20 November 2000

1. Persistent Male Breast Enlargement
2. Childhood Sexual Behavior
3. Ear Tag Removal
4. Head Lumps
5. Scaly Infant Rash
6. Empty Stomach for Taking Medication
7. Injection Missed Vein
8. Headache, Vomiting, ? Seizure
9. Disclaimer

• Read Questions & Answers in Another Column

Persistent Male Breast Enlargement

I too was told, at the age of 13, that this enlargement of my nipples would go away with time, but I am here to tell you that I still have this problem, and I cannot see it ever going away on its own.

I would like to ask you what treatments might be available to deal with this situation in adults. Is there a cosmetic surgical technique available, or some other type of therapy, and if so, what exactly might it entail?

I would also like to suggest to you personally that if doctors are still telling their young male patients with this symptom that it will go away on its own with time, perhaps there is a need for further, long term study on it. I have spent the last 12 years of my life, almost daily, despising the doctor that originally told me I had nothing to worry about. Needless to say, going through the most stressful years of one's life, puberty and high school (at least as far as physical appearance is concerned), has most definitely left permanent scars on my psyche. I would also suggest that there are probably quite a few more adult males out there, whom their doctors might think that their problem went away, yet their patients have been too mortified to bring this back up to them.

I won't go on here, as you probably don't have time to read such long letters, but if you desire to hear me elaborate on just how this effects one's life, I would be happy to tell you about it. It is no simple matter, believe me. I've had quite a long time to look back on how this has effected me, and can most likely point to certain problems I have present day that I can credit to this disorder.

I am sorry to be so long-winded, but I look forward to hearing your response, and hope that I will have some way of remedying this problem, even at a later age.

Sincerely
-Dave

Dear Dave: It's unfortunate that you had such a bad experience with adolescent gynecomastia (the term for swollen male breasts during adolescence). It's equally unfortunate that, since you were so distressed by it you didn't pursue the matter. The fact is that most teenage boys who have gynecomastia have a small degree of swelling which will go away on its own. Most of them are very happy to know that nothing is wrong with them, and since it usually goes away on its own, it is appropriate for their doctors to reassure them. If the degree of breast enlargement causes a major social or emotional problem for the boy or it persists into late adolescence, then the boy and his parents should also be informed that a plastic surgeon can do breast reduction surgery. If you read the letters about male adolescent gynecomastia posted on "Ask Dr. Warren," both mentioned the option of surgical treatment. While surgery may seem like a major step, as you can attest, the distress large breasts can cause for a boy is no small matter, and the psychological scars can have profound long lasting effects.

Now it's time for you to consult a plastic surgeon, after which, you should consider consulting a psychologist to deal with the effect your teenage experience had on you. Twelve years of despising a doctor whose advice didn't help you, cannot be good for you. Your anger is eating at you. It's time to let go of it and work on healing yourself.

Sincerely,
Dr. Warren

My husband and I have both talked to our son and he says he got the idea from the clowns at the circus (dropping the pants and showing the funny boxers). He has said that no adults have ever asked to see his rear-end 'adults know better'. My husband and I are satisfied that this is normal behavior, but our care-giver is very afraid and worried that this will happen again, especially when she is watching him. She is also worried that my son will confront her son again, even though he has promised to never do it again.

Is this normal behavior? What can I do to reassure my care-giver (who is very good with the kids) that this will not happen again? Our son is very, very active and if anyone will act on impulses, it is him. He may be borderline ADHD.

Thanks for any help you may be able to provide.

-Beth

Dear Beth: When children have an interest in sexual behavior, it does not always imply that they have learned the behavior from another person, but it certainly is a significant possibility which must be considered. Children have a natural curiosity about their bodies and other people's bodies, but forcing their curiosity on others against their will clearly goes beyond simple curiosity. I believe that your son knew that his behavior was not acceptable even if he lacked the impulse control and judgment necessary to prevent him from acting on his desire to engage in this behavior. Ask yourself if he would have even initiated this behavior in the presence of an adult. If the answer is "no," then you know that he knows adults wouldn't approve, even if he doesn't fully understand why. Your son is bright enough to come up with an explanation for his actions, but clowns don't bare their bottoms or put anything into other clown's bottoms, and their behavior is very public rather than secretive. You know that, and your son knows it.

I'm reluctant to call your son's behavior abnormal. He's only 6 and certainly not a pervert for acting on his impulse. But the average 6 year old does not engage in this kind of behavior. Even if you are satisfied that it is normal, it is totally unacceptable behavior. In fact, bullying younger children for any reason is unacceptable. In your desire for things to be okay, you accepted a contrived explanation from your son, and you may have missed the best opportunity to talk to him about the content of his behavior as well as respecting the rights and bodies of others. In addition, your son has the idea that if he can give you a plausible explanation for the unacceptable, it becomes acceptable.

Your caregiver is right to be reluctant to just trust your son. When behavior goes beyond certain limits, a 6 year old's promise that he won't do it again is not enough. Trust has to be earned. Your son should not be left unsupervised with children younger than he is until sufficient time has passed without any problems for you to be sure he is able to control his behavior. And even though your son is only 6, you need to talk with him in terms a 6 year old can understand about the privacy of the body and other people's rights to that privacy. While you may not wish to talk with him about sex, you need to talk to him about "urges" he may not understand which he must not act on.

