14 August 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
-Kim
Dear Kim: If a child is short and has not started puberty, as long as he has been growing steadily along his growth percentile, it is usually best to let nature take its course. When a child, especially an adolescent, begins to develop significant psychological problems as a result of his height, however, then the scales may tip in favor of intervention. The psychological scars of childhood sometimes affect people's attitudes and interactions with others for the rest of their lives.
Growth hormone is primarily indicated for children who are growth hormone deficient. It may be useful for those whose growth increment is less than two inches per year, but if that isn't a result of growth hormone deficiency, it still isn't known whether or not the treatment has any effect on the final height. If your son is growing at a normal rate, but is behind, growth hormone may not do anything to accelerate his growth. In addition, growth hormone is most effective in young children and less effective as children get older and progress through puberty, so that if a child's growth rate is not satisfactory, it is best not to delay considering growth hormone treatment.
Growth hormone is a fairly safe treatment. When the only source of growth hormone was human cadavers, growth hormone was scarce and was not available except for patients who had been proven to be growth hormone deficient. It was also found that growth hormone from cadavers could cause Jacob-Kreutzfeld disease. Today's growth hormone is made with recombinant DNA technology. It is plentiful and free of contamination, but it's use in the treatment of growth disorders unrelated to growth hormone deficiency is still experimental. Treatment with growth hormone is expensive and may not be covered by your insurance unless your son meets certain criteria for treatment. Treatment requires daily injections which you or he would have to learn to give.
Your son should see a pediatric endocrinologist for complete evaluation to determine what the cause of his short stature is. If growth hormone is the appropriate treatment, the endocrinologist will be able to tell you. If your son's growth is normal, considering his age and psychological state, he may benefit from a short course of hormone treatment to stimulate some pubertal changes thus accelerating his growth. The best treatment can be determined after a thorough evaluation by an endocrinologist.
Sincerely,
Dr. Warren
Thanks
-Concerned Aunt
Dear Concerned Aunt: I always find it regrettable when patients have to ask me questions about what other doctors tell them, and I have to try to figure out what they think the doctor told them by what it sounds similar to. Clearly, the doctor should have made sure his patient knew what he said, and what the significance of it is.
I can only guess that the word you think was "myochondria" refers to a mitochondrial defect which can lead to muscle weakness. The exact diagnosis of mitochondrial defects can only be made by muscle biopsy, but first, before considering a muscle biopsy, a determination has to be made that the cause of the weakness is muscular rather than neurological, so you will need the results of the blood work and EMG first. Without any test results, all the possible causes of muscle weakness are in the running, so if you wish to do any research, you should be looking up muscle weakness rather than focusing on one category of diagnosis which may not even be your niece's diagnosis.
Sincerely,
Dr. Warren
-KL
Dear KL: After a cold it may take time for the congestion of the eustachian tube to resolve. There may be fluid in the middle ear as a result, or the congestion of the eustachian tube may result in popping, pressure, or stuffiness of the middle ear. The congestion of the middle ear may result in an infection which can benefit from treatment with an antibiotic. Perhaps this is what your doctor means by "dirty stuff," but there is no such thing as dirty stuff in the middle ear.
Sincerely,
Dr. Warren
Thanx for listening and if you have time to help I would appreciate it.
-Fawndly ... Mom of three great kids!!! :o)
Dear Fawndly: Usually the concern about immune deficits is raised by of the nature of infections a child has rather than the frequency of infections. If your child is having primarily the usual childhood upper respiratory infections, these are things to which nobody is immune and the likelihood of catching them is more related to exposure. Exposure can be increased by children drinking from the same glass or sharing utensils. Exposure can be decreased by hand washing which is NOT a usual childhood habit.
If your child is having more serious infections like pneumonia or unusual infections with organisms that usually don't cause problems in healthy children, then your child deserves a thorough evaluation of his immune system.
Some children tend to run high fevers whenever they are sick. The height of the fever does not indicate anything about the child's immune response. If the fevers were all caused by upper respiratory viruses and nothing more exotic, and the child's recovery is uneventful, then the immune system is doing its job. Keep in mind that asthma and allergies can complicate the picture. A cold becomes much more than a cold to an asthmatic since the cold can provoke and aggravate the asthma.
All that having been said, my reassurances can only be general since I haven't seen your child. Even if you are overreacting because of anxiety, a mother should never ignore her instincts. If you don't feel satisfied that your child is okay, ask your doctor to run some tests or refer you to a pediatric immunologist.
Sincerely,
Dr. Warren
The question I have is, how do I go about now in finding a qualified, specialized plastic surgeon for burn scar revision in the western U.S.? We would be willing to travel about in the north west. Her physicians in Salt Lake City have pretty much done what they can. She continues with check ups every six months or so but the area of specialty in cosmetic area is limited.
I really look forward to hearing from you very soon. Please do guide me in the right direction. I see my daughter slipping into a depressive state. She does have some pretty rough scars. We would be very pleased if some revision was possible at least in the arm.
