31 July 2000

1. Prolonged Newborn Jaundice
2. What Does Dr. Warren Like About Being a Pediatrician?
3. Sandy Bowel Movements
4. Too Much Water?
5. Premies, Reflux, Apnea, Feeding, HMOs
6. ? Night Terrors?
7. Childhood Sexual Experimentation
8. No Weight Gain
9. Disclaimer

• Read Questions & Answers in Another Column

Prolonged Newborn Jaundice

with all respects from croatia
-NK

Dear NK: Sometimes breast milk can prolong jaundice; however, the levels of bilirubin with a peak of 15 and a decline to 11 are not dangerous. While the jaundice may persist longer because of the nursing, there is no reason to stop or restrict nursing for a bilirubin of 11 in an otherwise healthy baby. A GGTP of 175 is only minimally elevated for a baby at 1 month of age. Without other blood work results, I am unable to say if it is a cause for concern, but it should be checked periodically. From the information I have been given there is no basis to conclude that the baby has any form of hepatitis.

The list of causes for persistent jaundice is quite large, and only your doctor, who has examined the baby, can determine whether or not additional tests should be run. If there is evidence of hemolysis, your doctor will want to check for different blood disorders which may cause hemolysis. It is important to be sure there is no evidence of infection or hypothyroidism. It is possible the jaundice could persist because of an inherited abnormality of bilirubin metabolism. If the important causes of jaundice are ruled out, the level of bilirubin you told me about does not pose any risk to the baby now or in the future.

Sincerely,
Dr. Warren

-Curious

Dear Curious: There are so many things to love about being a pediatrician I can't pick just one. I'd have to choose among the cuddly babies, the cute kids, the satisfaction of helping people, the joy of seeing an infant develop into a child and watch him grow through the teen years to young adulthood. If I keep thinking about it, the list will keep growing.

Schooling: College - 4 years. Medical school - 4 years. Residency (on the job training) - 3 years.

Sincerely,
Dr. Warren

Our 21 month old daughter started having very sandy, gritty stools about 5 days ago. Her b.m's are usually quite soft, but I have never really worried about this as she seems quite healthy and also breastfeeds several times a day which I think might keep them soft. Her diet is normal and I can't think of anything new she has been eating. She will not drink milk, but does eat a good amount of other dairy products, and calcium rich vegetables. She is not taking any vitamin supplements, which is something I need to bring up with her doctor. We are living out of the country for the year and she has only been sick once in the last 9 months, so we haven't been to the doctor to be asking questions like this. Any ideas on the sandy stool? Should we take her to the doctor for this?

Thank you so much :-)

-KB

Dear KB: If the stools are really sandy, you do have to consider the possibility that your daughter has been eating sand or soil. Some children will do that. What you are noticing is probably just a change in the consistency of the stool to a drier stool. This may happen if a child has less fluids, less fiber, less fruit, or more processed starches. Sometimes the consistency of the stool may change for no obvious reason.

If your daughter's appetite is okay and she does not appear to be having any abdominal pain or vomiting, you don't need to run to the doctor, but she should have regular checkups where issues like these can be addressed. If your daughter seems to be ill or in pain, then she should be checked by her doctor.

Sincerely,
Dr. Warren

Thank you very much.

-GE

Dear GE: By my calculation, the 16 month old you are asking about is drinking 60 ounces of water each day - almost 2 quarts! That's a huge quantity of water. One risk in drinking that much water is that it may make a small child hyponatremic (low serum sodium). In addition, such a large fluid intake may be preventing the child from consuming adequate nutrients because his stomach is full from constantly drinking water. It is possible that the parents are offering water in place of milk or food because they can't afford food, and/or they may have the misguided idea that it is okay to fill up a hungry baby's belly with water. An important question is, "What else is the baby eating or drinking?" If the baby's diet is adequate, he may be drinking so much water because of a medical problem like diabetes mellitus of diabetes insipidus. From your description of the situation, something sounds wrong. The child should be evaluated by a pediatrician.

