5 February 2001
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
-WG
Dear WG: Colic can be an extremely distressing problem for both parent and infant. If a baby has a formula sensitivity, changing formula can help. It may take up to a week to see an improvement after changing formula. There are a variety of hypoallergenic formulas such as Nutramigen, Alimentum, or Pregestimil, which can be tried. If a baby is gassy, Mylicon drops may help. If the baby is constipated (stools are formed to hard) a formula change, a little prune juice, or a medication like Malt Supex may help.
You should try not to use rectal stimulation or suppositories unless absolutely necessary so that the baby has an opportunity to develop his own natural rhythm. If the baby's stools are liquid to soft and he is still unable to have bowel movements without stimulation, then you should consult a pediatric gastroenterologist to make sure that the baby does not have anal stenosis (the opening too tight) or Hirschsprung's disease ( a congenital condition where a segment of the lower intestine does not propel stool forward into the rectum).
Some colicky babies scream a lot not only because of pain, but also because they are easily stimulated and have a low threshold of tolerance for internal as well as external stimuli. These high needs babies leave their parents frustrated and exhausted. As they get older, the situation can improve considerably, but during the early months their parents need some relief. It is important to have some time away from the baby. Even a small break can be very restorative. It is also important not to run for every cry. While I don't advocate ignoring cries or letting babies scream, when an exhausted, overwrought mother keeps dropping everything to try to comfort an infant and then succeeds in getting only a few peaceful moments to get something done, the mother is constantly caught between her infant's demands and her other responsibilities. Sometimes it would be more reasonable to try to complete the task at hand and when it is done, take care of the baby. That way Mom can be more relaxed and spend time with her baby without worrying about what else she has to do. When Mom is calm and relaxed, it is easier to comfort the baby.
Sincerely,
Dr. Warren
-Eduardo
Dear Eduardo: I am not aware of any web site which would provide the information you are looking for. The complications of prematurity can include respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, apnea, retinopathy of prematurity, jaundice, necrotizing enterocolitis, sepsis - just to name a few. Whole books have been written on these subjects. As a medical student, you will need the kind of detailed information that can be found in books like Schaeffer and Avery's "Diseases of the Newborn" and Klauss and Fanaroff's "Care of the High-Risk Neonate." I'd suggest a visit to your school library rather than the Web.
Sincerely,
Dr. Warren
I am now looking for:
Thank you very much for listening and I hope for answering me.
- Shauna
Dear Shauna: The problem of sensorineural hearing loss should be dealt with by an ENT surgeon (Otolaryngologist) and an audiologist who is experienced in dealing with hearing aids in children. Based on your doctor's position as chief of and ENT facility, I'm sure his credentials are excellent. If you wish another opinion, he could probably direct you to the tops in his field.
The best treatment could depend on the cause of the hearing loss and the child's response to hearing aids. A cochlear implant can be used to treat sensorineural hearing loss. Your ENT surgeon would probably be the best person to tell you if your daughter meets the criteria for such surgery.
Sincerely,
Dr. Warren
Another major concern of mine, is he has had a cold for 7 weeks now that has resulted in two ear infections in the same ear. He has been on Rynatus (sp?) for 2 weeks now and he hasn't gotten over the cold. He coughs every day and night and now he is so hoarse I can't hear him cry. I know he is miserable and I don't know what else to do for him. We have been to his ped 4 or 5 times during this stretch to keep checking his ears and I think he thought the virus would get over with and he would be okay. He is in daycare setting unfortunately, but I need to do whatever I can to help my baby get better. I already make him as comfortable as I can with a humidifier, salt drops, and the Rynatus but I know he can't be on it forever. Could there be a deeper underlying problem? Thank you so much for your help, I just feel so stressed because I feel everything I do is the wrong thing. Thank you.
-Laura
Dear Laura: The traditional order for introducing foods to infants provides the foods which are least likely to cause any problems as the first foods. The order is cereal, fruit, vegetables, meats, and later yogurt, eggs, fish. It often takes time for an infant to adjust to a new food, so if your baby is happy and feeding well, don't rush to discontinue a food because of a change in bowel habits or a rash (as long as it isn't hives).
Colds don't last seven weeks, but children in daycare sometimes go from one cold to another without a break. Cold medicines provide symptomatic relief, but nothing cures a cold. Only give cold medicine if the symptoms are bothersome to your child. As long as he doesn't have any undesirable side effects from the medication you can continue to give it when needed.
Persistent cold symptoms in a sick child could suggest a sinus infection. Colds don't respond to antibiotics, but sinus infections may require 2 to 3 weeks of antibiotics.
