20 August 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
-KP
Dear KP: There are several ways to answer your question.
In general, a healthy 2 to 3 week old can tolerate a flight. There are no specific complications of flying unique to newborns. Young children are more prone than adults to ear problems during flight if they have nasal congestion. Flying will involve exposure to large numbers of people in both the airport and the airplane increasing the risk of exposure to infectious disease. For that reason, caution should be exercised in flying or going to any public facilities with infants younger than 8-12 weeks of age.
In general, with regards to health, Mexico is a safe country to travel to. Under no circumstances should an infant have any food prepared with tap water or well water unless it has been sterilized. Even foods washed with tap water must be considered to carry an increased risk of causing travelers' diarrhea. Major resort areas in Mexico do not carry any risk of malaria exposure, but there is some risk in certain rural areas.
Sincerely,
Dr. Warren
We've been looking at the internet and found something call fever of unresolved origin (FUO). Not sure if it could be that.
Do you have any ideas of what it could be or recommendations of where to go for help? We live in the Xxx Xxx area.
Any help would be greatly appreciated.
-EJ
Dear EJ: FUO (fever of unknown origin) is actually not a definitive diagnosis, but rather, is an indication of a need for further evaluation to try to determine the cause of the fever. It is useful to categorize a prolonged fever as FUO if it meets the criteria for duration and no cause can be found since there is a fairly standard approach to evaluating FUO. If you are researching the subject, looking up FUO will help you to find information about the possible causes.
Even though you tell me that he has been tested for a number of things, I don't know anything about the expertise of the physician(s) doing the evaluation. Routine tests for certain conditions may not be sufficient to rule them out and a consultation with appropriate specialists may be necessary. The nature of your nephew's symptoms suggests that he should have a complete evaluation by a rheumatologist. The fact that the symptoms are cyclical could suggest that the child has cyclic neutropenia, therefore, even if he has had a thorough evaluation, it may be crucial to repeat his CBC when he is ill or consult a hematologist/oncologist.
When faced with undiagnosed illness after evaluation by many doctors, I always have to recommend evaluation at a teaching hospital where the most experienced specialists teach. There should be a university children's hospital in your area. That's where to start. If you feel a need to go outside your area, there are many fine teaching institutions in most of the major cities in the US.
Sincerely,
Dr. Warren
Also, I recently switched to Nutramigen from a soy-based formula that I had been using all along. This appears to be helping tremendously. My pediatrician never suggested that a hypoallergenic formula may help. I have heard that babies who suffer from eczema can benefit greatly from these types of formulas. Why did my doctor not suggest this in the first place? Perhaps I wouldn't have had to use so much steroid cremes in the past if I had fed him this type of formula all along. Is it a nutrition issue? Is it safe to feed him this formula now?
Sincerely,
Itching in Texas
Dear Itching in Texas: I can understand your concerns about keeping your child on medications which may have side effects. Unfortunately chronic conditions sometimes require chronic treatment. The alternative is persistent symptoms. For that reason, chronic conditions should always be treated with an eye toward the least side effects with the most benefit. I must caution that this doesn't mean withholding treatment until it is absolutely necessary. Sometimes the amount of medication required to get a neglected condition under control is greater than the amount of medication necessary to maintain control. Additionally, untreated conditions may result in complications. In the case of eczema, those complications could include secondary infection and poor sleep for your child.
I think it is reasonable to use steroid creams sparingly, but it is also reasonable to use enough to control the condition. Steroid creams used on the face are generally low in potency. Unless an extraordinarily large area is covered with a high potency cream, the amount of steroid absorbed into the system is usually not enough to cause any systemic effects. To minimize the use of steroid creams, you need to continue to be diligent about moisturizing and avoiding soap. When you do wash the baby's face use a soap alternative like Cetaphil. Cetaphil also makes an excellent moisturizer.
Since eczema is often caused by allergies, avoiding the allergens that provoke it can be very helpful. In infants, the first possibility to consider is food allergy which often means formula allergy. A hypoallergenic formula like Nutramigen or Alimentum is the best bet, but they are more expensive and many people find them much less palatable than other formulas. For the milk allergic child, soy may be a good alternative. For a long time, it was the only alternative. Unfortunately, soy is just as potent an allergen as milk, so a child with severe eczema or other allergy symptoms who doesn't do well on soy should definitely be switched to a hypoallergenic formula. My preference is to start with a hypoallergenic formula, and if a baby is doing well on it, if the parents wish, try the soy at some point. The main advantage of soy over hypoallergenic formulas is price. Hypoallergenic formulas are readily available, come in powder, concentrate, and the convenient ready to feed, and are safe and nutritious.
Sincerely,
Dr. Warren
-Beth
Dear Beth: The average hemoglobin for a 13 month old is 12.0 g%. The normal range may be as low as 10.5 g%. In an otherwise healthy child, the most likely causes of anemia are iron deficiency and familial (genetic) anemias like Thalassemia minor.
