9 July 2001

1. Missing Muscle Above Lip
2. Too Much Milk
3. Contagion of Mononucleosis
4. Constipation
5. Pediacare for an Infant's Cold
6. Frequency of Colds in Former Premies
7. Craniosynostosis and Hydrocephalus
8. Risks of MMR
9. Disclaimer

• Read Questions & Answers in Another Column

Missing Muscle Above Lip

-Jill

Dear Jill : The following two sentences are the extent of information I found in Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company

Congenital absence of the depressor angularis oris muscle causes facial asymmetry, especially when the infant cries. It is not a facial nerve lesion but is a cosmetic defect that does not interfere with feeding.

Sincerely,
Dr. Warren

Thanks

-DT

Dear DT: The evils of milk have become popular fodder in the lay press but I honestly have no idea what you mean by "too much milk can break down enzymes, etc." Milk is excellent food, providing both quality protein and carbohydrate as well as essential fats. I know of no reliable evidence that milk consumption poses any risk to healthy children. Of course, children who have milk allergy or lactose intolerance cannot drink milk without some ill effects, and adults are well advised to drink skim milk because milk fat is saturated and high in cholesterol.

I certainly do agree that a child who lives on bottles of milk will eat less food. This could result in iron deficiency since milk is a poor source of iron. Even though it provides the basic nutrients, milk is also a poor source of fiber. I would consider it desirable to cut down on the number of bottles in an older child in order to encourage him to eat other foods. As to whether or not a 14 month old should drink his milk from a glass rather than a bottle, I would say that depends on the 14 month old, but if the child is learning those skills in your daycare facility and decreasing his dependence on bottles, I hope his mother appreciates your efforts.

As to whether or not you are wrong not to give the milk the child's mother sends, if the child is eating nutritious meals in place of the milk, what you are doing is nutritionally sound, but the right or wrong depends on the agreement you have with the parents and the degree of latitude they have given you in making decisions for their children or for that matter, the degree of latitude you require before accepting a child into your program. If your agreement with the parents specifies that you provide the meals and they understand that you are making decisions about their children's nutrition, then you are right. But if parents expect you to provide the food they bring you cannot make decisions about nourishing their children without their approval.

Sincerely,
Dr. Warren

Thank you!!!

-Brendan

Dear Brendan: Mononucleosis can cause fatigue for months after the acute illness, but at that point it is no longer contagious. If your girlfriend's illness was more than a few weeks ago, it is unlikely that she is still contagious.

If you were exposed to mononucleosis and are just beginning to feel ill, it is too soon to be tested. Usually the blood test will be positive after two weeks or more of illness. Unfortunately, if you do have mononucleosis, there is no treatment which will prevent any acute illness symptoms or the fatigue which follows, but your symptoms certainly don't sound like full blown mononucleosis with fever, tonsillitis, and swollen glands. It sounds like you have the same cold or allergy symptoms as your father and fatigue most likely due to your busy schedule and lack of rest.

Sincerely,
Dr. Warren

Sincerely,
Annette and Daughter

Dear Annette and Daughter: Mineral oil can be used along with stool softeners. It is not better than stool softeners, but is particularly beneficial in the child who holds stool in voluntarily. In an eight year old, the mineral oil is best used with a behavior modification program which encourages and rewards regular efforts at having a bowel movement.

Mineral oil and stool softeners, including bulk formers, are not addicting since they do not alter the normal function of the intestine; however, constipation may be a lifelong problem for some people, and they may continue to need stool softeners in order to maintain normal bowel function.

A diet to relieve or avoid constipation should avoid processed, white starches like white rice and white flour, replacing these with whole grains such as wild or brown rice and whole wheat flour. Pastas should be made from multigrain flour when possible. Avoid bananas. Encourage other fruits, fruit juices, whole grain starches, bran, vegetables, especially raw vegetables, and whole grain cereals.

Sincerely,
Dr. Warren

-DV

Dear DV: Pediacare Infant drops are dosed the same way as Tylenol Infant drops. A 12 pound child would take 1 full dropper (0.8 ml). The dose may be repeated up to 4 times daily as needed. Since cold medicines are used to relieve symptoms and don't cure anything, and have side effects which include irritability, "as needed" means when the symptoms make the infant uncomfortable.

Sincerely,
Dr. Warren

-Greg

Dear Greg: By two years of age your daughter's immune system should work as well as any other two year old's in spite of her prematurity; however, if she was on a respirator and had immature lungs, she may be more prone to complications of colds such as bronchitis. A two year old who gets a high frequency of colds is usually exposed to a lot of colds by being with other children.

Sincerely,
Dr. Warren

Hoping to hear from you about our Angel child!

Kind regards

-MA

Dear MA: The condition to which you are referring is called craniosynostosis. If some of the growth lines of the skull are fused, the skull can only grow along the unfused lines, resulting in an odd shape to the head. This can also put pressure on the growing brain, but as long as there is sufficient growth of the head to accommodate brain growth, there should not be any neurological damage. The treatment is surgical.

