19 March 2001

1. Skinny Children Can Be Healthy
2. Top 10 Things Parents Should Know
3. Daytime Wetting
4. Bump Near Fontanel
5. Head Banging
6. Evolution
7. Sodium Concentration in Softened Water
8. No Eye Contact
9. Disclaimer

• Read Questions & Answers in Another Column

Skinny Children Can Be Healthy

Thank you very much.

-HT

Dear HT: I have certainly seen plenty of skinny kids like your son. They typically have small appetites just like him. Since you say he is healthy, as long as his pediatrician agrees and his weight gain and growth are adequate each year even though he is thin, then there is nothing to worry about. The only advice I would give is that since your son's appetite is small, make sure the foods he does eat are nutritious. If your son fills up on empty calories, he will not eat any healthy food.

Sincerely,
Dr. Warren

Thank you!

-TB

Dear TB: Your question is more difficult than you might think. If you ask me for medical information, if I don't have the answer, I know where to find it. If you ask my opinion on a variety of topics from child rearing to medical ethics, I could talk for hours. I could tell you tons of things that parents should know, but distilling it down to the ten most important things..... That's tough, but I'll try. Here they are in no particular order.

1. Infants won't break from normal handling.

2. Parents should love and enjoy their children. You can't spoil a child by giving him love and attention. Neither will withholding attention prevent a child from getting spoiled. Your time is the most valuable gift you can give a child. Children are more likely to get spoiled by parents who offer gifts and poor discipline in place of spending time with their kids.

3. Discipline and punishment are not the same thing. Discipline means exercising control and teaching a child the correct behavior. It doesn't mean winning every battle with your two year old. It does mean saving your voice and getting out of your chair to direct your child's activity, providing firm but loving direction when necessary, distraction and redirection when possible, having realistic expectations based on your child's age, and genuinely appreciating your child's efforts to follow your direction even when these efforts fall short.

4. Being a parent is hard work. Forget the TV shows of yesteryear that create a fantasy ideal of family life. Babies cry, sometimes for hours. Parents of infants are sometimes exhausted beyond belief. If you think nervous parents have difficult kids, don't forget to consider that the difficult kids may have made the parents nervous. The rewards of parenthood are great, but anyone who approaches parenthood with unrealistic expectations is in for a rude awakening.

5. Each child has his own unique inborn personality, part genetically Mom, part genetically Dad, and part mysteriously his own. Some children are easy from the beginning, and others are tough. Just as the easy ones may make the world a more pleasant place to be the tough ones may be the ones who make us proud with their achievements. There is no best personality to have. A parent's job isn't to change Johnny into Jimmy, but to help Johnny be the best Johnny he can be.

6. Fever will not hurt your child. It is important to find the cause of high fevers (more than 104 F, 40 C) and treat them appropriately. Every effort should be made to bring a fever down for the sake of comfort, but there is no urgency to get the temperature into the normal range. Please see my article on fever for more details.

7. Childproof your home. Swimming pools, cabinets with medications and cleaning agents, windows, electric wires, loaded guns.... these are tragedies waiting to happen with a toddler around, and these tragedies are preventable.

8. Immunizations save lives.

9. All of life is a learning experience for young children. Set a good example and create a world for your children that teaches them the lessons you want them to learn.

10. Each stage of life has it's challenges. You may no longer be excited, challenged, or frightened by the things your two year old is, but he's never walked this path before. Let your child benefit from your wisdom and experience with the utmost of understanding and empathy from you.

Sincerely,
Dr. Warren

-W

Dear W: Daytime wetting without nighttime wetting is unusual. A normal urinalysis excludes diabetes, but if a culture wasn't done, infection hasn't been ruled out. If infection were the cause, however, your daughter would probably have discomfort, urgency, and wet at night as well. You could consult a pediatric urologist to make sure all physical problems are ruled out; however, you might expect nighttime wetting as well if there were a physical cause for the wetting.

Many 4 year olds who have mastered the skills necessary for taking care of themselves in the bathroom develop a habit of waiting until the last minute. They are too busy with other things to be bothered with going to the bathroom, and when they first get the urge, they KNOW they can wait, because this is already an old skill and they have mastered control. The same thing happens with the next bladder spasm. Busy little girls can't be bothered stopping what they're doing just to urinate. And so it goes, but as the bladder becomes more full, suddenly the 4 year old gets an urge she can't ignore and runs to the bathroom, but either it's too late, or the underpants get a bit wet before she gets to the potty. If this is what's happening with your daughter, the best approach is to schedule bathroom breaks into her day. Make it part of her routine to go to the bathroom several times during the day and anytime prior to starting any prolonged activity.

