25 September 2000

1. Eating But Not Gaining
2. Abdominal Migraine
3. Prednisone and Nursing
4. Absent Little Toe
5. Persistent Yeast Rash
6. Help Me Gain Weight
7. HPA Axis Suppression
8. Child Cross Dressing
9. Disclaimer

• Read Questions & Answers in Another Column

Eating But Not Gaining

Thanking you in advance.

-(unsigned)

Dear Grandparent: Thalassemia minor causes a mild anemia but would not affect growth or weight gain. If your grandchild eats well but doesn't gain weight he needs to be evaluated to determine why he won't gain weight with a good caloric intake. This could happen if he were hyperthyroid because his body would be burning excess calories. If he had diabetes, he would be losing calories by spilling sugar in the urine; however, diabetes would be extraordinarily rare at 3 months, and if he had diabetes for any period of time, he would very likely be quite ill. Your grandson could be losing calories by not absorbing all the calories he eats. This can happen with cystic fibrosis and with certain formula intolerance. Usually formula intolerance causes gas pains and diarrhea. Excessive spitting, vomiting, or diarrhea could also prevent adequate absorption of calories. Since there is a family history of CF, your grandson should be tested. If the test is positive he should see a specialist experienced in dealing with CF. If the test is negative, he should have blood tests to look at his thyroid function and blood sugar and chemistries. If all is normal, you should consult a pediatric gastroenterologist for evaluation of malabsorption.

Sincerely,
Dr. Warren

We discussed this again with our pediatrician, and she did a physical exam. she has diagnosed this as Abdominal Migraines.. She said it is a recently recognized condition affecting primarily children. She has put my daughter on Cyproheptadine..2mg in am and 4mg in pm. We are to follow-up with her in 6-8 weeks to see if this treatment is effective.

I have faith in my pediatrician and trust in her judgment..but I have been trying to find info on this condition so I can educate myself and have not been able to find anything...Can you help??? Where can I find reading material on this condition??? Are there any other changes I can make to help this situation etc. I would appreciate anything you can give me.

Thanks

-AJC

Dear AJC: Abdominal migraine is a rare entity which causes abdominal pain on an episodic basis much as classic migraine causes headache. It need not be associated with headache. Between episodes the patient has no abdominal or intestinal problems. There is no diagnostic test which establishes the diagnosis of abdominal migraine, so other possibilities must be ruled out before the diagnosis is made. Abdominal migraine may respond to the same medications used to treat classic migraine. Cyproheptadine, an antihistamine, is used because it is sometimes effective in preventing migraine. It is not useful for the treatment of acute symptoms. Since migraines are often treated by neurologists, if the cyproheptadine does not help sufficiently, your pediatrician may want you to consult a pediatric neurologist for advice on management.

All of my searches for information on abdominal migraine led me to cyclic vomiting. Although abdominal migraine need not result in vomiting, it often does, and sometimes the most prominent symptom may be vomiting. Cyclic vomiting and abdominal migraine are related disorders. You might try contacting the organization listed below. I found this information on the Web. I hope it is up to date.

Cyclic Vomiting
Abdominal Migraine
Address: 13180 Caroline Court; Elm Grove, WI 53122
Contact person: Kathleen Adams, President
Phone: 414 784-6842
Fax number: 414 821-5494
WWW site URL: http://www.beaker.iupui.edu/cvsa/
Founded: 1993
Number of chapters: 11
Membership: 300

Some additional information can be found in the NORD database at http://www.stepstn.com/nord/rdb_sum/889.htm.

Sincerely,
Dr. Warren

Thank You

-DB

Dear DB: The following information comes from our local poison control center newsletter on lactation pharmacology. The information about prednisone would apply to any steroids.

Prednisone -- Use cautiously in low doses. Long-term effects not known. If doses greater than twice physiologic, consider alternative or discontinuing breastfeeding.

Sincerely,
Dr. Warren

-DS

Dear DS: Any congenital anomaly increases the risk that there may be other associated anomalies. Since the human central nervous system is so complex and the human social structure so dependent on cognitive function, there is always a concern with any complex anomaly that there may be an effect on intelligence. In this instance, the absence of a toe does not necessarily indicate a serious problem, but in association with facial anomalies (the asymmetry of the eyes), increases the risk. In my research I did not find any syndrome specifically associated with an absent little toe. Neither did I find anything associated with asymmetry of the eyes. Since the pediatrician brought it up, he should be asked if he was just speaking in general terms or if he had some specific syndrome in mind. If he has specific concerns, he should explain them to the parents in detail. If there is any major question, the parents should consult a geneticist.