If the baby has fluid on the brain, which is known as hydrocephalus, that is a separate condition from the craniosynostosis. Since there is only so much room inside the skull, a build up of fluid in the skull also increases the pressure on the brain. The craniosynostosis certainly complicates the problem further. The amount of brain damage caused by untreated hydrocephalus depends on how severe the hydrocephalus is and how long it has gone untreated. If the baby has an arrested hydrocephalus (the build up of additional fluid has stopped) in which the pressure on the brain is no longer increasing, the urgency of timely treatment is less. Hydrocephalus is also treated surgically by placing a shunt from the ventricles of the brain into the abdomen so that excess fluid can drain from the brain.

Most infants who don't have their own families are placed very quickly into foster care in the United States. The government does not systematically deny any treatment as far as I know, but whether it is the state or a private insurance company which is footing the bill, the decision about what gets paid is based on certification of medical necessity. The condition of the patient certainly factors into the definition of medical necessity, but not his social status. As to those children who might be in institutions, I cannot say if any decisions have been made not to seek or offer treatment. Unfortunately, most institutions are understaffed and cannot provide the kind of individual attention that group homes and foster care provide. This is a large part of the reason that big institutions like Willowbrook were phased out.

Sincerely,
Dr. Warren

Do you have any thoughts on the possible complications that arise for MMR and or any reason why we as parents should feel uncomfortable about proceeding with said treatment.

Thanking you in advance.

-RB

Dear RB: As parents, we never want to do anything which might cause our children harm, but the thing is, that nothing modern medicine has to offer is risk free. That includes all immunizations. The reason that we tolerate the risks of medical treatments, as long as we have the opportunity to make an informed decision about them, is that there is also a risk in doing nothing.

The following abstract is from an article in Pediatrics Volume 101, Number 3, March 1998, Copyright © 1998 American Academy of Pediatrics.

Acute Encephalopathy Followed by Permanent Brain Injury or Death Associated With Further Attenuated Measles Vaccines: A Review of Claims Submitted to the National Vaccine Injury Compensation Program

Objective. To determine if there is evidence for a causal relationship between acute encephalopathy followed by permanent brain injury or death associated with the administration of further attenuated measles vaccines (Attenuvax or Lirugen, Hoechst Marion Roussel, Kansas City, MO), mumps vaccine (Mumpsvax, Merck and Co, Inc, West Point, PA), or rubella vaccines (Meruvax or Meruvax II, Merck and Co, Inc, West Point, PA), combined measles and rubella vaccine (M-R-Vax or M-R-Vax II, Merck and Co, Inc, West Point, PA), or combined measles, mumps, and rubella vaccine (M-M-R or M-M-R II, Merck and Co, Inc, West Point, PA), the lead author reviewed claims submitted to the National Vaccine Injury Compensation Program.

Methods. The medical records of children who met the inclusion criteria of receiving the first dose of these vaccines between 1970 and 1993 and who developed such an encephalopathy with no determined cause within 15 days were identified and analyzed.

Results. A total of 48 children, ages 10 to 49 months, met the inclusion criteria after receiving measles vaccine, alone or in combination. Eight children died, and the remainder had mental regression and retardation, chronic seizures, motor and sensory deficits, and movement disorders. The onset of neurologic signs or symptoms occurred with a nonrandom, statistically significant distribution of cases on days 8 and 9. No cases were identified after the administration of monovalent mumps or rubella vaccine.

Conclusions. This clustering suggests that a causal relationship between measles vaccine and encephalopathy may exist as a rare complication of measles immunization.

One wonders whether or not we have learned from history. Of course there should always be surveillance of the reactions to vaccines, and we should never become so complacent with our success that we don't seek to improve our vaccines and decrease the risks to our children. But years ago, the backlash against pertussis vaccine began in Great Britain and doctors stopped immunizing against it. As a result, the rate of whooping cough began to increase and people began to remember why they tolerated this less than perfect vaccine.

In this era of increasing antibiotic resistance, we will begin to rely more heavily on vaccines to prevent bacterial infections rather than treating with ineffective antibiotics. The medical establishment will always have an eye on safety. What reason could we possibly have to offer treatments that do more harm than good?!? But it is in the interest of our children for parents to make sure that they are fully informed of the risks of the vaccines. Further, they must report any unusual occurrences after the vaccine and make sure that they are reported to the appropriate authorities. Without reports of adverse events, there would be no investigations to determine the role of the vaccine in the adverse event, and no likelihood of efforts to improve the vaccines. But the media circuses which get their ratings (and therefore their incomes) from capitalizing on the occasional bad outcome under the guise of informing, result in unnecessary hysteria. Who would be interested in the report if it was presented within the context of an unbiased statistical analysis of the data presenting realistic information about the risk of the bad outcome which is being publicized?!?

People cannot go to their doctors demanding risk free treatments when none are available. But they can make informed decisions when they have a realistic idea of what the risks and benefits of treatment are, and what the risks of not being treated are. In my opinion, the balance favors immunizing our children against all the childhood diseases. I would recommend that your child receive the MMR.

Sincerely,
Dr. Warren

MMR and Autism from the National Academies Institute of Medicine

Vaccines and Autism from the Center for Disease Control (CDC)

Six Common Misconceptions About Vaccination from the Center for Disease Control (CDC)

Sincerely,
Dr. Warren

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