25 April 2000
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
-JW
Dear JW: If your baby has dark, coarse pubic hair, it may be the result of a glandular disorder. If the baby has precocious puberty, he should also have enlargement of the testicles and penis and acceleration of his growth rate. If he has an adrenal gland problem, the testicles will be small, but the penis will enlarge and body development will proceed as if there is puberty. Adrenal gland disorders can also result in problems with salt and water metabolism. The endocrinologist is the doctor to see.
Sincerely,
Dr. Warren
My daughter will be 3 years old in May (less than 2 months from now). She is not potty-trained at all (though not from lack of trying on my part!). She had 2-3 painful BMs around Thanksgiving of last year (now 4 months ago) and after that started having infrequent BMs (like 2-3 times a week), although no longer painful for her.
I gave her the laxative Senokot for a few weeks (off and on) which gave her very loose movements. I slowly stopped giving that to her and started giving her a jar of baby-food prunes once a day. As I tapered off the prunes that I was giving her, then at the end of February she had a painful BM once again (that was a month ago). I started then giving her more prunes each day (twice as much). She has not had a painful BM since then but still has infrequent BMs (loose movements). By the way, my daughter has always had a very healthful diet of whole wheat breads/pastas, lots of fruits and vegetables, no snacks, very few sweets. I stopped giving her white rice and bananas after I read here (and elsewhere) that was potentially constipating. We are mostly vegetarians also, although my daughter does eat chicken once or twice during the week. Also, my daughter had always had regular BMs (like clockwork every evening) until last Thanksgiving. The pivotal event seemed to be that I tried to change her diet and she refused to eat the new foods I made. (I now make only her favorites! She does eat quite a lot for her age I believe.)
I read what you had to say about mineral oil. My daughter's pediatrician recommended that. So we are now going to start giving her 2 tsp to 1 Tbsp of mineral oil each day for the next 4-6 months.
So my questions are:
Sincerely,
-Anita
Dear Anita: Mineral oil acts as a lubricant because it is not digested or absorbed. Olive oil is a food. It may lubricate slightly, but it is mostly digested and absorbed.
Laxatives and enemas are habit forming because they interfere with the normal function of the intestines and chronic users depend on that interference to empty their bowels. Lubricants and bulk formers do not affect the normal movement of the intestines or force the intestines to expel stool. When the child stops holding the stool in and develops good bowel habits, the normal intestinal movement may suffice to have regular bowel movements without the use of lubricants or bulk formers (stool softeners). However, even though the oil and the softeners are not habit forming, a person who tends to be constipated may need to use them long term.
It is impossible to predict what will happen with toilet training, but of your daughter is resisting you and you are fighting with her, you are fighting a losing battle. You can make a child sit, but you can't make anything come out of her. Toilet training works best when a child has ample opportunity to use a potty but no pressure to perform or succeed. Please read my article Potty Training.
Sincerely,
Dr. Warren
-LS
Dear LS: Your child obviously has a complex neurological condition and finding the right combination of medications to control his symptoms may require some trial and error. This does not mean he is being used as a Guinea pig. As regards the safety of these medications, it is hard for me to comment since neither medication has been shown to be safe or effective in the pediatric age group. This does not mean that these drugs are dangerous or ineffective, but sufficient studies have not been done to answer the question.
Unfortunately, many good drugs that are used to treat adults take a long time to be approved for children because clinical trials involving children are generally not undertaken until a drug has been proven safe in adults. As a result, many pediatric specialists who have experience with a medication use it even when it isn't officially approved in order to provide needed treatment for their patients.
If your son has responded well to these medications, then he probably should continue them; however, your doctor should explain the risks, benefits and alternatives with you so that you can take part in the treatment decisions.
Sincerely,
Dr. Warren
Anyway after two pediatricians, a gastrointerologist, and a nutritionist, she was last recommended to see an Endocrinologist. Once again, I got the same nonchallant attitude and was told that "she looks good, has good muscle tone, happy, energetic and developmentally on target...so let's just wait 4 months and see what happens before we do any tests or prescribe medication." Dr. Warren, I'M SICK OF THIS. Why all the waiting? There are things that can be done for her now, like growth hormones and medications to increase appetite and stop wasting. Why won't anybody help us? I'm so horrified, I don't even like to see my baby naked because I'm reminded of just how thin she is. Please help me. What can I do to help my baby grow? She eats about 5 times a day, but usually only very small amounts. She is also very picky and only likes a few things. When I continually (over a period of a few weeks) give her the stuff she really likes, she grows tired of it and I have to find something new to give her. Thanks for your help!
On a lighter note, my husband has had 4 colds over the past year. When he blows his nose during these periods, blood comes out (not much but enough for concern). What could be causing this? Could it be serious? Should he see a doctor? I heard that unexplained bleeding from any orifice could be a sign of cancer. Is that true?