Sincerely,
Dr. Warren

1. My daughter Sarah is the youngest of the three and has severe reflux which she takes Cisapride for. The medicine does seem to help but she continues to spit-up 4-5 hours after she takes a bottle. Against her doctor's advice, I have begun to put rice cereal in her bottle after someone told me it would help keep it down. It has made a dramatic difference for my daughter. She is long and skinny but is beginning to put on weight. I sit her upright for an hour after she eats and then she is allowed to play on the floor with her siblings and manages to keep everything down. She seems much happier now. Why would her doctor be against putting cereal in her bottle when it seems to make such a wonderful difference?

2. I have an older daughter who's doctor (a family practitioner) had her take rice cereal at 4 months. The pediatrician for the triplets says not until they are 6 months corrected age. When does the AMA say to start solids. I cannot imagine my oldest triplet going 3 more months before taking solids. He already takes 32 ounces and is also tall and thin.

3. My daughter Sarah who has reflux was on a monitor because she stopped breathing about a week after I took her home and I had to give her several breaths before she started breathing again. The pediatrician said we could get rid of it and I was happy to send it back to Home Health. Shortly after that, the neonatologist who reads the downloads called and said that the most recent download showed Sarah was having 15 second pauses in breathing (the monitor did not alarm because it is set at 20 seconds). I was shocked because the pediatrician said all was well and we did not need it. I called and questioned her and she told me it had been two weeks since her last apnea event and it would be rare for her to have another. After I explained that Sarah hadn't had any apnea for 5 weeks when I took her home at only 7 weeks old (35 weeks gestation) and she stopped breathing and wouldn't revive even with vigorous stimulation - the doctor said she realized all of this and had the notes from the NICU but continued to make a point of telling me Sarah did not need the monitor and would not let me have the monitor back. Now that my triplets sleep through the night, I cannot because I am constantly checking to see if Sarah is still pink. I cannot get the picture of that blue baby out of my head. I know that the HMO puts a lot of pressure on the doctors in town because it is losing money and the birth of three very premature babies hasn't helped. The pediatrician has made many comments about "now they will get off my backs" about the monitors and so forth. I want the monitor back and feel that my insurance should pay for it. I am willing to pay the $600 per month but it would be nice to spend that money on something else (formula, diapers, bigger house). Am I being unreasonable for wanting the monitor back or is the doctor right? The neonatologist did several tests for Sarah and did not feel that her apnea was due to prematurity. They said it was either because of reflux or a possible near miss SIDS. Is she at high risk for SIDS and when do the risks lesson?

4. The NICU asked me to pick a pediatrician for the triplets because of their extreme prematurity but I'm wondering if I can take them to the family practitioner my older daughter goes to. Except for Sarah's apnea and reflux, they are acting like normal children and are ahead developmentally according to the pediatrician. I prefer the family practitioner. He came from L.A. and has experience with premature babies and I like and trust him which is an added plus.

5. The NICU said they should have developmental testing the first few years and continue if there are problems. The therapist told me to make an appointment when they were 4 months corrected age but the pediatrician says we do not need it and refused to make the referral. What would you do if they were your patients? What treatment is normal for extremely premature babies? I'm willing to pay out of my own pocket if this really is necessary.

My husband is a doctor but does not work with children and I've learned not to ask his oppinion and worry him with details of our children's health. He wants to be dad not doctor to our children.

Thank-you.

-BJ

Dear BJ:
1. As a routine, the American Academy of Pediatrics does not recommend putting cereal into the bottle. Adding cereal to the bottle does not provide any nutritional benefit since it only increases the carbohydrate content of the feeding. The purpose of introducing cereal is to introduce spoon feeding since eventually the child will be nourished by a variety of solid foods rather than formula. However, it is well known that thickening the formula with cereal reduces the amount of reflux, so while cereal should not routinely be added to formula, it certainly should be added to formula to thicken the formula for infants who have reflux.*

2. Solids such as cereal should not be introduced before 4 months of age because, as stated above, there is no nutritional advantage to offering cereal, and before 4 months of age, most infants do not have the head and swallowing control necessary for voluntarily eating from a spoon and refusing to eat what they don't want. Most infants do very well without solids for up to 6 months; therefore, introducing solids should generally be delayed until 6 months for those children who have a higher risk for allergy or any other potential problem with spoon feeding.

