23 October 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
What can be done to relieve the pain....the baby is only 3 wks old and is supposed to have a scope done on Thursday....
-SP
Dear SP: The dangers of ulcers are not age related. Other than discomfort, the main risks would be perforation and bleeding. I must admit I've never heard of an ulcer in a 3 week old. I have to wonder what would even make a physician consider that diagnosis. Is it possible the doctor is looking for gastroesophageal reflux rather than ulcer disease?
In a baby so young where another physician is in the process of doing a diagnostic evaluation, I could not recommend any treatment for symptoms. Proper treatment depends on the diagnosis. The specialist who is doing the endoscopy will advise you regarding treatment.
Sincerely,
Dr. Warren
Sincerely,
-Angella
Dear Angella: At 38¼ inches your 5 year old's height is below the 3rd percentile. She certainly deserves an evaluation by an endocrinologist to determine why she is so small. There are many causes for short stature besides growth hormone deficiency. The use of growth hormone to treat any cause of growth failure besides growth hormone deficiency remains controversial, especially since it is unknown whether or not the child's final height will be altered by such treatment. Even if a child's height is below the 3rd percentile, if his growth rate is adequate, treatment with growth hormone may not accelerate the growth rate. Usually the child's growth rate is just as important as the child's height in deciding whether or not to treat with growth hormone.
Other causes of short stature or poor growth include other gland disorders such as hypothyroidism, heart disease, chronic infection such as urinary tract infection, kidney disease, and most commonly genetic or familial growth patterns. The purpose of seeing the specialist is for evaluation and to discuss treatment options based on the results of the evaluation. You could leave the evaluation with a reassurance that no intervention is necessary. Endocrinologists do not routinely recommend growth hormone treatment unless the patients growth pattern meets certain criteria for trying such treatment or the patient is found to have growth hormone deficiency.
The incidence of side effects from treatment with growth hormone is low. Growth hormone is given by injection which means the parents or patient must learn to give the injections. Side effects reported with growth hormone include headache, flu like symptoms, localized muscle pains, weakness, mild elevation of blood sugar, sugar in the urine, cough, respiratory symptoms, upset stomach, and edema. Leukemia has been reported in a small number of children who have been treated with growth hormone. The relationship, if any, between growth hormone therapy and leukemia is uncertain. Patients with other glandular disorders, including diabetes and hypothyroidism, may need their treatment adjusted if they take growth hormone. Children receiving growth hormone may be at increased risk for developing slipped capital femoral epiphysis and so should have any limp developing during therapy evaluated. Intracranial hypertension with papilledema, visual changes, headache, nausea, and vomiting has been reported. These symptoms generally occurred within the first 8 weeks of therapy and resolved with reduction of the dose or discontinuation of growth hormone therapy. Patients with any active tumor should not receive growth hormone since it may increase the growth of the tumor.
Sincerely,
Dr. Warren
My step-daughter has been a stay-at-home mom throughout her son's life, and he is very attached to her. She will have physical custody of him after the divorce, as her husband has no plans to contest this. However, her husband wants significant visitation rights, such as having his son for the entire summer. My step-daughter feels that three months is too long for a 3-year-old to be away from his primary residence and caretaker. In fact, she's not sure than even a week away from home is appropriate for a 3-year-old and would rather work out a way for her soon to be ex-husband to come and visit his son here, with only a few, 3-day-weekend visits to Daddy's house until the child is a bit older. She understands her son's need to have his father prominent in his life, and also her husband's need (and right) to play an important role in his son's life, and thus wants to be fair about visition, but she is primarily concerned with her son's emotional well-being.
Do you have any advice, or guidelines, regarding what lengths of time away from home are appropriate for chidren? (I realize much of this decision depends on the emotional maturity of the child, also.) This information will be very useful for children leaving home to spend time with grandparents, go to summer camp, etc. Thank you for any advice you can give us!
If you use this letter in your column, please do not use my name. We very much appreciate your accessibility over the Web!
-HP
Dear HP: There is no simple answer because so much depends on the relationship between the child and each of his parents as well as the personality of the child. An equally important factor would be the arrangements for child care in the non-custodial home during the long visits. Three months is a long time for a 3 year old to be away from his mother, but 9 months is an even longer time for him to be away from his father. Divorce and the changes it brings to children's lives is difficult no matter what. If a child of divorce has 2 loving parents, maintaining the relationship with both of them is of equal importance. Just as the child of divorce has to get used to not being with the non-custodial parent on a day to day basis, he has to get used to separation from the custodial parent in order to maintain the relationship with the non-custodial parent. Vacations spent with the non-custodial parent usually provides the least disruption to the child's life allowing him to establish a school and activity routine which is not significantly disrupted by visitation. If the child suffers some short term separation issues, they may be a necessary price to pay for the long-term good relationship with the non-custodial parent. If the relationship with the non-custodial parent languishes early on, it may not be able to be restored when the child is older and has fewer separation issues. Strengthening of the relationship with the non-custodial parent should help to ease the separation problem.
