.

The colors of stool that would be worrisome are:

• Clay gray or white - meaning no bile is getting into the stool because of bile duct obstruction.
• Red - indicating a significant amount of blood in the stool.
• Jet Black (not just very dark) - which results from bleeding in the upper intestinal tract.

Sincerely,
Dr. Warren

My son suffered from a viral infection of some sort, possibly mononucleosis or something similar. He lost a lot of weight, from 16kg to 14 kg. Recently he had another infection, or maybe the same, and couldn't eat for several days and is now pitifully thin.

My question is, what should be our priority in terms of feeding and are there any special diets or supplements that are worth taking? Before the last attack I would feed him porridge with butter, milk, and syrup or honey.

I don't want to sound like over anxious when I know that kids all go through phases and not all are bonny bouncing babies, and nor should they be", but I really would appreciate some advice.

Many thanks,

Sincerely,
-LJ

Dear LJ: Most children will regain the weight they have lost during an illness just by returning to a healthy diet which is about 60% carbohydrate (fruits, vegetables, pasta, bread, starches), 20% protein (meat, milk, yogurt, fish), and the remainder of the calories as fat (oils, butter, cream, dressings). If your child is debilitated, then he may benefit from a high caloric feed like Pediasure. If you are not from the USA unfortunately I am not familiar with the equivalent products in other countries.

Sincerely,
Dr. Warren

-TU

Dear TU: The devices you are seeking information about and the web pages where information can be found are as follows:

• Sleep Tight Device - http://www.mocty.com/sleeptight/
• Nature's Cradle - http://www.infant-advantage.com/

Sincerely,
Dr. Warren

-BT

Dear BT: There isn't any illness that causes brief symptoms once a week, so the question remains whether this represents several brief illnesses with similar symptoms or a single more prolonged illness with intermittent symptoms. I favor the first possibility, but there are many causes for prolonged fever, so if the symptoms recur with regularity your daughter should have a thorough evaluation by her pediatrician.

Sincerely,
Dr. Warren

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