The fact that your baby drinks 32 ounces of formula a day does not automatically indicate a need for solids. If the baby is doing well on formula, it is still an excellent food to grow on. I have had infants doing well on 40 ounces of formula a day without eating any solids. On the other hand, if your baby has good head control and is able to handle spoon feeding, I see no harm in introducing cereal. One word of caution if you should decide to introduce solids at this point - Don't push the baby to eat solids. A baby's natural instinct when he's hungry is to suck. Eating from a spoon is a learned skill. I once had a mother tell me her baby was crying during the feeding because she couldn't get the cereal into him fast enough. When I asked her whether she was sure the baby wasn't crying because he didn't want the cereal or the spoon, she realized she had no idea.

3. The risk of SIDS decreases with advancing age, but still exists up to the age of 2. The relationship between sleep apnea and SIDS remains controversial. SIDS may be caused by a variety of things and may not be all one condition. By definition, the diagnosis of SIDS can only be made if no cause of death can be found. While it's easy to see how apnea could result in death with no diagnostic findings at autopsy, that doesn't establish apnea as a major cause of SIDS.

The decision regarding whether or not your infant should have a monitor is not dependent on the relationship of SIDS to apnea, but rather, whether or not your baby is still significantly at risk for apnea. This risk can be quantitated with a test called a pneumogram. If the downloads your neonatologist received were the results of a pneumogram, your neonatologist should give you the results and his opinion in writing. If the results of the testing are inconclusive and the baby hasn't had a pneumogram, then a pneumogram should be done. If the evidence supports a need for continued monitoring, you can provide documentation for the need directly to your insurance company and your neonatologist should help support your claim. If there is clear evidence that a monitor is indicated and your pediatrician is unwilling to support your claim you must reevaluate your relationship with your pediatrician. His first obligation is to be an advocate for his patient, not the HMO.

Before taking any action, you should be sure you have received and fully understand and expert's opinion about your baby's need for continued monitoring. Many parents whose infants have been monitored develop an extreme amount of anxiety about discontinuing the monitor. It is impossible for any physician to guarantee that no harm can come to a infant; however, in order for the infant to have a normal life, monitoring equipment must be removed when it is no longer necessary.

4. A well trained and experienced family practitioner should certainly be able to take care of your babies. Training is important, but it is not possible to see everything during 3 years of residency. Experience and continuing medical education are extremely important. It is certainly possible for a particular family practitioner to have more experience dealing with premies than a particular pediatrician. If you trust your family practitioner, by all means bring your babies to him. If he feels that there are any problems which require the expertise of a pediatrician or any other specialist, he will consult one.

5. I'd like to think that the routine pediatric check up is sufficient to pick up all developmental problems, but the reality is that it's not. Of course it's not reasonable to have every infant evaluated by a developmental specialist, but given the proven benefits of early intervention, it is reasonable for infants at risk for developmental problems to have periodic evaluation of their development for at least the first 2 to 3 years.

Regardless of the outcome, it sounds like you have some thinking to do about your relationship with your pediatrician and your HMO.

Sincerely,
Dr. Warren

Thank you in advance for your help.

-JN

Dear JN: I am not sure from your description that your daughter is having night terrors, and this may be an important distinction since the management of night terrors differs from the management of other sleep disturbances. Night terrors are more commonly seen in older children, more in the 3 to 5 year age range. During a night terror the child appears wide eyed and frightened but does not respond to any efforts at comforting or even appear to recognize his parents because he is not awake, and in reality, since he is not awake, he does not recognize his parents. There is no unanimity of opinion on the best management for night terrors, but one approach recommends trying to change the child's sleep pattern to prevent the night terrors. Night terrors usually occur at the same time each night, or at least, at approximately the same time interval after a child goes to sleep. The recommended method for avoiding night terrors is to log their pattern, and once you have determined the approximate time that the night terror is likely to occur, to rouse the child just enough to disturb his sleep and have him go back to sleep BEFORE the expected night terror. After several weeks of this approach, the pattern of night terrors should be abolished. As you can imagine, this would be a highly undesirable approach to use on a child who is having night time waking and then having difficulty getting back to sleep. Additional factors which should be considered in managing night terrors is to be aware of any stresses which may be contributing to them and make an effort to deal with them.