If that isn't the answer and your daughter has a negative urine culture and normal urinalysis, it is possible that stress is playing a role. In the absence of any other symptoms that's not high on my list, especially if you can't find any source of stress in your daughter's life. If you can't find any clues, you would have to consult a psychologist if you consider stress a real possibility.

Sincerely,
Dr. Warren

Our three-month old daughter has a persistent bump on top of her anterior soft-spot. My wife noticed it early on and brought up her concern with our family doctor at our daughter's two-month checkup. Stating that he had not seen this before, he referred us to a pediatrician about an hour and a half away. This peditrician examined our daughter and found her to be in excellent health. He and his colleagues also performed an ultrasound and found the brain to be developing normally and also ascertained that the "bump" was not attached to the brain. None of these doctors had seen anything like this before, but did not feel that it was cause for any great alarm. They told us to watch this closely and to have an MRI performed if there was a significant change in the size of the bump.

We have read up on what this could possibly be in books like Dr. Spock's. He said that a sunken in anterior fontanel is often indicative of dehydration, while a persistently bulging fontanel may indicate pressure of some sort. Our daughter gives no indication that there is discomfort of any sort. She is breast-fed only, mom does not and has never smoked, drank, etc. She sleeps thru the night for 7-9 hours, feeds and normally goes back to sleep for another 2-3 hours. Afternoons are fine, evenings are a bit tougher, but nothing out of the ordinary. Touching the bump does not seem to cause her discomfort of any sort.

We are trying not to be overly-worried but, on the other hand, we do not wish to foolishly dismiss something that may be serious.

Any assistance you could provide would be greatly appreciated.

-Mr. & Mrs. H

Dear Mr. & Mrs. H: I am trying to visualize what you are describing when you talk about the bump in your daughter's fontanel, but from your description I cannot tell if you are talking about something attached to or part of the bone, a bulging of the fontanel, or something sticking out of the fontanel. If so many doctors have examined your daughter and can't tell you what it is, it is obviously not ordinary. I would consider consulting a pediatric neurosurgeon for an opinion or having the MRI done to see if the nature of the bump can be clearly delineated.

Sincerely,
Dr. Warren

We have not had an abundance of doctors look at R, and are most concerned because we are in South Dakota. These doctors simply do not see the volume of babies which more urban doctors would. One doctor thought it to be a blood vessel, another thought it was a "crinkle" of the outer layer of the brain. Not sure what I think of these postulations. We asked another online doctor what they thought as well and they suggested it may be a cyst.

Do these clarifications help you to relate to something you may have seen in your years of practice? Your assistance is much appreciated.

-Mr. & Mrs. H

Dear Mr. & Mrs. H: If the lump is not part of the baby's skull and not connected to the brain or brain lining, it could be a cyst, hemangioma, lymphangioma, or lipoma. The small size (your subject line said pea-sized) is consistent with a cyst. The question is whether or not it has been established beyond a shadow of a doubt it is not connected to the brain or brain membranes since it is at the fontanel. If there is a connection to underlying tissue through the fontanel, it could also be an encephalocoele. I think, since the doctors who have seen it have been puzzled rather than giving you some definitive reassurance you need to find an answer. Therefore, I suggest my original advice which was to see a pediatric neurosurgeon and/or have an MRI of the head.

Sincerely,
Dr. Warren

We first-timers tend to try to steer clear of the "over-reaction" stereotype that seems to cling to new parents, even if you do not feel that you are that way. People seem to like to play to stereotypes. And yet, in such cases, it seems that one would prefer to err on the side of over-reacting and finding nothing rather than waiting for "image" sake and finding something too late which could have been treated if discovered earlier.

Thank you for letting me sound this out while writing to you. Having done so, I do not feel that I want to wait 2-3 weeks to find out what we are dealing with here. If you believe such a time frame to be acceptable for the possibilities you mentioned in your email, I would be more comfortable with this time frame. I do not know what the anomalies are which you mentioned. They probably sound worse than they are.

