14 May 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
-U
P.S.: I haven't finished puberty yet, I haven't shown any sign of hairy arms and legs and any underarm hair. How long do I have to grow?
Dear U: Girls usually stop growing about 2 to 3 years after they start menstruating, but some girls still manage to grow small amounts for a few years after that. I cannot predict your final height, although based on genetics, it will probably be between 5'4" and 5'7".
Sincerely,
Dr. Warren
My 4mon-3week son did not like to eat. His weight gain began to fall off the percentile he used to be. He was at 50% till about 2.5 month, and now he is off between 50% and 25%. Please don't think this is insignificant. I know there are articles saying baby's growth rates varies as they age, and as long as he is gaining weight he probably is okay. But I think my son's case is of great concern because I had similar experience with my first son who is now 7.5 Year old. And my first son is not okay, he had development delays, speech delays and now is at special education. He's been identified to have multiple learning disabilities. It all started at 4-5month of age, when his growth rate began to drop, but still in the range. And he was a fussy eater too. Now my second son seems following the same pattern. When he saw the bottle or we cradle him in a feeding position, he starts to cry and scream. We tried all kinds of methods to calm him down and he would drink a little then cries again. He only takes in 25-30oz of formula a day. At his age and weight (15 lb 2 oz.) he should drink 32-40 oz. plus solid food. He used to take 30 oz when he was much younger. I talked to the pediatrician. He pointed out that my husband is a thin built and he says about 4 month of age the gene's effect on weight will start to show. I am not much convinced by this answer. Because they said about the same thing to my first son. By the way the second son was bottle-fed by expressed milk for 3 months and we gradually switched to 100% formula recently.
How can I avoid the same thing happened to my first-born? How can I make him eat more food? I dare not to start solid because I am afraid it will reduce his milk intake. Some nurse at lactation center said the learning disability is not related to the weight gain. But I see the delayed weight gain is the first sign of developmental delay. Am I right? Is there any test? Is there any cure?
Thank you very much.
-Shen
Dear Shen : You are under the mistaken impression that your first son's developmental problems were the result of poor eating. In reality, it is likely that his fussiness and poor eating were a result of his neurological impairments. You could not have prevented your first son's problems by getting him to eat more. If your second son seems to be following the same path, it will not be solved by changing his eating habits.
Given your prior experience with your first child, if you believe the exact same thing is happening, you should have them both evaluated by a pediatric neurologist to determine if there is anything going on which could be altered by dietary changes or any other kind of management. If the neurologist does not feel they have the same problem, or does not feel that your baby has any neurological condition, you have to decide whether you think the baby is in pain, in which case a formula change or a gastroenterology consult may be in order.
Sincerely,
Dr. Warren
-K
Dear K: Excess protein in the diet is broken down and used as calories just as carbohydrates are. The excess nitrogen is excreted through the kidneys. As long as the children have healthy kidneys and don't have gout, and as long as they drink adequate fluids, they should not have any problem tolerating a high protein diet.
Sincerely,
Dr. Warren
What do you suggest? Can't wait to hear back from you.
And thanks so much for your Web site. So many medical advice sites are for members only at a cost I'm not comfortable paying.
-MH
Dear MH: The most serious cause of testicular pain is testicular torsion, a situation in which the testicle twists around on it's attachments cutting off it's own blood supply. The pain caused by testicular torsion is excruciating. Testicular torsion is a surgical emergency. If the torsion isn't reduced quickly the testicle will become gangrenous and die. I assume, after more than three days of pain at this point, that you probably don't have anything that serious. But the point is that severe testicular pain requires immediate medical attention.
Torsion of the appendix testis causes pain which can actually be localized to the upper pole of the testicle. It often appears as a blue dot visible through the skin of the scrotum.
Orchitis, an inflammation of the testicle, can be caused by viruses and bacteria. The best known cause of orchitis in young men before the vaccine became available was mumps.
I can understand people treating aches and pains in muscles and joints which are related to activity, or headaches, or other common afflictions without seeing a doctor, but when you don't know the cause of a pain, it should always be taken as a signal that something is wrong. Persistent pain in an organ (such as testicular pain) should be evaluated by a doctor. If you're still in pain by the time you receive my response, please make an appointment to see your doctor.
Sincerely,
Dr. Warren
He also never has a bowel movement without some rectal stimulation with a thermometer. Is this good for him? We have been giving him Children's Mylanta qid. This seems to help. If we only gave him this and not the Zantac and Propulsid would this be beneficial or not? I am a RN in the ER but I'm not very smart when it comes to my children. Thank you for your help. Please respond.
