25 June 2001

1. Speech Delay and Drooling
2. Pediatric Nurse Practitioner vs. Pediatrician
3. Gender Identity
4. Tonsillar Follicle
5. Swelling in Nose
6. Groin Lump
7. Lazy Eye
8. Excess Urination
9. Disclaimer

• Read Questions & Answers in Another Column

Speech Delay and Drooling

Our child loves us to read to him. We read about 20 books a day and he points to his favorite objects without clear vocalization. Should we simplify to only letters, "A's, B's,..." instead of reading words, sentences, and books?

-JC

Dear JC: Drooling associated with speech delay may be a result of oromotor dysfunction. In English rather than medicalese, that means, s child could be drooling because of an inability to control the muscles of his mouth including his tongue, lips, and swallowing. These same muscles are involved in the production of speech sounds. Oromotor dysfunction as a cause of speech delay need not be associated with any receptive language delay. A child who cannot produce speech sounds may still understand language perfectly well. Or oromotor dysfunction could be part of a larger neurological problem such as cerebral palsy and may or may not be associated with intellectual deficits including language delay.

Regardless of the cause, language stimulation requires exposure to language. Since your child loves to be read to, you should not decrease the complexity of the material you read to him, but you should applaud his successes at repeating less complex sounds.

You should also consider a complete evaluation by a speech pathologist. If any significant oromotor dysfunction is found, the speech pathologist will probably recommend further evaluation by a pediatric neurologist as well.

Sincerely,
Dr. Warren

Thank you.

-Jenny

Dear Jenny: Both nursing and medicine are honorable professions which can offer ample opportunity for a caring individual to provide care to his patients. There may be some aspects of being a physician which are inherently less hands on in terms of caring than what a nurse does. Of course, the physician must examine his patients, and depending on his manner, his touch may provide reassurance and comfort to his patient, but there is basically nothing soothing about being examined. The examination makes most patients nervous.

The medical doctor's training puts its greatest emphasis on diagnosis. Proper treatment requires first establishing a diagnosis in order to follow current treatment protocols. To some degree, that makes physicians sleuths. The idea that you have to help a patient deal with his symptoms even if you don't immediately have a diagnosis is something that doesn't really become apparent to most physicians until after they go into practice. Some inexperienced physicians don't realize that their job isn't done the minute they make their brilliant diagnosis. However, a good deal of the patient's faith in his physician derives from the fact that the patient trusts in his doctor's ability to make an accurate diagnosis. When a worried patient goes to his doctor and the doctor says there is nothing to worry about, the patient's faith in his doctor is what lifts the burden off the patient's shoulders.

When it comes to providing treatment, the physician's role is more geared toward prescribing than doing. If a patient needs physical therapy, the physician prescribes it and the patient does it with the therapist.

Those physicians who go on in their training to learn hands on skills such as surgery and other advanced procedures are once again putting their emphasis on becoming proficient at highly complex procedures, most of which would not be considered comforting to patients. There is, of course, room for the surgeon to become proficient at comforting his patient as well, but if given the choice, most patients would pick the surgeon who has the reputation for the best surgical skills rather than the best bedside manner.

Nursing approaches the patient from a different point of view. The nurse's job isn't to make the diagnosis or perform the surgery, but rather to care for the patient. The nurse, who is in the hospital for 8 to 12 hours or more per shift, is at the bedside when the patient needs a hand to hold. But today's complex medical procedures and monitoring require nurses to have highly advanced skills as well. A nurse who has experience working in a cardiac care unit can read an EKG as well as any physician and know what medications to use in an emergency. What is more important, is that the nurse is right there on the front lines monitoring the patients and determining when action needs to be taken. The nurse's skilled observations and ability to monitor the patient is what makes a CCU save lives. I could give other examples outside the CCU, but the point is that the skills a nurse acquires will vary with the job he/she does. Nurses can advance their careers into administrative positions that involve little hands on care of patients. They can also work inside and outside of hospitals in various capacities such as school nurse, public health nurse, operating room (scrub) nurse, nurse in a physician's office, lactation consultant, and nurse practitioner. I'm sure that someone more familiar with nursing than I could provide even more possibilities. The nature and degree of patient contact varies considerably in the different fields of nursing just as it does in medicine.