Even if the boy's father plans to have him for 3 months of the summer, I cannot imagine that Dad will go the remainder of the year without seeing his son. The same concept can apply to the boy's summer with Dad. Just because the boy gets a taste of living with Dad for 3 months during the summer does not mean that Mom cannot see him during those 3 months. Mom should have the same kind of visitation during the summer that Dad has during the remainder of the year. And always, the boy's needs, wants, and opportunities to enjoy special occasions should take precedence over a visitation schedule.
Sincerely,
Dr. Warren
History:
At about 6 months we successfully fed her rice cereal for 1 week, then barley for 4 days, at which point she got her 6-month immunizations (don't know if this is related). That night, 3 hours after feeding her barley, she started vomiting. Two days later we tried rice, with the same response. Just to make sure, we performed an upper GI barium scan, which showed everything should be normal. The pediatrician said to hold off solids for one month and try again.
One month later we tried oatmeal cereal (for the first time), with the same results. The next day we tried bottled vegetables with no problem. After feeding bottled vegetables and fruits for three weeks we tried feeding her rice (mixed with her normal vegetables) that we had boiled to mush (to rule out any potential processing causes). 3 hours later (right on schedule) she vomited again.
The pediatrician thinks it may be a gluten allergy, though he is not sure. He indicated we would need to do an intestinal biopsy when she is older to properly diagnose it. Meanwhile just feed her fruits, vegetables, and meats.
What is your opinion? Might this be a gluten allergy, or perhaps coeliac disease? Based on what I have seen on the internet people allergic to gluten can generally eat rice, which is definitely not true in this case. Also, it seems the symptoms for gluten allergy/coeliac disease are bloating, discomfort, and diarrhea, of which our daughter has none. What other possible causes are there for this type of delayed reaction? Should we be on the lookout for any other related symptoms?
Thanks in advance for your reply.
-SP
Dear SP: Gluten is a protein found in wheat, rye, barley, and oats. According to Nelson's Textbook of Pediatrics, only the gluten in wheat and rye have been shown to cause gluten enteropathy. The most common symptoms are chronic diarrhea, irritability, vomiting, and failure to grow and gain weight. Not all symptoms need be present and the diagnosis must be considered in a child who is anemic and failing to thrive even in the absence of the intestinal symptoms. An intestinal biopsy is necessary to establish the diagnosis; however, if the child is on a gluten free diet the biopsy will be normal. Other names for gluten enteropathy are celiac sprue, childhood celiac disease, and nontropical sprue. Since the condition is life long, it is an important diagnosis to make.
Since rice is not known to cause gluten enteropathy, it is possible that some other ingredient common to the cereals is responsible for the problem. The ingredient causing the problem may even be related to the processing of the infant cereals rather than to the cereal. That's just a hypothesis to consider, since I don't know what else is in the cereals besides the grains. I did once have a patient who became pale, unconscious, and vomited every time he ate oats. We never established a diagnosis, but the problem resolved as he got older. At this point, I would consider it reasonable to simply keep your baby off cereal and allow her to thrive; however, since grains are such a large part of the diet, at some point you will want to try reintroducing them, and if the result is the same, further evaluation by a gastroenterologist, and possibly even an allergist, will be necessary.
Sincerely,
Dr. Warren
My son not only doesn't want to go to bed at bedtime, but only wants to go to bed when I do. Then he wants to sleep with me. I have tried cutting out the nap in the afternoon, but by 5:00 he is so overtired and crabby that not only can I not stand him but the neighbors in our apartment building cant stand him. If I have cut out the nap by 6:00 he is falling asleep and by 7:00 he is completely out, then he is up by 4:30 or 5:00am.
When he is on visitation with his father, I am confident that he allows him to sleep with him because he only gets to see him once a month and therefore spoils him. Every night and every afternoon we argue and battle the going to sleep issue. At night the war lasts 3-4 hours and in the afternoon it lasts 2 hours. I put him in his bed and I sit beside him until he falls asleep or is drowsy. The first slight sound he hears from me he wakes up and screams his lungs out. I leave and he comes out again. I put him back in his bed and he comes back out. After about a half an hour of this I am slightly frustrated, if not livid. I will spank, just enough for him to know that I mean business. I put him back in his bed, and he is usually following me out of the room. Then I will spank harder, same situation over and over until I am near tears or near falling asleep myself. This is an EVERY NIGHT thing. I am trying to be as consistent as possible. Then once he has fallen asleep for the night, a hour or two later he wakes up again and the process starts all over again. A lot of the time he will sneak into bed with me, and I don't even know it until it is AM. After he has fallen asleep for the second time, approximately 2 hours later he will wake up again and scream his head of for hours unless I do something. The neighbors nor I take kindly to a kid screaming for hours at 2 am. Then when it is time to go for the day, he is tired and wants to sleep till 10 or 11. I love him very much, but he is driving me nuts and my friends don't have a clue what to say about him.
