19 June 2000

1. Diaper Rash
2. Red Birth Marks
3. I Saw Worms on the Toilet Paper
4. No BMs Without Help Since Birth
5. Green Stool
6. It's Separation Anxiety!
7. Safety of Cortisone Cream
8. Henoch Schonlein Purpura
9. Disclaimer

• Read Questions & Answers in Another Column

Diaper Rash

I don't know why it keeps occurring? I am using water to wash her diaper area.. Day care also seems to be doing it properly according to their record. Could you please let me know why she is getting this rashes again and again? And also please let me know whether I am giving with the right medicine for her rashes? How do you differentiate between bacterial, viral and yeast infection rashes?

Thanks

-jaya

Dear Jaya: If you've read some of the questions about rashes on "Ask Dr. Warren" you know that it's almost impossible to give advice about a rash without seeing it. Most rashes that are confined to the diaper area are the result of heat and moisture causing irritation. These rashes can sometimes become raw and painful. The best treatment is heavy use of a protective ointment like Desitin, Balmex, or A&D, and frequent diaper changes. Cleaning with a dry tissue and then oil causes less discomfort than water, soap and water, or premoistened wipes.

Yeast infections are fairly common in infants because yeasts like to grow in moist, warm areas like the diaper area. Antibiotics increase the risk of developing a yeast infection by killing harmless bacteria on the skin which compete with the yeasts. Corn starch may aggravate a yeast infection since it serves as food for the yeast. Yeast infections are usually very red with an advancing border of bumps called satellites (new places where the yeast starts growing). The rash may itch, but in spite of how red it looks, it is not usually painful. It is treated with an antifungal cream such as Nystatin or Lotrimin. Difficult cases could be treated with a systemic antifungal like Diflucan.

Bacteria don't usually cause diaper rashes, but if you see little pus pimples, these may be bacterial and benefit from an antibiotic ointment. Impetigo, another superficial skin infection, looks almost like cigarette burns with a honey colored crust on them. Impetigo is often treated with a prescription antibiotic cream called Bactroban. More serious bacterial infections would usually cause swelling and tenderness of the red area, plus fever and other signs of illness.

Viruses often cause rashes, but not generally just in the diaper area. Most viruses also cause fever or other specific symptoms of illness.

If you are in doubt about the diagnosis and treatment of your daughter's rashes, consult a dermatologist.

Sincerely,
Dr. Warren

-Dane

Dear Dane: You should consult a pediatric dermatologist. He will give you the correct diagnosis as well as the recommended treatment options. The new laser treatments available today can do wonders for vascular marks; however, some vascular marks should be left alone during early childhood since they often shrink. Most strawberry hemangiomas have begun to involute before 5 years of age.

Sincerely,
Dr. Warren

Earlier, after going to the toilet, whilst wiping my behind I noticed a couple of small worm like creatures on the toilet paper. They were white, thin and about 3 to 4 mm long.

I am a young man and have a healthy diet, and am in quite good shape, but this has me slightly worried.

What should I do???

Any help would be greatly appreciated.

-Daniel

Dear Daniel: If what you noticed were worms, you need to have a specimen of your stool examined in a laboratory for ova and parasites so that a correct diagnosis can be made. If you have worms, it can be treated with medication. By your description, it sounds most like pinworms. These usually cause intense anal itching, especially during the night.

It is possible that you saw fibers from something you ate or shredding of the toilet paper, but if you have any doubt, you should see a doctor for diagnosis and treatment. If anything you saw moved, you should assume it was a worm and get it checked out.

Sincerely,
Dr. Warren

She has even gone 10 days without a BM and is very irritable in between.

On tenth day I finally gave her a suppository.

Have been to 2 doctors both saying more water, use the suppositories and that it should get better. Have tried it all and nothing seems to get her going on her own without the suppository. She is now going for a barium enema to see what is wrong. How common is this and what would your thoughts be on the possible problem? I do not want to keep giving her the suppositories!

Thank you for your time.

Sincerely
-Kerri

Dear Kerri: Since your daughter has had difficulty moving her bowels from the time she was born, it is possible she might have a congenital condition such as Hirschsprung Disease, in which a segment of bowel is not innervated and so does not propel it's contents down to the rectum. A barium enema may suggest the diagnosis, but a rectal biopsy will be needed to confirm it. Hirschprung can be surgically treated. An early diagnosis and treatment should result in a satisfactory outcome.