-Mr. & Mrs. H

Dear Mr. & Mrs. H: I can understand your being anxious, especially since your doctors appear to be puzzled; however, your daughter sounds healthy and her condition is stable, so I doubt there is any urgency to be seen before two to three weeks.

Sincerely,
Dr. Warren

-CT

Dear CT: Head banging and other rhythmic movements can occur as a healthy child drifts off to sleep. These types of sleep disturbance do not imply any pathology. They generally cease by adolescence. If these movements occur multiple times during the night, especially if there are any other associated abnormal movements, it is remotely possible that you could be describing a seizure. If you have any doubt, consult a pediatric neurologist.

Sincerely,
Dr. Warren

I have another question. I also learned that sharks, because some species are about 50 million years old, have evolved out of cancer. Does that mean that we will someday evolve out of cancer? (Or even just out of some other diseases like TB or AIDS.)

Thank you again for your response- it was greatly appreciated. I know you've heard this before because I've read it in some of the letters on your website, but I think that what you are doing is really great- helping people over the internet. I know that for me, it was a lot easier to ask a doctor whether or not I was going to grow anymore when I wasn't sitting right in front of him or her. Thank you!

Sincerely,
-KT

Dear KT: The course of evolution is unpredictable and complex. If one accepts "Survival of the Fittest" as one of the factors influencing evolutionary pressure to eliminate undesirable genes, one must consider that all it takes for a particular gene (such as a susceptibility to cancer) to persist, is for an organism to survive long enough to reproduce. The evolutionary pressure on sharks 50 million years ago was very different from the evolutionary pressure on man today. It is hard to know how modern man's ability to treat disease including cancer alters the evolutionary equation. At the same time, modern society exposes us to more pollution and certain carcinogens that ancient sharks never had to deal with and in some instances may increase our risk of cancer. In addition, while childhood cancer is certainly a troublesome medical problem, most cancer occurs in old age, well beyond the childbearing years. Our ability to treat and prevent many of the diseases that killed our ancestors has allowed us to live to a ripe old age and develop cancers our ancestors didn't have.

Who knows where evolution will lead us. One can only hope it leads to better things, but it can also lead to yet unknown problems. While man evolves, so do other organisms. Twenty years ago AIDS (HIV) was unknown.

Sincerely,
Dr. Warren

-CO

Dear CO: I was unable to locate any research on the subject of softened water and newborns; however, I did find an article about sodium (salt) and water softeners. The abstract of that article follows:

Sodium concentration of water from softeners.
Yarows SA - Archives of Internal Medicine - 1997 Jan 27; 157(2): 218-22 From NIH/NLM MEDLINE, HealthSTAR
Author Affiliation: Division of General Internal Medicine, University of Michigan Medical Center, Ann Arbor, USA.
Authors: Yarows SA; Fusilier WE; Weder AB

Abstract:

OBJECTIVES: To determine whether water is safe for consumption after it has passed through a water softener and whether there are any health and environmental implications of cationic water softeners.
METHODS: Sodium concentration was measured in 59 water samples that had passed through a water softener and was compared with the sodium concentration of 5 samples from 4 different local municipal sources.
RESULTS: The mean +/- SD sodium concentration of softened well water was 278 +/- 186 mg/L (range, 46-1219 mg/L). There were 10 (17%) households with sodium levels greater than 400 mg/L. The mean +/- SD sodium concentration of municipal, nonsoftened water was 110 +/- 98 mg/L (range, 0-253 mg/L). CONCLUSIONS: Softened well water in our area on average contained a 2.5-times-higher concentration of sodium than local municipal water, comparable with previous reports. It is unlikely that the increased sodium from softened water would have any health risks for most people. This may not be true for people on severely sodium-restricted diets. le.comSodium concentration of water from softeners.

Sincerely,
Dr. Warren

He also has been refusing the breast even though he seems hungry. I would appreciate any feedback you can give.

Thank you so much.

-AH

Dear AH: If the symptoms you describe are recent in onset, your baby sounds miserable and should be evaluated to see what is making him ill. If your baby has always been as you describe it is also worrisome. A five month old who rarely makes eye contact, rarely smiles, and is extremely fussy could either be suffering with frequent pain or be neurologically impaired. Please have your son evaluated by a pediatric neurologist.

Sincerely,
Dr. Warren

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