8 January 2001

1. Bloody Diarrhea
2. Risks of Long Term Medication
3. Creatine Safety and Efficacy
4. What are Ketones?
5. Recurrent Fever
6. Vaginal Pain After Swimming
7. Switching from Formula to Milk
8. Joint Pains from Fifth Disease
9. Disclaimer

• Read Questions & Answers in Another Column

Bloody Diarrhea

-BL

Dear BL: Diarrhea may be caused by intestinal infections with viruses or bacteria. This is called gastroenteritis. I assume the test run on the stool was a stool culture to check for bacteria. The negative test may rule out infection by certain bacteria like Salmonella or Shigella. Some labs do not include Yersinia, Campylobacter, or enteropathogenic E. coli as part of their routine culture, so these infections may not have been ruled out. In addition, if symptoms persist, a repeat culture may be in order. Negative bacterial cultures do not rule out the possibility of virus infections, but virus infections don't generally last so long or cause blood in the stool. Bacterial infections often cause high fever and cause the child to be quite ill.

Lactose intolerance can cause or aggravate diarrhea but generally does not result in blood in the stool, although sometimes the blood may appear simply as a result of anal irritation from the diarrhea. Excess fruit juice can also contribute to diarrhea because of the high concentration of fruit sugars. If a lactose free formula doesn't help, lactose intolerance is probably not the cause, but it depends what else the baby is eating and drinking.

Milk protein allergy may cause diarrhea, colic, and intestinal bleeding. This usually becomes evident early in infancy. Lactose free formulas may still have other ingredients such as milk protein which could cause a problem in an allergic child. Such children need to be put on hypoallergenic formulas like Alimentum or Nutramigen.

Parasites would be unusual in a 10 month old, but could account for persistent diarrhea. The test for parasites is a different test than the culture for bacteria. In this instance, I don't know which the doctor did, or if he tested something entirely different.

Finally, with diarrhea and bloody stools, there is the unlikely possibility that the infant could have inflammatory bowel disease. While it is uncommon in infants, I have seen a 4 month old with Crohn's disease. If the symptoms persist, an evaluation by a pediatric gastroenterologist would be in order.

Sincerely,
Dr. Warren

-Lois

Dear Lois: Both Prilosec and Propulsid* have side effects, and, at least theoretically, the longer a person is on a medication, the greater potential that he could experience one of the side effects. There do not appear to be any specific side effects associated with long term use. The thing to keep in mind is that without the medication your son had intolerable symptoms. The medications aim not only at symptom relief, but at healing. Therefore, if your son is tolerating the medications well, he should continue them as long as needed.

Sincerely,
Dr. Warren

-Billy

Dear Billy: In answering a previous young man's question about creatine, I said, "I cannot fully answer your question, but let me explain. In researching your question I looked for medical articles about the safety of creatine. I didn't find any. That means I didn't find any study indicating there was anything unsafe about creatine, but neither was there one establishing its safety, and most especially, I didn't find anything addressing the issue of safety in teens.

"Creatine is marketed as a nutritional supplement rather than as a drug. The FDA rules for nutritional supplements are much less stringent than for medications. That means there is much less study of safety and effectiveness required for nutritional supplements then for medications to be out on the market. Nutritional supplements are a very big business in the US. There is a lot of profit to be made and the hyped advertising stays just barely within the requirements of law regarding false claims.

"The questions you should consider are.

• Why do you need to take creatine?
• Are your expectations for the benefit of creatine realistic or inflated?
• Do you know the appropriate amount for a person your size?

The most recent article I found about creatine was from the Journal of the American College of Nutrition, 1998 Jun;17(3):216-234 in an article titled "Creatine supplementation and exercise performance: an update" by MH Williams and JD Branch from the Department of Exercise Science, Physical Education, and Recreation, Old Dominion University, Norfolk, Virginia 23529-0196, USA. The abstract of that article follows:

Creatine, a natural nutrient found in animal foods, is alleged to be an effective nutritional ergogenic aid to enhance sport or exercise performance. Research suggests that oral creatine monohydrate supplementation may increase total muscle creatine.... Some, but not all, studies suggest that creatine supplementation may enhance performance in high-intensity, short-term exercise tasks ..., particularly laboratory tests involving repeated exercise bouts with limited recovery time between repetitions; additional corroborative research is needed regarding its ergogenic potential in actual field exercise performance tasks.... Creatine supplementation has not consistently been shown to enhance performance in exercise tasks dependent on anaerobic glycolysis, but additional laboratory and field research is merited. Additionally, creatine supplementation has not been shown to enhance performance in exercise tasks dependent on aerobic glycolysis, but additional research is warranted, particularly on the effect of chronic supplementation as an aid to training for improvement in competitive performance. Short-term creatine supplementation appears to increase body mass in males, although the initial increase is most likely water. Chronic creatine supplementation, in conjunction with physical training involving resistance exercise, may increase lean body mass. However, confirmatory research data are needed. Creatine supplementation up to 8 weeks has not been associated with major health risks, but the safety of more prolonged creatine supplementation has not been established. Creatine is currently legal and its use by athletes is not construed as doping.