-DW
Dear DW: If your infant has been put on a variety of medications by his doctor you should not be making any changes in his medication without talking to the doctor. Your baby may not be tolerating the medication, or his underlying condition may be worsening in spite of the medication. His doctor cannot possibly provide good care unless you stay in touch with him. I would be happy to answer questions about the medications or about reflux, but it would not be in your son's best interest for me to direct or interfere in his care by e-mail. From your description, your son sounds like he has significant gastrointestinal problems. If your doctor does not or cannot provide adequate ongoing care for this, you should consult a pediatric gastroenterologist.
Intussusception is a serious problem which requires emergency care. If your son is in a lot of pain or has bloody stools he needs immediate medical attention.
Sincerely,
Dr. Warren
-DE
Dear DE: Even though you report that your daughter had normal blood tests, since I don't know what tests were done, I have to tell you that if your daughter's thyroid functions were not tested they should be. If your daughter's thyroid function is normal, then I would suggest a consultation with a dermatologist.
Sincerely,
Dr. Warren
-KB
Dear KB: The following information has been summarized and edited form Nelson's Textbook of Pediatrics:
Von Willebrand Disease is similar to and sometimes considered a form of hemophilia. Clinical manifestations include nosebleeds, bleeding from gums, heavy menstruation, prolonged oozing from cuts, and increased bleeding after injuries or surgery. Spontaneous bleeding into joints, which is common in hemophilia, is rare in Von Willebrand Disease.Von Willebrand Disease is inherited as an autosomal (a chromosome other than the sex chromosomes [in other words not X or Y]) dominant trait, meaning, if a person gets one gene for the disease, they have the disease. However, as with many autosomal dominant traits, there is variable penetrance, meaning some of the people carrying the gene (which means they actually have the disease) have mild or no symptoms and so may not be diagnosed until later in life, or may never find out that they carry the gene. A few families with severe disease have been described in which the genetic transmission was autosomal recessive, meaning a carrier with one gene would not have the disease and the affected person would have had to inherit the gene from both parents.
The disease is caused by underproduction of von Willebrand protein or, in some families, by the synthesis of a malfunctioning protein. The von Willebrand protein contains a platelet-adhesive component (von Willebrand factor) and also the protein functions to carry factor VIII in the plasma.
There are at least three major varieties of von Willebrand disease, based on genetic and laboratory studies. The bleeding time is prolonged in all von Willebrand syndromes. The platelet count and prothrombin time are normal. The partial thromboplastin time may be normal but usually is mildly to moderately prolonged. Type I patients (classic von Willebrand disease) have reduced plasma levels of von Willebrand protein, von Willebrand factor activity, and factor VIII activity. The platelets in von Willebrand disease have decreased adhesiveness and do not aggregate when the antibiotic ristocetin is added to platelet-rich plasma (because von Willebrand factor is missing), unlike platelets from normal individuals. Rare patients may show increased reactivity to ristocetin (type II B).
Therapy consists of replacement of the von Willebrand factor using fresh frozen plasma or cryoprecipitate. Cryoprecipitate is the preferred form of therapy for serious bleeding or for preparation for surgery. Patients with mild to moderate type I von Willebrand disease who have minor bleeding manifestations (e.g., nosebleeds), or who are to undergo certain surgical procedures (e.g., dental extraction), may be given DDAVP as for those with hemophilia A.
Sincerely,
Dr. Warren
My 8 yr old son has been complaining of rectal bleeding for over a week now (started out of town at Grandparents) and I witnessed it tonight. Bright red blood on the tissue and a stream of blood from his anus about 1 " and 1/4 long. He had had a hard BM. I have read the info on fissures and hemoroids but this was an awefull lot of blood. Turned the water red and the tissue covered.
He has no stomach aches or any other symptoms. Is this an urgent matter?
-Christina
Dear Christina: Bright red blood in the toilet bowl and on the toilet paper is generally anal bleeding. The most common causes being hemorrhoids or an anal fissure resulting from constipation. Even a small fissure or hemorrhoid may cause a surprising stream of blood since the process of pushing to have a bowel movement squeezes or milks the blood out of it.
If the blood appears dark rather than bright red and your child suffering any dizziness or rapid heart rate it would be consistent with a larger volume blood loss from higher in the intestines. This would require more urgent attention.
Of course you should have your son evaluated to determine the cause of the bleeding as soon as possible, but as long as he is feeling well it is not likely urgent.
Sincerely,
Dr. Warren
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