-Desperate, Worried Mom/Wife
Dear Desperate: Proper treatment always requires proper diagnosis. And proper diagnosis requires testing, which may sometimes involve painful or invasive procedures. Therefore, when a specialist looks at a child who is basically healthy but small, he may want to gather some growth data under controlled conditions before proceeding with testing. What the doctor has told you or at least implied to you is that your child is NOT wasting.
Growth hormone is an appropriate treatment for a child who is growth hormone deficient. Its use for other conditions remains controversial, and there is no evidence that it can alter the final height of someone who is not growth hormone deficient. That may be proven or disproven as growth hormone is used under appropriate experimental protocols. And let's keep in mind that treatment with growth hormones requires daily injections, which means the parents must learn to give the injections. If your child's health requires it, that's reasonable, but if your child is perfectly healthy, the issues contributing to or causing her poor appetite and poor growth should be sorted out first. I understand your anxiety, but the perspective you need is, "Is your child in any danger?" Apparently the doctors who've seen her don't think so. Are they all wrong? I don't know. Although I remember communicating with you many times, I don't remember your baby's age, and I would need growth data (height and weight) for multiple ages to see what her growth looks like on a growth chart.
As far as medications are concerned, I know of no medication that has been shown to have long term benefit on growth by increasing appetite. Remember that all medications have side effects, and even if a medication helped stimulate your daughter's appetite, it might be required long term to make a difference. Children often experience increases in appetite when they take steroids, but long term steroid use is extremely dangerous. Periactin, an antihistamine, sometimes increases appetite, but it also causes drowsiness.
So what should you do? You could consider consulting another endocrinologist for a second opinion, but I think you would benefit most by having a complete discussion with the endocrinologist who has already seen her. It might go something like this.
"Doctor. I appreciate your reassurances and your conservative approach, but while I trust you, I need more than your reassurances. I need information. Have you reviewed my daughter's previous growth data? If you haven't gotten it, I will make sure her pediatrician sends you the information. If you have reviewed it, I'd like you to review her growth chart with me and show me how she is doing and explain to me, based on the growth information you already have why you need 4 more months to decide if evaluation is warranted. I know she is a new patient to you, but we have been having this problem a long time, which is why we're here to see you, and unless you feel that her prior growth pattern is normal, we're ready to proceed with further evaluation. Would you please explain what diagnoses you're considering and what kind of evaluation needs to be done to pursue these possibilities."
Sincerely,
Dr. Warren
-JH
Dear JH: Since the problems seem to involve feeding, a formula sensitivity or intestinal problem may be the issue. A child who vomits Alimentum and not other formulas would be unusual, therefore it may be worth another try. If not, Nutramigen and other brands of hypoallergenic formulas are available. If your pediatrician suspects reflux, a visit to a gastroenterologist might be helpful. If the diagnosis is confirmed, there are medications which can help reflux.
Sincerely,
Dr. Warren
-Connie
Dear Connie: If your daughter still has an elevated sedimentation rate, it indicates that there is some ongoing inflammation somewhere. Therefore, it seems reasonable to try to track it down. Since the only positive finding on examination was enlargement of some lymph nodes (I assume mesenteric nodes from your description), if those persist, perhaps an infectious disease specialist could help to determine why. Mesenteric adenitis may not respond to the particular antibiotics used to treat H. pylori, depending on what was used. Since an elevated sedimentation rate suggests an ongoing process, I lean toward there being an underlying physical cause, but I have to at least suggest a psychological component since your daughter's symptoms only appear to be in the evening, and that seems unlikely with physical disease.
Sincerely,
Dr. Warren
The pain is normally around her navel.
Please what may be the cause of this?
I look forward to receiving a response.
Regards
-Paula
Dear Paula: There are so many possible causes of abdominal pain in children that if your daughter's symptoms are recurrent or persist, she needs to see her doctor. Since she had pain after drinking chocolate (I assume milk) she might have lactose intolerance. Using a low lactose milk like Lactaid could help. The most common causes of abdominal pain in children relate to bowel habits and diet. Children who don't eat enough fiber or who can't be bothered to take the time to have complete bowel movements often have abdominal pain secondary to constipation. Stress may also cause abdominal pain in children. There are also some illnesses which can cause abdominal pain, so a visit to the doctor is in order.
Sincerely,
Dr. Warren
-KM
Dear KM: Many infants are pigeon toed because of the position of their legs in the womb. In most instances, this is self correcting. Years ago, the Dennis-Brown bar was popular to change the internal rotation of these infants' feet, but that has gone out of vogue because, for the most part, it hasn't been shown to be more effective than doing nothing. Additionally, if a child is mildly pigeon toed, it is at most a cosmetic issue since it doesn't affect walking. I would be reluctant to suggest any restrictive treatment for your daughter such as a brace, but the answer depends on whether or not your daughter has a significant deformity or the normal appearance for an 18 month old. I would have to suggest seeing a pediatric orthopedist, and even then, you should make it clear that you are looking for answers and not necessarily intervention unless it is medically necessary. A specialist who can provide a treatment that will give you the result you wish may sometimes be more than willing even if the treatment isn't medically necessary.
Sincerely,
Dr. Warren
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