I found no information regarding kidney or liver damage from creatine supplementation. Neither did I find any information about a substitute. Without knowing just what the substitute is, I cannot provide any additional information.

I hope this answers your question.

Sincerely,
Dr. Warren

Thanks.

-YB

Dear YB: Ketones in the urine occur as a result of the body's burning fat. This can occur when a person is ill and unable to eat, especially if he is vomiting. Fasting will cause ketones in the urine. So will high fat, low carbohydrate diets cause ketones in the urine. Some children have ketones in their urine in the morning just from not eating overnight. After they eat the ketones clear. Uncontrolled diabetes mellitus is the most serious cause of ketones in the urine. When a diabetic doesn't have enough insulin to metabolize the amount of carbohydrate his body needs for energy, his body must burn fat. Ketones are a byproduct of burning fat and they are excreted in the urine.

Sincerely,
Dr. Warren

Thanks,
-LC

Dear LC: While four illnesses with fever in one month is a lot, their spacing one week apart does not clearly indicate that it is all one illness. Whether or not to look further depends on what other symptoms the baby had. If she is losing weight, eating poorly, or has been lethargic, or irritable over the course of the month, then you need to look further. If she has had fever 50% of the days or more over the course of the month, further investigation is warranted. If each fever has been associated with common childhood illness symptoms such as colds or diarrhea, especially if the illnesses were different from each other, additional investigation may not be needed at this time.

You should keep a written log of fevers and symptoms. Make sure you document fever with a thermometer. A parent's impression that a child feels feverish is not sufficient to make a decision about embarking on medical investigations. If the fevers are recurrent your daughter should have a urine culture since urine infections may cause recurrent fevers and cannot be ruled in or out without obtaining a specimen for culture.

If your daughter has persistent fevers, there are many possible causes; however, the testing can become quite involved, so you will want to keep an accurate diary as suggested above and review it with your doctor.

Sincerely,
Dr. Warren

-JL

Dear JL: Since genital pain after swimming is not a common complaint, I cannot tell you what might be causing your daughter's problem. From your description I cannot tell if she is having external or internal pain. If she has external pain from sensitivity to chlorine, a heavy coating of Vaseline or Desitin applied to the area before swimming may help. If the pain is not external, we could be talking about a hernia, gas pains, or muscle cramps related to physical activity. Muscle cramps related to physical activity can be avoided by conditioning exercises which build up to a level of activity rather than overdoing it all at once.

I am sympathetic to your embarrassment at having a doctor examine you, but if you find the experience humiliating, you need to talk to your doctor to see if he can make the experience less distasteful to you. In any event, you should avoid projecting you attitude onto your daughter. When children feel their parents anxiety about a procedure it makes it more difficult for them. At 9 years of age, many girls are not the least bit disturbed by disrobing for the doctor. The doctor can make it easier for her by respecting her need for privacy during the examination. If she continues to have pain or has severe pain, she needs to be examined by her doctor.

Sincerely,
Dr. Warren

Thank You.

-HO

Dear HO: There are two ways you can switch from formula to milk. If your child is on a milk based formula such as Enfamil or Similac, you can make the switch quickly by offering one bottle of milk and the rest of the bottles as formula. Every few days eliminate a bottle of formula and replace it with milk. Continue that way until the baby is drinking all milk and no formula. If the baby is on a soy or hypoallergenic formula, offer the baby an 8 ounce bottle made with 6 ounces of formula and 2 ounces of milk. After a few days, increase the milk concentration by mixing 4 ounces of formula and 4 ounces of milk in the bottle. Then go to 6 ounces of milk mixed with 2 ounces of formula as the final step before going onto all milk.

You should be aware that the American Academy of Pediatrics recommends keeping infants on formula until 1 year of age. When switching to milk, you should switch to whole milk. At 2 years children should be switched to skim milk.

Sincerely,
Dr. Warren

-KW

Dear KW: Fifth Disease is caused by Parvovirus B-19. Arthropathy (joint pains, swelling) occurs in children as well adults with acute parvovirus B-19 infection. In adults, joint symptoms are common and are usually brief and self-limited generally lasting no more than a few weeks, although a chronic arthropathy due to parvovirus B-19 infections can occur occasionally persisting for months or years.

I am not aware of any treatment which can eliminate the virus. If your symptoms persist you should consult a rheumatologist.

Sincerely,
Dr. Warren

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