2 April 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
-NS
Dear NS: Sensitivity to something an infant is eating could certainly cause blood in the stool. Since a nursing infant should not be sensitive to human milk, the mother must look at her diet to see if there is anything the baby may be sensitive to. Cow's milk allergy is high on the list. If the mother is drinking milk, she should try discontinuing it.
Infection may also cause blood in the stool but would usually cause the infant to be ill.
Treatment is highly dependent on diagnosis. If they baby doesn't improve with changes in mother's diet, he will need to see a pediatric gastroenterologist for evaluation.
Sincerely,
Dr. Warren
Sincerely,
Sandra
Dear Sandra: Most physicians who work for hospitals will get standard benefits such as health insurance, malpractice insurance, sick leave, vacations, CME (continuing medical education). I cannot give you details since I am self employed. The majority of physicians in the USA are self employed like me. They may take vacation, but the less they work, the less they earn. A self employed person purchases his own health insurance. Malpractice insurance is a business expense. Self employed physicians have the option of contributing to a retirement plan like any other self employed person. Usually, to have a retirement plan, a self employed person must also contribute to a retirement plan for his employees. What I'm saying, is the self employed have benefits, but they are also the ones who pay for the benefits.
Average health and strength should suffice to be pediatrician. There are no special physical requirements although examination skills do depend on normal eyesight and hearing or eyesight and hearing which can be corrected to normal with aids or lenses. Intelligence is a basic requirement for the other skills to be learned.
There will always be a need for pediatricians but salary and availability of positions may be affected by insurance companies and federal regulations.
New technologies and discoveries can have a dramatic and unpredictable impact on the practice of medicine. The future of all medical fields will include an ever increasing burden of paper work to meet requirements of governmental regulators and insurance companies. Since the independent (self employed) practitioner must know how to manage the business aspect of his practice, a significant amount of his time will be spent dealing with the changing requirements of both government and insurers.
Sincerely,
Dr. Warren
-SM
Dear SM: The following information about ITP was gleaned from Dambro: Griffith's 5-Minute Clinical Consult, 1998 ed., Copyright © 1998 Williams & Wilkins:
Acute ITP occurs predominantly in children ages 2-9 years old. 80-85% completely recover within 2 months. 15% proceed to chronic ITP.I am not familiar with any evidence regarding the success of alternative treatments, diet, or vitamins. If an alternative treatment is safe and does not interfere with appropriate medical therapy parents always have the option of trying it, but I must caution that desperate patients can always find quacks willing to line their pockets by promising cures not provided by traditional medicine. Their overblown claims of success may provide patients temporary false hope, but unlike physicians, these "healers" are not held to any standard of care or proof that their treatments work.Chronic ITP occurs predominantly in 20-50 years old. 10-20% recover spontaneously. The remainder have diminished platelet counts for months to years. Spontaneous remissions (5%) and relapses occur.
Patients who fail medical treatment may require a splenectomy.
Intravenous immune globulin, (IVIG, gamma globulin) may be used as an alternative treatment for Acute ITP. Gamma globulin may be effective alone or as a pretreatment to facilitate platelet transfusion. Treatment with IVIG may delay the need for splenectomy.
Patients with Chronic ITP may be treated with high doses of intravenous gamma globulin in emergencies. Other alternative medications include azathioprine, cyclophosphamide, vincristine, vinblastine, danazol, plasmapheresis [a procedure, not a medication], interferon, and rho(D) immune globulin.
Sincerely,
Dr. Warren
-DW
Dear DW: Current recommendations are to keep children on human milk or formula until 1 year of age, whole milk until age 2, and then switch to skim milk.
Sincerely,
Dr. Warren
(1) Is it possible that our son is spitting up so much because we are feeding him too much, and not because he has reflux?(2) If he does have reflux, are the available tests and treatments worth pursuing since he does not experience any real discomfort?
(3) How long will it take for him to grow out of the reflux problem, and are there any long term concerns?
(4) If he spits up at night while sleeping could he choke, and if so what do we do to prevent that from happening?