The nice thing about working in pediatrics is that the little kids are not at all impressed by my degrees. It helps me keep a proper perspective in my practice. Only a pediatrician can cuddle and kiss his patients as part of routine care. My ability to soothe and comfort my patients is crucial to my success at doing anything with them.

The demands of medicine and nursing can sometimes make any hard working physician or nurse forget how much a patient is depending on us to meet his every need. Sometimes the most demanding patient can be turned into the sweetest, most appreciative patient when he knows that someone is paying attention to his needs and cares about him.

The doctors who have lost their way in the process of acquiring their vast database of knowledge and skills have given medicine an undeserved reputation. The vast majority of physicians are dedicated, caring individuals. Sometimes it may only be evident in the long hours and behind the scenes work the physician does to take care of a sick patient rather than a squeeze on the shoulder or a pat on the back, but the caring is there. I can't imagine anyone living the life and being on call the hours of a doctor for any reason other than dedication to the ideals of caring for patients. In spite of what the general public has to say about the medical profession as a whole, most people still love their own personal physician.

Don't you think that most of the people who write to me for advice hope, if not believe, that I care about them when I take the time to answer their queries? If I can care from a distance, can you believe that most physicians could become so jaded as not to care about the patients who put their lives in their doctor's hands?

So there you have it. Two different but similar professions, one certainly no better or more honorable than the other. The amount of caring you do as a practitioner is most dependent on what part of yourself you bring to your job.

Sincerely,
Dr. Warren

We have put him in a lot of plays so that he can experience acting as different characters, wearing make-up (another of his fantasies) and be accepted wearing costumes. For Halloween I've always made him costumes to sort of parallel what girls get to wear- i.e. an Aladdin costume made out of satin, a wizard costume with a gown and a cape. He loves wedding dresses. I told him that perhaps he could design and make wedding dresses. He said "Why would I want to make them? I want to wear them!" He was recently lamenting that he wished he were a girl so that he could wear one of the pretty dresses the girls in his play are wearing. I told him that he was a boy and would grow up to be a husband and father (I don't think it's appropriate at 8 years old to tell him about the possibility of a sex-change operation). I told him that a lot of people spend their whole lives wishing for something that will never be and that I would hate to see him sad and disappointed for the rest of his life. It would be like me wishing I were short - it cannot and will not ever happen. He is very lucky that his father is not a "macho" man. He isn't happy seeing his son wear dresses but, we don't make a big deal out of it. Our big concern is him getting teased. He was mortified last year when a girl saw his underwear and teased him about it and I've told that if any one from school saw him wearing a dress he would never hear the end of it. Recently he was playing with 3 little girls and the oldest one said "Let's go have girl talk" my son went happily skipping along with them and when he realized that he wasn't included he looked crushed.

I know how cruel kids can be and I'm getting terribly concerned that he is going to be "labeled" throughout his school years as the "boy who thinks he's a girl." (He's going into 3rd grade). We've been walking a rather fine line all these years- letting him indulge his fantasies to a certain extent and still making sure he understands what "reality" is (i.e., he is a boy).

We really need some advice on how to keep dealing with this. I feel that if we handle this wrong we're going to have one depressed, screwed up, unhappy child.

Thanks for your time.

-A Concerned California Parent

Dear Concerned California Parent: I'd like to commend you on the manner in which you've been handling your son. Unfortunately, there is a very fine line between helping a child to deal with the real world and demanding that the child be something he isn't. As parents, we wish for our children to be "normal" not only to fulfill our dreams of how our futures will unfold, but also to spare our children the inevitable pain that is associated with being different. And while it's admirable for you to want to spare your son any pain and to prepare him to deal with what the world will hand him with the least pain possible, the reality is that you cannot protect him against all the pain of being who he is. The fact is, that you and he do not yet really know who he is.

Sexual identity is the issue rather than orientation, since homosexuality is a separate issue and is not implied in the desire to wear women's clothes or be a woman. Is this a phase that will pass with proper direction? I doubt it. His preferences appear to have developed over a long period of time. If his interest is primarily in women's clothes, he may be a transvestite. A transvestite can have entirely normal sexual preferences and sexual identity. Your efforts to provide your son an outlet may help him deal with a desire to wear women's clothes while still keeping a male identity. Your son's expressed desire to be a girl and be with girls is more consistent with a transsexual, but given that your son's current understanding of gender identity has more to do with clothes and games and choice of friends than sexuality, you will not be in a position to know if he will ultimately only be happy as a woman until he is old enough to understand how he feels.