Sincerely,
Dr. Warren

Sincerely,
-Latoya

Dear Latoya : After an inflamed rash the skin may become darker or lighter. The discoloration may persist many months, but unless it is red, scaly, or itchy, the pigment change does not mean there is any more active rash. There is no treatment for post-inflammatory pigment changes except to allow time for the skin color to return to normal.

If the yeast infection keeps recurring you need to look for possible factors which could increase the chances of your daughter getting a yeast infection. If she has been on antibiotics, an effort should be made to keep her off antibiotics when possible. If you are using powder with cornstarch, keep in mind that the yeast is a living organism and the cornstarch is feeding it.

The redness and itching of a yeast infection may clear more quickly by using an antifungal medication combined with an anti-inflammatory steroid, but the steroid in Lotrisone is too strong to use long-term on young children. It is okay for a temporary measure, but with the many recurrences your baby has had, I would not use Lotrisone. If the yeast rash has not responded to Nystatin, you can treat the baby with Lotrimin, the antifungal in Lotrisone. Lotrimin is available without a prescription. If the yeast can't be cleared with a cream, your doctor could prescribe a systemic antifungal like Diflucan.

If there is a major concern or question about the rash, consider getting the opinion of a dermatologist.

Sincerely,
Dr. Warren

I need to gain some weight becuase I think I'm slightly underweight for my age (I'm 13 years old.) I would like to try to reach 110 by the end of the summer. I only weigh 82 pounds with all my clothes on. If you can help me get a slightly "fat" belly, I'd love your advice. If you think that I should try for a higher weight goal, tell me in your response. Please help me!!!

-(unsigned)

Dear Kid Sending Message: You didn't tell me how tall you are or whether you're a boy or a girl, so I cannot determine how reasonable your goal of weighing 110 pounds is, but I can tell you that it would not be reasonable or healthy for you to try to gain 30 pounds (25 -30% of your body weight) in 3 to 4 months. First, the eating habits you would develop by ignoring your natural appetite would not be healthy habits for the rest of your life. Second, the high fat content you would probably have to eat to gain that much weight so quickly would not be healthy for your arteries or heart. Third, the volume of food as well as the fat content required to gain that much weight so quickly would probably upset your stomach. Fourth, exceedingly rapid weight gain could cause stretch marks on your skin and cause you to look flabby rather than better. Fifth, you may have more trouble than you think adjusting to a body that has changed so dramatically and so quickly.

There is nothing beneficial about becoming fatter. Healthy children gain weight as they get older because they are growing, not because they are getting fatter. Usually people who want to gain weight need to put on muscle to improve their appearance. While this may require more calories and protein in the diet, the main thing that is necessary to build muscle is resistance exercise such as weight lifting. The ability to put on muscle is also affected by body maturity. Before puberty, boys and girls can't bulk up by lifting weights and shouldn't try because to the risks to their growing bones and ligaments. Body shape is also affected by puberty. If you haven't started puberty and you're comparing your body to the bodies of friends whose bodies are developed already, you' simply need to be patient and allow time for your body to do what it's going to do. You can't make yourself have a more mature body build by getting fatter. You also have to consider genetics in setting reasonable goals for your self. Your body build is inherited. If your parents have a slim build, you will probably have a slim build too.

Assuming that you really do need to gain some weight and are willing to be patient enough to do it safely and reasonably, the best way to do it would be to drink malteds or milk shakes after a meal. If you drink it before or during the meal, you will lose your appetite for your food. You could try something like Carnation Instant Breakfast added to whole milk for extra calories, protein, vitamins, and minerals. Before you start anything like that, you should make sure your goals are reasonable. You should make sure your parents know what you want to do and have your pediatrician review your growth with you to set reasonable goals. If you want to contact me with information about your height and gender, I could tell you what a reasonable weight goal is. But keep in mind that whatever your goal is, you cannot go on an unhealthy, unnatural diet to try to achieve your goal at an accelerated pace.

Sincerely,
Dr. Warren

-LH

Dear LH: HPA axis suppression means hypothalamic pituitary axis suppression. This usually refers to the effect that therapeutic doses of steroids have on the body. Steroids are normally produced by the adrenal gland in the amount needed by the body. The adrenal gland is stimulated to produce steroids by a hormone called ACTH produced by pituitary gland. When the level of steroid in the body is sufficient to meet the bodies needs, the steroids the hypothalamus, a part of the brain, sends a message to suppress production of ACTH by the pituitary gland. As a result of the decreasing level of ACTH, the adrenal gland produces less steroids. This feedback loop between the pituitary and the adrenal keeps the amount of steroids produced by the adrenal in the range needed by the body.