-Mr. & Mrs. H
Dear Mr. & Mrs. H: Most infants have some degree of reflux because the rotation of their stomachs makes the valve between the stomach and the esophagus incompetent. Reflux occurs when stomach contents come up into the esophagus. Spitting up is a result of reflux. Reflux is considered pathological when an infant has symptoms from it such as weight loss or poor weight gain, cough or wheezing, or irritability from esophageal irritation. If a baby is gaining well, healthy, and happy, even if he is spitting up which implies some degree of reflux, one would not do a medical workup or offer treatment. The answers to your questions are as follows:
If the baby has multiple choking episodes, coughing, wheezing, or aspiration pneumonia, then the baby will need further evaluation for the diagnosis and management of reflux.
Sincerely,
Dr. Warren
My husband, myself and our 2 year old daughter get boils about every 2-3 months. My husbands is usually on his legs & knees. He started getting them while in the military. Mine are in the right armpit( I never had one until after we were married) and our daughters are in her genital area, she has had two since birth. My husband works on farm equipment and gets really dirty while on the job. I usually get a boil not too long after shaving with a electric/disposable razor(used once). My daughter's starts out like a heat bump and then all of a sudden its a very painful boil. These are so painful and very embarrassing that I am at my wits end. We have all been checked for diabetes. Negative. I even change my daughter's diaper about every 1/2-1 hour just to keep her dry in case wetness is a contributing factor. I feel I am not doing something right. I just do not have anyone else to turn to. Yes I have talked this over with our pediatrician. He states that my daughter probably scratched herself and then he prescribes an antibiotic and phisohex washing of the affected area TID. I would appreciate any advice!
-GW
Dear GW: Boils are generally caused by infection in the skin by the bacterium, Staphylococcus aureus. Some people are more prone to boils than others because of individual differences in their immune systems. While it is possible for both a child and parent to have similar susceptibilities because of genetic similarities in their immune systems, since you and your husband are not blood relatives, it is unlikely that would be the explanation. Nonetheless, if the problem persists, you might want to have some tests done to evaluate your immune responses.
Some people carry Staph in their noses. It can be very difficult to eradicate Staph from the nose of a carrier. If one of you is a Staph carrier, it is very easy to get the Staph on your hands and from there to surfaces and other people's hands. Once Staph is on the hands, it is a simple matter to get it into breaks in the skin and get an infection. The only way to deal with that is to wash hands frequently with an antibacterial soap.
You might also ask your doctor to prescribe Bactroban ointment to apply to any cuts, scrapes, or irritations in an attempt to prevent infection.
Sincerely,
Dr. Warren
-S
Dear S: Breath holding spells are indeed as innocent as you have heard they are. If an infant holds his breath long enough to turn blue and pass out, once he passes out he can no longer voluntarily hold his breath and he will start to breathe again. There may even be some brief seizure activity as a result of the breath holding spell. Breath holding spells always follow an upset which results in the child starting to cry and then hold his breath. A true seizure disorder would not occur only as a result of breath holding and would occur at times not associated with crying.
If there is a question about whether or not your child has breath holding spells, then an evaluation by a pediatric neurologist and an EKG and EEG should clarify the issues. Once you are certain that you are dealing with breath holding spells, the only treatment is to avoid reinforcing the behavior by giving the child his way to placate him or avoid the spells.
Sincerely,
Dr. Warren
-April
Dear April: Young infants, premature or not, have more pliable bones than adults; however, their bones are also much smaller and thinner. As a result, these bones would not be able to tolerate the same degree of force as a much larger adult bone without bending to the breaking point.
I cannot postulate how a young infant might have fractured a rib. I can only say that unless the baby has a medical condition causing brittle bones such as osteogenesis imperfecta, normal handling will not fracture the baby's ribs. If the fracture you are referring to is old, it may have occurred in relationship to emergency medical care or resuscitation.
Any variety of pediatric texts and child care books will tell you about fractures, but I don't think you can expect to find information specifically related to infants having fractures or the degree of pliability of a premature infant's bones. If a healthy infant gets a fractured bone, somebody better have a clue when and how it may have happened.
Sincerely,
Dr. Warren
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