If a child responds quickly to parental intervention or receiving a bottle, it is highly unlikely that the child is having a night terror. Infants often do start complaining before they are fully awake and may often respond to parental comforting or bottles without ever fully awakening. If a child is having difficulty sleeping at night and responds well to a specific intervention, it is hard to imagine recommending against it; however, while falling asleep is a biological necessity, how we fall asleep is a learned behavior, and if a child uses a specific method to fall asleep, for example, taking a bottle, he will continue to need that intervention every time he wakes up. There is virtually nothing we can do to prevent a child from waking at night other than to eliminate stresses and disturbances that may contribute to awakening, but our goal in dealing with night time waking is to keep our interventions as minimal as possible and for the child to ultimately learn to put himself back to sleep. For more information, please read my article, Helping Your Child to Sleep Through the Night

Sincerely,
Dr. Warren

-BPW

Dear BPW: It is perfectly natural for a young girl to be curious about her body and to enjoy touching herself. There is nothing wrong with that. However, an 11 year old girl should know and understand that it is not socially acceptable behavior to pull down her pants or masturbate in public. She should only do those things in her bedroom or the bathroom.

Many little children stick object into openings. I have had to take items out of children's noses an ears. You would think that an 11 year old would know better, but sometimes children can do some strange experiments to see what will happen. Your daughter may find using objects to stimulate herself exciting, but she should be warned that she could injure herself.

If your daughter seems to be preoccupied with stimulating herself and sexual behavior, it could be a sign that she has learned this behavior elsewhere. You have to at least consider the possibility that your daughter has been sexually abused and talk to her about it. Tell her that if anyone has done anything with her and told her to keep it a secret, that person is not her friend, and she should tell you about it.

Sincerely,
Dr. Warren

I have to ask something else. I saw my daughter with a boy and my daughter was letting the boy put his finger in her vagina and my daughter was touching his penis. Is this normal? What do I do?

-BPW

Dear BPW: As stated in my previous reply, it's normal for children to be interested and curious about sex, their bodies, and other people's bodies, but it's inappropriate behavior for an 11 year old girl to be handling a boy's genitals or allowing him to touch her. It's potentially dangerous behavior, since without limits, your daughter could be having sex at a very early age, risking pregnancy, sexually transmitted disease, and emotional consequences for which she is not ready. A child who relates to the world in a sexual way loses an opportunity to learn more about relationships without sex and risks sexual abuse by those who will take advantage of her willingness to engage in sexual activity.

Just like parents make rules about bedtime, how much TV children should watch, when they should do their homework, what their curfew is, etc., you have an obligation to set limits on behaviors that are potentially dangerous or inappropriate for you child. You wouldn't allow her to experiment with drugs if she were curious about them, and you shouldn't let her experiment with sex.

It's time to sit down and have a long talk with your daughter. First, you should make sure she knows all the facts about sex including birth control and sexually transmitted diseases including HIV. Then you need to talk about trust. Make it clear that as the parent you will set the rules and you have to trust her to follow them. Make her understand how valuable your trust is, and that if she loses it by not following your rules when you're not there to watch her, you will have to severely restrict her activity while she regains your trust. Then make sure you follow through on what you say. If you can't trust her not to engage in sexual activity with boys, make sure she is always chaperoned so that she will not have the opportunity to do things you don't approve of.

Sincerely,
Dr. Warren

I know that you are rather busy but I would appreciate what you think might be going on and what tests I should request from my current doctor.

I must say that asking for this help does not mean in any fashion that I do not have faith in my doctor. I do realize however that according to where you live and what you have been exposed to determines what all you are willing to think a problem is.

Thank you for your time and your answer.

-JW

Dear JW: I am concerned about two things in your e-mail. First - dark, tarry stools usually means there is bleeding in the upper GI tract. If your daughter's stools haven't been checked for blood, they should be. If they were checked and found to have blood in them and a blood disorder has been ruled out as the cause, then she needs a complete evaluation of her GI tract to determine the source of the bleeding, If she has an intestinal problem, this could also account for her poor weight gain.

My second concern is your daughter's lack of weight gain for 9 months. Even if she was enormous at 6 months of age it isn't normal for her to stop gaining weight. If she also isn't growing, she needs a thorough evaluation for occult infection including urine culture; evaluation of liver and kidneys by urinalysis and blood chemistries; evaluation of glandular function including thyroid; and of course, evaluation of her GI tract which could include x-ray studies, tests for malabsorption, and endoscopy, depending on what is found each step along the way.

Sincerely,
Dr. Warren

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