When steroids are given to patients as medications, if the dose is high enough to be at or above the amount normally needed by the body, ACTH production by the pituitary gland will be suppressed. As a result, function of the adrenal gland will be suppressed. When the steroids are given for a long time, HPA suppression is a concern because it takes time for normal HPA function and adrenal function to return. As a result, if the steroids are stopped abruptly, the patient's physiologic (normal) need for steroids will not be met and the patient could go into shock.

This all becomes a theoretical concern with steroid creams because the amount of steroid absorbed into the body is rarely sufficient to affect adrenal function unless a large portion of the body is covered with a potent cream for a long time. If that is the situation, your daughter should be monitored by her doctor.

Sincerely,
Dr. Warren

Now, he wants a tutu after seeing the girls in his Kindergarten performing a dance recital. I asked him how it makes him feel to wear the Barbie outfit. He whispered (with an embarrassed look on his face) that he felt "beautiful." He says he's a big fan of girls, that's why he likes it. He did admit that he wishes he were a girl "just a little bit."

He has always seemed "all boy" to me with this exception. He sees commercials for toy guns and says he wants one. He plays hard and is usually the leader. At the same time he is a sensitive child who uses "Blankie" to wipe his tears.

So, in your opinion, is he developing into a cross-dresser? Or is this likely a phase that will pass as he matures? If he is a cross-dresser, what is the healtiest way we, as parents, can handle it?

Any insight would be most helpful!!!

-GEB

Dear GEB: By 5½ years of age gender identity is very well established. Boys know they're boys. Girls know they're girls. And both know what the culturally accepted norms of behavior are. This explains your son's embarrassment and his desire to keep his behavior a secret. Keep in mind that cultural norms vary from culture to culture and within cultures. In many native cultures men wear a great deal of colorful makeup, clothing, jewelry, and head gear. In our western culture many men (including from "tough" neighborhoods) wear gold chains and rings that the previous generation would have considered unmanly. The same can be said about long hair and earrings. While these differences point out how much the norms are determined by a particular culture, the fact is that your son is fully aware that his preferences include clothing that is meant for girls. Is this desire to "feel beautiful" his reason for wishing to be a girl "just a little bit?" Or is there a greater degree of gender identity confusion? From your description I suspect that your son's issues revolve around clothing, but if he should express the desire to be a girl or regret about being a boy, you might want to explore the issue with the help of a professional.

Many cross dressers state that they remember wanting to dress in women's clothes in early childhood, so it is clear that these preferences can develop early, long before children can understand what it all means. But not every boy who plays with women's clothing becomes a transvestite. Many boys go to the dress up corner in nursery school and put on high heels and a purse so that they can play the mommy, but it is more make believe for them than a preference. Your son's expressed interest in being beautiful suggests that it is more than play to him, and yet only time will tell. I don't believe there is any evidence that intervention at this age can change whether or not your son will be a cross dresser, but there is no question that such activities can cause guilt feelings even when parents understand. And there can be related tensions in the household due to unsolicited input from friends and relatives, or even disagreement between the parents. Therefore, you would be well advised to consider professional counseling early on should there be any sign that you or your son are having difficulty coping with his behavior.

My first concern about how you, as parents, are handling the situation, is your son's expressed desire to "not tell Dad." I do hope that Dad is aware of what's going on. It cannot do your son any good to feel he has a big secret from Dad. Nor can it be good for him to believe that he can make you an accomplice in keeping secrets from Dad. Both you and Dad need to become fully educated about cross dressing so that neither of you will be dealing with your son's behavior out of concerns created by myths and misinformation. If you have not discussed your son's behavior with your husband, you must. If you have concerns about letting your husband in on what's going on, then you need the intervention of a counselor who can also start educating you on the subject. If your husband is already aware of what's going on, your son needs to know that Dad knows, and he also needs to know how Dad feels about it. Keep in mind that it is possible to reassure your son that you love him and accept what he is doing without telling him that you approve of it.

Your ultimate goal, if your son should be a transvestite, is for him to understand that what he is doing is not socially acceptable enough for him to go public. For his own protection he needs to understand the need for keeping his behavior private. But he also needs to know that there are other boys with the same interests. Try to make sure he doesn't develop a sense of guilt about playing with women's clothes, but don't create such a structureless environment that he doesn't know and understand that you expect him to wear boys clothes. It's fine to accept that he loves women's clothes, but you can't encourage him to pursue his interest without sending mixed or confusing messages about your expectations. If possible, help him find socially acceptable outlets for his desire to dress up such as participation in theater.

Sincerely,
Dr. Warren

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