Sometimes the anus is not in the normal location and may be tight. This may respond well to dilation.

I cannot quote any figures for you, but any infant who has difficulty having bowel movements since birth deserves further evaluation to determine if there is an anatomical correctable cause.

Sincerely,
Dr. Warren

Thank you again.

-Riaz

Dear Riaz: Normal newborn stool is usually yellow, somewhat loose, and seedy looking. Babies fed iron fortified formulas or soy formula often have darker or green stool. The stool may often be more green when a child has diarrhea, but if the stool is otherwise normal, the green color is of no significance and not a cause for concern.

Sincerely,
Dr. Warren

Three weeks later my daughter was still hanging onto this behavior. Needless to say, Momma was not getting a lot of sleep. So, I tried the "let her cry method." I have to say it does work. She sometimes stirs at midnight or 4 in the morning but now she cries for a couple of minutes and puts herself back to sleep. This is after only 5 days.

Okay, so what's the problem right!!! The problem is that during the day I have noticed some changes in her normally pleasant personality. She has grown very clingy to me. She cries when I leave her at Grandma's to go to work. She has a tantrum (at least I think it is -- no tears, just mad screaming) when I try to put her in her play pen or walk out of the room. She doesn't want to take naps, which before we were taking on average 2 hours in the morning and afternoon. I hoping this is a temporary adjustment to the new routine, but I'm not sure. Any thoughts????

They don't come with an owner's manual do they???

Thanks.

-JP

Dear JP: It is possible, at 1 year of age, that your daughter is simply going through some normal separation anxiety. She may be resisting naps more because she is getting older and needs them less. But it is also possible, that the experience she has had regarding sleeping has taught her that she can't always have you every time she cries. While this is true and she has to learn it, it could certainly have aggravated her separation anxiety.

I wouldn't suggest undoing what you have done to get your daughter to sleep. Neither would I suggest not leaving her when it is appropriate to leave her someplace. But when you leave, tell her where you're going and when you'll be back. When you have time to spend with her, you should make an effort not only to provide her with extra comfort, but also to point out to her that Mommy always comes back home. Talk about separation on her level, explaining that Mommy goes to work, and then comes home every day. Baby goes to sleep in her crib, and every morning Mommy comes to take care of her. Keep explaining these cyclical patterns to her and as she develops language, she will begin to repeat them to comfort herself.

Sincerely,
Dr. Warren

Thank you.

-KK

Dear KK: Cortisone creams are rarely absorbed enough to have any significant effect on the body. If a high potency cream is used covering a large surface area, and if an occlusive dressing is used, there may be some significant absorption, but even then, it would require prolonged or chronic use to have a significant effect. While systemic effects of steroids are sometimes a significant concern, the anti-inflammatory steroids, which are not anabolic steroids, do not effect the reproductive system adversely.

With regard to alternative treatments, steroid creams are NOT appropriate treatments for yeast infections. Yeast infections can be treated with antifungal creams like Nystatin or Lotrimin. These may also be used combined with a steroid to reduce the inflammation more quickly, but the steroid is not a necessary part of the treatment.

Sincerely,
Dr. Warren

His treatments are Amoxicillen, Motrin for the stomach discomfort, and observing the urine and stool for any visible signs of blood.

I would like to know if I am giving my son the proper course of treatment, and or , should he see a pediatric rheumatologist? Is this a very serious condition that should be monitored at a research or medical university?

Please respond as soon as possible!

-KB

Dear KB: Henoch Schonlein purpura may involve many organ systems, but there is no definitive treatment to cure the illness. It usually runs its course in 4 to 6 weeks. The major manifestations are in the gastrointestinal tract, kidneys, skin, and joints. Treatment is aimed primarily at symptom relief.

Many pediatricians, including me, have little experience with Henoch Schonlein Purpura. If your pediatrician has experience and feels comfortable monitoring it, he will know when to consult a specialist. Because of the many manifestations of HSP, a rheumatologist may be the appropriate specialist to see. If the abdominal pains and bloody stools are the most bothersome symptoms, a gastroenterologist may be helpful. In terms of the most serious consequences of HSP, the most worrisome long-term consequences relate to the kidneys, so if you were to consult just one specialist for a second opinion, unless there are specific symptoms that direct your choice of specialist, I would consult a renal specialist. In the absence of any kidney complications, the prognosis for complete recovery is excellent.

Sincerely,
Dr. Warren

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