The most likely cause of iron deficiency in a 13 month old is nutritional, i.e., inadequate iron in the diet. After iron deficiency is corrected, as long as there is a sufficient source of iron in the diet, it should not recur. An older child who was not previously iron deficient who becomes iron deficient should be evaluated to be sure there is no blood loss by checking the stool and urine for blood. Girls and women may become iron deficient from menstruation.
Sincerely,
Dr. Warren
-Beth
Dear Beth: Infants are more prone to iron deficiency anemia than older children on a nutritional basis because their rapid growth requires that they make enough new red blood cells for the increasing volume of blood associated with their growing bodies. As a result, they may not be born with enough iron supplies to meet their needs. This is the reason that the American Academy of Pediatrics recommends iron fortified formulas. Nursing babies generally absorb enough iron without supplementation because human milk has a substance called lactoferrin which enhances iron absorption.
While it is true that red meat is an excellent source of iron, there are health concerns about overemphasizing red meat in the diet. Most infant cereals and many other cereals are fortified with iron. In addition, green leafy vegetables like spinach are excellent sources of iron. Raisins and prunes can also serve as a source of iron; however, raisins may pose a choking hazard in a young infant because they get stuck in the teeth and are hard to manipulate.
If an infant is found to be iron deficient around one year of age and is treated with an iron supplement, once the iron deficiency is corrected, a normal, healthy diet should be sufficient to prevent iron deficiency. The children who are primarily at risk for recurrence of iron deficiency are those who drink a lot of milk and don't eat food as a result. Milk is a notoriously poor source of iron.
Sincerely,
Dr. Warren
I find this whole thing still odd since she was breastfed until 6 months old and has generally had a healthy diet - though once she went on milk at 11.5 months she did reduce her food intake drastically and drink way to much. We then took her off the bottle and onto a cup and she virtually tripled her food intake and her milk intake is more normal, if a bit low. It sounds like from what you are saying that this could have caused it since the original test was taken only 2.5 weeks after her last bottle (and a normal food intake) and 2 weeks after she had had a bad virus (105 fever for two day then 103 for two days.)
Again, many thanks for your time and attention! You don't know how helpful you have been.
-Beth
Dear Beth: If your daughter had iron deficiency anemia as a result of insufficient iron intake, once the iron deficiency is corrected, it should not recur on a normal diet. Frequent retesting of the hemoglobin is not necessary unless her doctor suspects a problem, but screening every year or two is certainly reasonable.
If your daughter had a significant illness prior to her blood test, she may have been anemic because sometimes red blood cell production decreases during the illness or recovery. If this is the case, her repeat test should be okay.
Sincerely,
Dr. Warren
-Mrs. H
Dear Ms. H: Epstein-Barr Virus is the virus that causes mononucleosis. If you no longer have any acute illness there is no risk to people around you or future pregnancies.
Sincerely,
Dr. Warren
-RH
Dear RH: Hoarseness or laryngitis may be seen as part of a cold, allergy, or the croup. In a child who is not otherwise ill, a few days of hoarseness or loss of voice is not a cause for concern. Persistent hoarseness requires evaluation for possible vocal nodules. An older adult who has persistent hoarseness must also be checked for laryngeal cancer, but this is not an issue in children.
Sincerely,
Dr. Warren
-Stressed Out Parent
Dear Stressed Out Parent: If you make an effort to change a particular behavior in a consistent manner, you can probably change most childhood behaviors, but the question is, at what price? Remember that, aside from being consistent in disciplining children, I also recommended being realistic about what you can expect from a child at a given age and choosing your battles wisely. You could spend all day for several weeks trying to alter this behavior and end up totally stressed out and have a miserable child. Two year olds run indoors. It 's reasonable to ask him to slow down when he does run, but I can't see making it a disciplinary matter. Can his running possibly be that disturbing to others? Obviously, he can't be running around early in the morning or the middle of the night, but during normal waking hours you should expect your landlord and neighbors to tolerate normal childhood activity.
Is there a compromise here? Perhaps you could get your child into a baby exercise program or spend time in a park so that he can use some of his energy outside the house. Perhaps you can find some quiet activities your child really enjoys that you can direct him into when he gets rambunctious. If you participate in these activities with him, he's more likely to enjoy them and stick with them.
Sincerely,
Dr. Warren
-O
Dear O: If there is a Web site where you can type in your symptoms and get a diagnosis and recommended treatment, I don't know about it. If there was such a site, I'd want to know how it will examine patients, run diagnostic tests, and prescribe treatments. Good computers, including search engines on the internet, can help physicians diagnose and treat patients, but they cannot take over the physician's job. And they couldn't be sympathetic or caring.
Sincerely,
Dr. Warren
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