6 August 2001

1. One Side of Body Larger Than the Other
2. Doctor Says, "Boys Shouldn't Wear Diapers"
3. Stool Really Smells!
4. Cheek Dimple from Injury
5. Neglect, Failure to Thrive
6. Growth Cessation and Puberty
7. Recurrent Ringworm
8. Nursing Baby Constipated
9. Disclaimer

• Read Questions & Answers in Another Column

One Side of Body Larger Than the Other

Thank you!

-Jennifer

Dear Jennifer: The condition of one side of the body being larger than the other is called hemihypertrophy. The most important conditions associated with hemihypertrophy are Wilms' tumor and Beckwith-Wiedemann syndrome. According to Walsh: Campbell's Urology, 7th ed., Copyright © 1998 W. B. Saunders Company,

the incidence of hemihypertrophy in the general population is 1 in 14,300 persons, whereas in those with Wilms' tumor, it is found in 1 of 32 cases. An increased incidence of other cancers is associated with hemihypertrophy, e.g., embryonal carcinomas, especially adrenal cortical carcinomas and hepatoblastomas. These patients often manifest multiple pigmented nevi, hemangiomas, and genitourinary anomalies.

The Beckwith-Wiedemann syndrome consists of visceromegaly involving the adrenal cortex, kidney, liver, pancreas, and gonads. Additionally, omphalocele, hemihypertrophy, microcephaly, mental retardation, and macroglossia.

Not surprisingly, there has long been a recognized relation between disorders of increased growth and predisposition to cancer. Two related syndromes in particular, Beckwith-Wiedemann syndrome (BWS) and hemihypertrophy, are linked to a significantly increased risk of developing abdominal tumors, including Wilms' tumor and hepatoblastoma. BWS is characterized by excessive intrauterine and postnatal growth, organomegaly, macroglossia, and unusual linear ear creases. The organomegaly can lead to omphalocele and umbilical hernias. Hemihypertrophy in a child is defined as asymmetric growth due to overgrowth of one side relative to the other. It can be limited to a limb or the face or include the whole side. Hemihypertrophy can be a feature of BWS or an isolated finding. For children with hemihypertrophy, the risk of Wilms' tumor is approximately 3%. However, children with hemihypertrophy are less likely than those with BWS to be diagnosed with the disorder before the diagnosis of their Wilms' tumor. In at least one study, children with both BWS and hemihypertrophy had a very high risk of Wilms' tumor, approaching 40%. Given the increased risk of Wilms' tumor in these conditions, screening for Wilms' tumor by regular serial ultrasound examinations is recommended for children with BWS, hemihypertrophy, or both. Screening is often carried out by abdominal ultrasound examinations every 4 months until the age of 5 years, with decreasing frequency of examinations at later ages. The recommendation for serial ultrasound scans is controversial and is based on small numbers. Results from the National Wilms' Tumor Study found more stage 1 tumors in children who had been screened. However, one study of children from the Childhood Cancer Research Group in Oxford found that eight children who had their Wilms' tumors diagnosed by ultrasound screening did not have more favorable outcomes than those in the group that was not screened, suggesting that serial ultrasound examinations may not be necessary. Parents should be counseled to bring the child in for evaluation if they suspect any change in abdominal girth or feel a mass, regardless of whether ultrasound screening is performed.

Sincerely,
Dr. Warren

Thanks for your answer.

-Slava

Dear Slava: I answered a similar question in June 1997, about diapers causing impotence. The question was posed to me by a mother from Russia. Am I correct in assuming from your name that you are from Russia or the surrounding area?

I can't imagine that there is anything dramatically different about diapers in any other country compared to the diapers we use in the USA, but I can assure you that wearing diapers during infancy has never been found to be associated with any decrease in adult male fertility or sexual function here in the USA.

It is true that heat decreases sperm production. This is the reason that testicles hang outside the body rather than being internal organs like a woman's ovaries. In some situations where a man's sperm count is low, if he wears briefs, he may improve his situation by switching to boxer shorts which don't hold the testicles as close to the body. If a man was wearing diapers and had difficulty having children, I would certainly advise him that the diapers may be causing a problem; however, the sperm producing cells do not proliferate in the testicles until after puberty.

I don't know of any doctors in the USA advising infant boys to not wear diapers. Diaper use is very common in the USA including the disposable diapers with plastic linings. I am not aware of any evidence that we are less fertile or less potent as a result. I see no reason to advise against male babies wearing diapers. If I did, my patients would look for a new pediatrician.

Sincerely,
Dr. Warren

Is he lacking certain vitimans or need to eat certain foods. What could possibly cause this problem??? Is there anything that can help???

Please respond ... Even after he cleans himself with soap & water it lingers on him for awhile. Its almost like it settles his clothes. He won't use the bathroom anywhere but home, and doesn't like to then cause it smells so terrible. It really is almost stomach turning. Can you give any information that can help??