Sincerely,
Dr. Warren
Thank you.
-Nancy
Dear Nancy: The term growing pains refers to a variety of childhood leg pains, most typically evening or nighttime leg pains. They occur at the end of the day when the muscles cramp after a day of use. If your daughter is not having any daytime pains, limp, or pain that interferes with activity, you probably don't need to worry. The asymmetry could suggest that your daughter's left leg muscles get more stressed. This does not imply anything serious, but could be something as simple as a flat foot or some other cause that puts more stress on the left leg. If the pains are severe, you might want to have her checked by an orthopedist.
Sincerely,
Dr. Warren
-(unsigned)
Dear Parent: If your baby takes cold formula well, by all means give it to him that way. I can't think of any reason it would be harmful.
Sincerely,
Dr. Warren
Thank-you.
-LB
Dear LB: Before you proceed with treatment, a diagnosis must be made. Reflex Sympathetic Dystrophy Syndrome (RSDS) seems a much greater likelihood than Multiple Sclerosis (MS) since the symptoms follow treatment for a fracture (one of the things which can lead to RSDS). If, based on your doctor's examination, MS is a real possibility, then your daughter should be evaluated by a neurologist. An MRI of the brain may help in making the diagnosis.
RSDS is often treated and evaluated by rheumatologists. You should have your daughter evaluated by a pediatric rheumatologist or a pediatric orthopedist who has experience with RSDS.
The following information is quoted from Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company
REFLEX SYMPATHETIC DYSTROPHY This disorder is a form of local causalgia, usually involving a hand or foot but not corresponding to the anatomic distribution of a peripheral nerve. A continuous burning pain and hyperesthesia are associated with vasomotor instability in the affected zone, resulting in increased skin temperature, erythema, and edema due to vasodilatation and hyperhydrosis. In the chronic state, atrophy of skin appendages, cool and clammy skin, and disuse atrophy of underlying muscle and bone occur. More than one extremity is occasionally involved. The pain is disabling and is exacerbated by the movement of an associated joint, though no objective signs of arthritis are seen; immobilization provides some relief. The most common preceding event is local trauma in the form of a contusion, laceration, sprain, or fracture days or weeks earlier.The following information about Causalgia Syndrome written by Dennis E. Hughes DO is quoted from Dambro: Griffith's 5-Minute Clinical Consult, 1998 ed., Copyright, © 1998 Williams & WilkinsSeveral theories of pathogenesis have been proposed to explain this phenomenon. The most widely accepted is reflexive overactivity of autonomic nerves in response to injury, and regional sympathetic blockade often affords temporary relief. Physiotherapy also is helpful. Some cases resolve spontaneously after weeks or months, but others continue to be symptomatic and require sympathectomy. A strong psychogenic component is suspected in some cases but is difficult to prove.
For additional information and support, check the RSDS Web site at http://rsds.org/
- DESCRIPTION
Pain syndrome following injury to bone and soft tissue.
Pathogenesis is obscure.
- System(s) affected: Nervous
- Genetics: No known genetic pattern
- Incidence/Prevalence in USA: Unknown
- Predominant age: No predominant age
- Predominant sex: Male > Female
- SIGNS AND SYMPTOMS
- Deep aching pain
- Burning pain with superimposed lancinating pain
- Hyperesthesia
- Hyperalgesia
- Pain from a non-noxious stimulus
- Pain most likely in palm or sole, aggravated by minimal physical stimulus such as friction or heat
- Skin - discolored, edematous, cold, hyperesthetic, smooth, glossy
- Stiff joints
- Nails curved and brittle
- Hyperhidrosis
- CAUSES
- Partial interruption of nerve conduction by injury, such as gunshot wounds. Possible shunting of efferent sympathetic impulses into sensory fibers at site of injury in a mixed nerve.