He is also self abusive. He bites, slaps, bangs his head on the floor and bites and slaps others. He has seriously hurt himself and the other doctors say " he'll grow out of it". He has been doing that for about a year. I have always had sleep problems with him since the first night I brought him home.
He NEVER listens to a word I say, he has no respect for me. He is very destructive. He also will want to touch a hot object, when he was previously burned by it a week ago, or he wants to run out into the street when there are cars coming. I thought maybe at one point it was a attention getter, but I don't feel that way anymore.
Do you see why I am frustrated? My friends see how he runs me ragged and insane and I am at my ropes end. Please help,
Depressed and tired,
-Stacey
Dear Stacey: When I started reading your e-mail, I thought that perhaps your son was reacting to inconsistent discipline as a result of living in two households. I was prepared to suggest several possibilities to establish control over keeping him out of your bed as a first step. The first would have been to lock him out of your room. Even if he didn't sleep in his bed he would have to learn to stay out of yours. Once learned, you could try to establish more control over the going to bed process. The other possibility was to consider eliminating his nap. Even if he were up early, establishing a pattern of going to sleep in his bed and sleeping the night would be a first step toward developing good sleep habits.
But then I read more of your e-mail where you talked about his being self abusive, biting, banging his head, and slapping. I read how he hurts others, that he doesn't learn from painful experiences, that he doesn't listen to you or respect you, that he has been a difficult child since day one. And I asked myself, "Is this a normal child, or does he have a neurological problem or psychiatric problem?" I can't tell you how many parents whose children were schizophrenic or neurologically impaired endured years of difficult behavior from their children along with years of guilt about their inability to deal with their children, until a diagnosis was made. These children require a highly structured environment of a type that doesn't come naturally to parents. Professional counseling can help establish the techniques necessary to deal with these special needs children. Medications can also help. But the most important thing which may come from a proper diagnosis is understanding. The parents no longer feel inadequate. They can stop listening to all the unsolicited advice and explain to all those who will deal with their child what the realistic expectations should be for the child's behavior. They can hold their heads high and maybe get an understanding or sympathetic look instead of a disapproving glance as they walk past their neighbors. Do you see yourself in this picture?
Take your son for a complete neurological and psychiatric evaluation. If there is no medical problem contributing to his behavior, at least get professional counseling to learn how to deal with him. Don't let anyone make you feel guilty. You have a difficult child. You need help.
Sincerely,
Dr. Warren
-Mom A
Dear Mom A: The lower limit of normal for an infant's hemoglobin is 11.0. A hemoglobin below 10 is a significant anemia. Hemoglobin levels below 9 would be unusually low for beta thalassemia trait; however, children with thalassemia trait have a stable hemoglobin and do not require transfusion even at those levels. Transfusion becomes a more urgent issue in patients who have blood loss or whose hemoglobin levels drop rapidly.
Diarrhea does not cause anemia; however, during any prolonged illness, there may be a decrease in red blood cell production resulting in some degree of anemia.
Iron supplements are not useful for treatment of thalassemia trait; however, even if your daughter has thalassemia trait she could be iron deficient. Your pediatrician will have to interpret the results of the blood work to determine if iron supplementation would be useful. If your daughter was formula fed with a formula that wasn't fortified with iron, she could be iron deficient.
Sincerely,
Dr. Warren
-DS
Dear DS: Mental health care, just like medical care, is provided mostly by local practitioners. I'm not aware of any national agencies to which I could refer you. You should investigate your local mental health facilities to determine what your best options would be. Your pediatrician, who should be familiar with the psychologists and mental health facilities in your area should help you find an appropriate treatment facility. Do not be discouraged by your prior experience. It sometimes takes a while to find the right therapist, but if your son has persistent behavior problems, it is worth the effort to find him the right kind of help.
Sincerely,
Dr. Warren
Thanks,
-CNN
Dear CNN: The condition in which one or more sutures in the skull fuses prematurely is called craniosynostosis. Repair of craniosynostosis is major surgery. It is not done just for cosmetic reasons. If a child has craniosynostosis the head cannot grow properly and that puts pressure on the brain. The diagnosis of craniosynostosis can be made by doing a CAT scan of the head. If your pediatrician has any concern that your child has craniosynostosis, he could arrange for your child to have a CAT scan or refer him to a neurosurgeon or craniofacial surgeon for evaluation.
Many infants have flat spots on their heads from lying on the same spot all the time. This often improves when the child starts to spend more time sitting up. Some infants actually develop a tightening of the neck muscle from keeping their heads turned onto the flat spot. This aggravates the flattening of the skull and requires that the parents make a conscious effort to position the baby so that he will turn his head in the other direction. Sometimes it is necessary to do head rotation exercises with every diaper change to stretch the neck muscle. I have also heard of helmets that help to remold the shape of the head, but I have never used one with any of my patients, so I cannot recommend them.
Flattening of the back of the head or one side of the back of the head has become more common in the USA because more babies are sleeping on their backs in accordance with the current recommendations to reduce the risk of SIDS.
Sincerely,
Dr. Warren
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