Therefore, the best thing you can do is to keep your son's options open, always helping him to see what society expects from him at each age. Constantly reassure him that you love him and that your love has nothing to do with what he wears. That does not mean that you have to act like it doesn't matter to you at all what choices he makes. But in helping him to understand how his choices affect you, him, and others, make sure he knows that your love isn't contingent on this choice. Your ever-present love can act as his safety net when life gets tough for him, but it cannot get him through this unscathed. The process of growing up requires decreasing the attachment to parental love and values and seeking approbation from peers. As your son gets older and his choices more clearly defined, he will need to know that he is not alone in the outside world and that he has the potential for happiness outside of your loving arms. At that time you will need to find appropriate support groups currently available for a variety of gender related issues. While there are still people out there who would hurt a person just because they believe he is different, today's teens are a lot more accepting of the differences among them than they were when I was growing up.

Sincerely,
Dr. Warren

-M

Dear M: It sounds like you're describing an enlarged tonsillar follicle. While it is still attached to the tonsil, you may see a white spot on your tonsil. As it enlarges and gets ready to detach from the tonsil, it may irritate your throat or the back of the tongue causing the feeling you get which makes you cough until you dislodge the follicle and either swallow it or bring it up. The follicle appears white to off-white and has a consistency of a spit ball (wet paper). Enlarged follicles can result from inflammation of the tonsils but does not necessarily mean you are ill. You might also be describing debris or food which gets caught in an enlarged tonsillar crypt which is then eventually ejected by the tonsil in much the same way as the follicle.

Sincerely,
Dr. Warren

-JS

Dear JS: The inside of the nostrils are not smooth. The ridge like tissue inside the nostrils are called turbinates. Depending on the shape of the nose, the turbinates may sometimes be visible in a healthy child. The turbinates may swell in response to allergies or colds making them more visible. I cannot be sure if this is what you are seeing, but at one month of age, your infant should be having fairly regular checkups at the pediatrician, so you should point out your concern at the baby's next doctor visit.

Sincerely,
Dr. Warren

-(unsigned)

Dear Grandparent: Given the variability of marble sizes, I'm not sure just how large a large marble is, but you could be describing a lymph node in the groin. Most infants have palpable lymph nodes in the groin. They may enlarge in response to virus infections or inflammation of the feet as might occur with a rash on the feet.

Since your description does not clearly tell me where in the groin you felt the lump, if it is at the lower end of the abdomen just above and lateral to the penis, you could be describing a hernia. If he appears to be in pain, or the lump feels bubbly, or comes and goes, or is clearly located where I described a hernia, it needs to be checked by his pediatrician.

Soft green bowel movements are of no special significance. I see no relationship between that or teething to the lump.

Sincerely,
Dr. Warren

-KG

Dear KG: The term "lazy eye" can refer to an eye turn caused by a muscle imbalance, or the amblyopia (weakness of vision) caused by poor vision in one eye or an eye turn. Some people refer to any eye turn as a lazy eye.

Amblyopia is usually treated by patching the good eye so that the weaker eye will be used and by treating the cause of the amblyopia. If the amblyopia is caused by an eye turn due to muscle imbalance, ultimately surgery may be required to align the eyes. If an eye turn is due to farsightedness, appropriate spectacles can help.

Sincerely,
Dr. Warren

-F

Dear F: If you have always had to urinate frequently, you may have a small bladder capacity or a spastic bladder. This may be amenable to medical treatment, but would require evaluation to determine a course of action.

If your need to urinate frequently is new, it could be due to a urinary tract infection, diabetes mellitus, diabetes insipidus, or stress. If you are an older man, it could be due to prostate enlargement.

There are a number of possibilities. Untreated diabetes can certainly become serious. No diagnosis can be made without seeing a doctor, and no treatment can be offered without a diagnosis. It may not be anything serious, but it would be wise to see your doctor.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

ask Dr. Warren a question?!?