- Reflex sympathetic dystrophy
- RISK FACTORS
DIAGNOSIS
- Trauma
- DIFFERENTIAL DIAGNOSIS
- Rule out infection, hypertrophic scar, bone fragments, neuroma, central nervous system tumor or syrinx
- LABORATORY TESTS
- none
- PATHOLOGICAL FINDINGS
- Partial or complete damage to afferent nerve pathways and probably reorganized central pain pathways
- Most common nerves involved are median and sciatic
- Atrophy in affected muscles
- Incomplete nerve plexus lesion
- SPECIAL TESTS
- none
- IMAGING
- Bone scan
- DIAGNOSTIC PROCEDURES
TREATMENT
- Intravenous regional sympathetic block with guanethidine or reserpine (this is a specialized anesthetic technique that may also be therapeutic)
- APPROPRIATE HEALTH CARE
- Outpatient, except for operative procedures or intravenous sympathetic nerve blockade
- GENERAL MEASURES
- Treatment is empirical
- Anesthetic blockade (chemical or surgical) of sympathetic nerve function (transient relief suggests that chemical or surgical sympathectomy will be helpful)
- Intravenous regional sympathetic block with guanethidine or reserpine by pain specialist or anesthetist
- Physical therapy (essential during all phases of treatment)
- Transcutaneous electric nerve stimulation (controversial)
- Inject myofacial painful trigger points
- Briskly rub the affected part several times per day
- Acupuncture can be tried
- Hypnosis
- Relaxation training (alternate muscle relaxing and contracting)
- Biofeedback
- Discourage maladaptive behaviors
- Refer the patient to a specialty pain clinic in difficult cases
- SURGICAL MEASURES
- Sympathectomy sometimes necessary
- ACTIVITY
- Maintain as high a level of physical and intellectual activity as possible
- DIET
- No special diet
- PATIENT EDUCATION
MEDICATIONS
- Stress staying active physically
- Careful instructions about any prescribed medications
- DRUG(S) OF CHOICE
Contraindications: Refer to manufacturer's literature
- Following agents reported to be of benefit in some cases:
- Prazosin, 1-8 mg orally in divided doses
- Phenoxybenzamine 40-120 mg daily, orally in divided doses. The initial dose should not exceed 10 mg.
- Nifedipine 10-30 mg tid
- Prednisone 60-80 mg/day orally, tapered over 2-4 weeks
- Tricyclic antidepressants (see manufacturers recommended dose)
- Anticonvulsants. (Require serum drug level monitoring, except for clonazepam. Doses must be individualized.):
- Carbamazepine 200-1000 mg/day orally
- Phenytoin 100-300 mg/day orally
- Clonazepam 1-10 mg/day orally
- Valproic acid 750-2250 mg/day orally, maximum of 60 mg/kg
- Skeletal muscle relaxant:
- Baclofen 10-40 mg/day orally - may act synergistically with carbamazepine and phenytoin
Precautions: Refer to manufacturer's literature
Significant possible interactions: There are many with this group of drugs. Refer to manufacturer's literature.- ALTERNATIVE DRUGS
FOLLOW-UP
- Narcotics - only after all non-opioid therapies are exhausted
- Other alpha-adrenergic blockers or dihydropyridine calcium channel blockers may be tried though experience with them is limited
- PATIENT MONITORING
- Watch carefully for adverse reactions to medications
- Several different forms of therapy may need to be tried
- PREVENTION/AVOIDANCE
- Mobilization following injury
- Avoidance of nerve damage during surgical procedures
- Splinting of an injured extremity for adequate period of time
- Adequate analgesics during recovery from injuries
- POSSIBLE COMPLICATIONS
- Drug mishaps
- Joint contractures
- Contralateral spread of symptoms
- EXPECTED COURSE/PROGNOSIS
MISCELLANEOUS
- Course - variable; chronic; remitting
- Outlook only satisfactory, may need attempts at several treatment modalities. No one form of therapy is superior to others. Failure to respond to one form does not mitigate against success with another.
- Those patients receiving work compensation for an injury or secondary gain from family or friends are in a separate category and may never get well
- ASSOCIATED CONDITIONS
- Serious injury to bone and soft tissue
- Herpes zoster
- AGE-RELATED FACTORS
- Pediatric: none
- Geriatric: Painful perception is frequently worse in older patients. Start with smaller than usual doses of drugs.
- Others:
- Postherpetic neuralgia is a result of partial or complete damage to afferent nerve pathways
- Pain occurring in dermatomes as a sequela of herpes zoster
- SYNONYMS
- Erythromelalgia, traumatic
- Weir Mitchell causalgia
- Minor causalgia
- Reflex sympathetic dystrophy
- Posttraumatic neuralgia
- Sympathetically maintained pain
Sincerely,
Dr. Warren
Thanks,
-Debbie
Dear Debbie: There's no question that I'm seeing a lot more babies with flattening of their heads since we started recommending that babies sleep on their backs. Most of these heads will round out nicely once the child starts spending more time upright. If your grandson keeps his head turned toward one side, his mother should make sure he doesn't develop a tightness in his neck muscles by rotating his head toward the other side with each diaper change. The child should not be put in on his stomach. Even though the incidence of SIDS was low in this country, it has dropped as a result of putting infants in to sleep on their backs.
Sincerely,
Dr. Warren
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