Sincerely,
Dr. Warren

My seven year old boy has had a small ear tag since birth and has recently asked us to have it removed. His pediatrician has determined that there is no cartilage involved but then refered us to an ENT for his review. The ENT wants to do additional research but thinks it would be removed under a general. The older members of my family have told me to just tie a thread tightly around it and it will come off on it's own within a week. Now that I have both extremes covered I thought I would ask someone else. I'm a little dubious of the thread idea but I'm dead set against having my son under a general unless there's a better reason than a skin flap. Your opinion please?

Thank you!

-GF

Dear GF: I'm in full agreement with your opinion that a minor cosmetic procedure need not be done under general anesthesia. The risks of anesthesia are small, but are best reserved for more serious matters. Your son can always have the ear tag removed, if he wants, when he is older and can tolerate the procedure under local anesthesia. If the tag is causing a great deal of emotional distress for your son because of teasing or because he feels different, then it may be more urgent to consider having it removed now. If that is the case, you should consult a plastic surgeon who has experience with children. Unless the tag is more complicated than a simple tag, I cannot see why the tag couldn't be removed under local anesthesia even on a 7 year old.

With regard to tying the tag off with thread, the thread must be tied tight enough to cut off the blood supply to the tag. I can't imagine a 7 year old being better off walking around with a suture and dead tissue hanging near his ear for a week or more rather than just leaving the tag alone. I also doubt that he would sit still while the thread is tied or that you would be comfortable tying it as tight as you can as close to his face as you can while he screams. Imagine tying a thread around a piece of yourself (a finger for example) tight enough cut into the skin and stop the circulation it. It's not painless. Then there's the risk of infection. And if the job isn't complete and the tag doesn't fall off the site may ulcerate.

Sincerely,
Dr. Warren

-AB

Dear AB: There are several chains of lymph nodes that can be felt on the back of the head. The post-auricular chain can be felt behind the ear along the mastoid bone. The occipital chain runs down the back of the side of the head. Since there isn't much tissue between the bone an the skin on the head, tiny pea sized lymph nodes may be very prominent, but they are not worrisome. Lymph nodes commonly occur in theses areas in response to scalp inflammations and virus infections. Any persistent or enlarging lymph node should be checked by a doctor to be sure there is no cause for concern.

Sincerely,
Dr. Warren

-Susan

Dear Susan: It is possible that your baby's rash could be eczema, but I cannot tell you if it is since I haven't examined him. Even nursing babies can develop eczema. If a nursing baby has a tendency to develop allergies, he may react to something in his mother's diet.

If the patches are very dry, you might want to try switching to a moisturizing soap like Dove and use a moisturizing ointment like Eucerin after you bathe the baby.

Sincerely,
Dr. Warren

Thanks!

-GC

Dear GC: Most medications are absorbed more quickly and reliably on an empty stomach, but some medications should be taken with food to avoid stomach irritation. In the early days of antibiotic treatment taking the medication on an empty stomach was more of an issue because penicillin G was not stable in stomach acid. Taking Lorabid with food in the stomach reduces the absorption to about 60% and delays the absorption. To a certain extent, this is true for most medication. It is almost impossible to find a time during an infants waking day when you can give him medication on an empty stomach and then keep his stomach empty for two hours. The Lorabid will work just fine even if your son's stomach isn't empty, although, depending on his current dose, your doctor may wish to increase the dosage to ensure adequate absorption. If you do try to give it to him on an empty stomach, you can consider his stomach empty for this purpose even if he drinks water.

Sincerely,
Dr. Warren

My questions are :Is there some treatment that should be done now? Is there some problem with the iodine injected to the hand that can raise later? Can it really be non radioactive iodine as I was told? (I am looking for a second opinion)

Thank you for your kindness

-RK

Dear RJ: Warm soaks may help at this point if there is still some tenderness. Otherwise, no treatment is necessary. The CT scan is not a nuclear scan. The dye which is used for contrast is not radioactive. There should not be any late consequences to the injected material having missed the vein and going into the surrounding soft tissue. Whatever local reaction occurred at the time of the injection should be the worst you will see from this incident.

Sincerely,
Dr. Warren

-JC

Dear JC: A certain percentage of the normal population has abnormal EEGs. If the neurologist is certain that your son did not have a seizure, then the main concern regarding an abnormal EEG would be if it indicated a structural lesion or tumor in the brain. Since the MRI was normal, the neurologist is satisfied that there is nothing to worry about. That's great news, but if your son has persistent symptoms, somebody should be helping him. If your son has headaches and vomiting, he could have migraine headaches. Certainly a neurologist would offer some help for that even with a normal MRI.

Perhaps you should consider getting a second opinion. The place to start would be with your pediatrician. If your son is vomiting, losing weight, and eats more than you do, has he been checked for diabetes? Your pediatrician should do a complete exam including a urinalysis, blood count, and perhaps some blood chemistries. If everything is normal and the pediatrician does not feel comfortable trying treatment for migraines, then he should refer you to another neurologist to review your son's case.

Sincerely,
Dr. Warren

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