Sincerly,
-Desperate

Dear Desperate: Foul smelling stool is not a symptom of nutritional deficiencies. There is no specific dietary advice which can improve the smell of stool; however, you should pay attention to your son's diet and see if there is anything he eats which tends to make the smell worse. All stool smells, but if you and your son sincerely believe that the odor of his stool is unusually offensive I would have to recommend that you consult a gastroenterologist and have a stool analysis done to see if there is anything unusual causing the odor.

Sincerely,
Dr. Warren

Thanks for your help.

-Robin

Dear Robin: I have seen hematomas from injuries result in hard lumps which persist in soft tissue for months. Initially, ice is beneficial to decrease tissue swelling and hematoma formation, but after that, ice is not useful. Heat may hasten resolution, but at this point, I think you should just leave it alone.

Since you have seen your pediatrician, he should advise you whether or not you need to see a specialist. Even if he is uncertain as to the diagnosis, he should be able to decide if his findings warrant further evaluation or intervention.

Sincerely,
Dr. Warren

-JA

Dear JA: I tried to find a reference to the specific condition to which you were referring but could not find any such information. Of course, I cannot imagine a situation in which an infant is deprived of touch and yet is actually loved and nurtured, so while lack of touch may be a crucial part of the condition you describe, I suspect it is part of an overall neglect pattern. Neglect is one of the major causes of Failure to Thrive. Aside from the bleak picture for these infants' future emotional condition, many neglected infants are sufficiently malnourished to die. Those that live, if they have severe failure to thrive during the first 6 months of life when the nervous system experiences its major growth, will suffer permanent neurological damage with significant intellectual deficits.

Considering the severe impact of neglect and it's potential to cause failure to thrive, the medical profession should do all it can to foster early bonding between mother and infant. In that regard, you might want to read the article Bonding: recent observations that alter perinatal care. by JH Kennell in Pediatrics in Review - 1998 Jan; 19(1): 4-12. The article discusses the physiologic and biochemical aspects of bonding pointing toward some clear reasons to initiate infant and mother contact as soon as possible after birth (preferably immediately). The study also discusses the experience with early mother infant bonding which causes a significant reduction in child abandonment.

Sincerely,
Dr. Warren

-Tony

Dear Tony: Some boys stop growing by age 15 and others may grow until they're 21. The key factor is puberty. At the end of puberty the growth plates are fused and growth ceases. Somebody who goes through puberty early and quickly will stop growing early. A boy who doesn't start puberty until 15 or 16 and proceeds through the body changes of puberty at a slow to moderate pace (over several years) may grow into his early twenties.

Sincerely,
Dr. Warren

-Tony

Dear Tony: The earliest signs of puberty in boys is enlargement of the testicles. This is followed by enlargement of the penis and the development of pubic hair. As puberty progresses, The amount of hair around the penis increases and hair starts growing under the arms and on the face. The general body build becomes more mature with sharper facial features and broader shoulders. The voice deepens, and finally body hair develops. Since the amount of body hair and facial hair varies from family to family, it is difficult to judge whether or not puberty is complete by the degree of hairiness. During mid puberty (around the time facial hair starts) most boys experience a growth spurt where they may grow as much as three or 4 inches a year. Once the growth rate starts to slow to an inch or less per year, you can be fairly certain you are nearing the end of growth. The only way to know for certain if you are at or near the point of growth cessation before it occurs is to x-ray the long bones to see if the growth centers are fused.

Sincerely,
Dr. Warren

Thanks so much for your time!

-MK

Dear MK: There are pills which can be used to treat ringworm. If you have ringworm of the scalp or nails, cream alone will not treat it effectively and medication by mouth is necessary. If you are having recurrences because you have not successfully treated the ringworm, pills may help. But if you are having recurrences because of repeated exposure, pills will not increase your resistance to reinfection, therefore you would have to eliminate the source of infection. If it's a pet, that may require a visit to your veterinarian. Make sure that clothing items and hats which have been in contact with the ringworm are cleaned before they are reused. With regard to the pills you asked about, they require a prescription, so make an appointment with your doctor or a dermatologist.

Sincerely,
Dr. Warren

I would greatly appreciate your help as I haven't had more than three hours sleep combined in a night since this began. Thank you for your time.

-TS

Dear TS: If your baby was having normal bowel movements since birth and only recently has become constipated, it is unlikely that it is anything serious which can't wait until the appointment with the specialist. The consistency of the stool sounds unusual for a nursing baby. You might ask your pediatrician about the advisability of offering the baby a small amount of fruit juice, such as pear or prune juice, to soften the stool.

Some healthy, nursing baby's have bowel movements as infrequently as every 4 to 5 days. That's okay as long as the stool remains soft and the baby is comfortable. For more information about how your diet may affect your nursing baby visit the Parents' Place lactation consultant.

Sincerely,
Dr. Warren

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