-Concerned Mother
Dear Concerned Mother: When I need a patient of mine to see a specialist, I consult a specialist I know. If his expertise is not sufficient to meet my patient's needs, he refers me to the specialist he sends his difficult cases to. This method if taken to the extreme should lead me to the top person in a particular field. Your pediatrician or the surgeons who took care of your daughter in Salt Lake City should use the same approach, contacting a plastic surgeon they deal with leading them to find the one who has expertise in cosmetic repairs of burns.
Another approach would be to contact your state medical society or the American College of Plastic Surgeons to see if they can help you.
Sincerely,
Dr. Warren
Thanks!
-PR
Dear PR: Your pediatrician is correct that if a child cries right after a head injury and then acts fine afterward, the child is probably fine. Sleepiness, vomiting, and confusion are the most important signs to watch for afterward. In a child who is too young to verbalize discomfort you need to watch for irritability as a sign of pain such as headache. With regard to neck or limb injuries, you should make note of whether or not your child is moving his neck and extremities fully and whether he holds his neck straight or has his head tilted. Even if your child is well, it makes sense to examine your child after a head injury to be sure there are no visible injuries which might require attention.
Sincerely,
Dr. Warren
Sincerely,
-Tara
Dear Tara: I'm not sure what happened to your son by moving in with your mother. Did your mother somehow undermine your authority, or did your son simply change because of the emotional stress of the move, or are you simply seeing your son's personality as it develops? I can't answer those questions, but your son is still only a child. While it is reasonable to be firm with him in order for him to learn to behave, it is not reasonable to be abusive to him, either physically or emotionally. For more information about dealing with your son's behavior, you should read my article, Managing the Difficult Child: School Age Children.
Some children can do well in spite of adversity, rising to the challenge, and other children develop emotional difficulties in spite of being treated well, but it is likely that most children who grow up abused will have lifelong emotional scars as a result. Many abused children grow up to be abusers themselves, continuing a cycle of abuse onto the next generation. Your boyfriend's behavior toward your son is immature as well as abusive. I understand that there are times when our kids drive us nuts and it's hard to like them, but they are children. We can't deal with them based just on how they make us feel. As adults we have an obligation to nurture them as well as discipline them. With an appropriate mixture of affection and discipline, your son could turn into a delightful child to be with, but even the most delightful child has awful moments, just as adults do. If your boyfriend treats your son as unlovable as a result, your son will respond in kind.
Finally, it sounds like you are in the unenviable position of being caught in the middle. You want to maintain a relationship with your boyfriend, but as a result of that relationship you find yourself defending your son against the abuse putting you in the position of having to chose between your adult relationship and your child. Your boyfriend's telling you to "shut up" when you ask him to leave your son alone could be the first step toward his becoming verbally abusive toward you. He may treat his own daughter like an angel now, but given the nature of his responses to you and your son, don't be so sure that he won't be just as verbally abusive to his daughter once she has a mind of her own and places demands on her father or requires discipline.
If you're going to have a continuing relationship with your boyfriend, you need to have a family where both of you are equally parents to both children. To accomplish this, you both need to take some parenting classes and attend counseling to deal with the disagreements and emotional stresses in your lives. Your boyfriend doesn't need to be rid of all his rough edges. Foul language won't hurt the children unless it is directed toward them, and he could be hurtful toward them without ever uttering a four letter word. Your goal is to create a loving household and reach an agreement on how to raise your children. This shouldn't require you to leave your boyfriend, but if he is unwilling to attend counseling and make the effort to change, you may have a choice to make.
Sincerely,
Dr. Warren
-SB
Dear SB: I am not familiar with PETA, so I cannot comment on their agenda. Since you don't refer to your daughter's mother as your wife, I sense that you are not living in the same household. This may tend to aggravate differences of opinion regarding your child's welfare. Even if you were living in the same household, I would have to suggest that you consider counseling to deal with any major disagreements about dealing with your daughter since your daughter will end up caught in the middle, either confused, or forced to choose sides.
It is possible for a vegetarian diet to be nutritious. There are a variety of approaches to being a vegetarian. Some vegetarians include milk, milk products like yogurt and cheese, and eggs in their diet. Since these foods have complete protein, their diets will not be lacking in any vital nutrients. Those vegetarians who do not consume any animal products at all need to use combinations of high protein vegetables in order to get complete protein. If your daughter's diet does not include any animal products, rather than fighting about the issue of whether or not a vegetarian diet is adequate, I would suggest consulting a nutritionist to review her diet and prescribe a mix that will be adequately nutritious. To ensure that her health isn't sacrificed while she is adjusting to her diet, be sure that your daughter sees her pediatrician every 3 to 6 months to be weighed and measured. If the first year of her vegetarian diet shows her growth to be adequate and she and her mother become sufficiently educated about what is necessary to have a nutritious vegetarian diet, I think you can relax.
Sincerely,
Dr. Warren
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