5 November 2001

1. Perthe's Disease
2. Cancer Fear - Get Complete Medical Evaluation
3. Two Languages
4. 4 Year Old Wants Pacifier Again
5. Epi-Pen: Safety and Use
6. Chronic Stomach Pains - No Diagnosis
7. Constipation, Rectal Lump
8. Cause of Congenital Pneumonia
9. Disclaimer

• Read Questions & Answers in Another Column

Perthe's Disease

-TW

Dear TW: If Perthes disease is diagnosed early and followed closely by an orthopedist with treatment aimed at preventing damage to the femoral head while it is healing, a child should recover completely, but this depends on the age of the child at onset, and the condition of the femoral head at the time of diagnosis.

According to Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company,

the short-term prognosis relates to the femoral head deformity at the completion of the healing stage. Adverse risk factors include older age at clinical onset, extensive CFE (capital femoral epiphysis) involvement, femoral head containment, reduced range of hip motion, and premature growth plate closure. The long-term prognosis relates to the potential for osteoarthritis of the hip in adulthood. Older children with significant residual femoral head deformity are at risk for degenerative arthritis. The incidence is essentially 100% in children who are 10 yr of age or older at onset and who have residual femoral head deformity. This compares with a negligible risk in children who are 5 yr of age and younger at onset and 38% when onset occurs between 6 and 9 yr of age.

Sincerely,
Dr. Warren

Do you have any suggestions? I don't trust doctors anymore. I started hurting again and my husband wants to take me to a doctor, but I am afraid that he will say I have some kind of cancer, just like another one of them did. Please, try to understand me. We need your advice...

I really appreciate your time. Thank you!

-Tonia

Dear Tonia: First things, first. Find a gynecologist you trust and have a thorough evaluation. It's hard to counter emotion with logic, but I'm going to try anyway. I understand that you are frightened to be told you have cancer, but either you do have cancer of you don't. If you do, staying away from doctors will NOT protect you from what the cancer will do to you. The best chance for recovery from cancer with the least ill effects is early diagnosis and treatment. I find it hard to believe that a doctor told you that you had cancer and just left it at that. Go to a university hospital. Get a referral from friends or neighbors. Do something to find a gynecologist you trust.

I can understand why you don't trust doctors after getting five different opinions. It's obvious that your diagnosis can't be made just by one visit to a doctor. You need a thorough diagnostic evaluation which would most likely include some blood work, a pelvic ultrasound, and perhaps some cultures. Additional imaging studies may be needed. If you doctor shop and go from one doctor to another, no physician will have the opportunity to follow up on his findings and do the next step diagnostically. There may be several possible explanations for your pain, which is why you may have heard so many possible diagnoses, but your diagnosis needs to be confirmed by appropriate testing and follow up. After testing is complete, you doctor should review it all with you and help you understand how the diagnosis was made, what your prognosis is (what you can expect as a result of your condition), and what your treatment options are. If the doctor cannot be positive about your diagnosis, he should explain how to proceed with treatment (possibly a therapeutic trial) or further diagnostic evaluation, or he should refer you to another specialist who can take it a step further. You do not have to be a doctor to understand what your doctor thinks and why, and you are entitled to a complete explanation in terms a nonmedical person can understand.

After the source of your pain and the status of your reproductive tract has been thoroughly evaluated and properly treated, then, if you still have difficulty having a child, your gynecologist should refer you to a fertility specialist.

Sincerely,
Dr. Warren

There is something else I would like to get an advice from you on. For the last six months my breast hurt really bad with 10 days before my menstrual cycle. I feel they are real heavy, hard and I feel hard knots in my breast. There is also, some white (kind of) dry milk that gets out of my breast. It has never happened before these six months. I don't know what it is. Do you have any answer for this? Or any suggestion?

Thank you very much!

-Tonia

Dear Tonia: Milk production is under hormonal control. Many women develop swollen, tender breasts during their menstrual cycle, but I do not believe it is normal to secrete milk. It sounds to me like you may have a hormonal problem. You really need a thorough evaluation by a gynecologist and/or and endocrinologist.

Sincerely,
Dr. Warren

I read a lot of book to try to find a response but I'm frustrated. I hope you could help me. Take your time to write to me

-CT

Dear CT: Children who grow up in bilingual homes tend to start speaking a little bit later, but they understand both languages early on and even learn whom to speak to in which language. There is no better time to learn two languages than in infancy. I have never heard of anyone regretting the ability to speak more than one language. You should definitely provide your child with the opportunity to learn both French and Vietnamese now. If you don't, your child may even regret the missed opportunity to become fluent in both languages.

Sincerely,
Dr. Warren

Thank you in advance for any help you are able to give!

-AA

Dear AA: After 2 years, it is unlikely that sibling rivalry suddenly plays a role in your grandson's desire to not grow up. It is more likely that the start of preschool plays a role. He sees the younger children staying home and worries (on a preverbal and unsophisticated level) that the babies can now have Mom's full attention and that he isn't there to protect his position.

I have to admit, after 1½ years without a pacifier, I don't quite understand why Mom decided to allow it. That will of course, make it much more difficult to eliminate. Hope the 4 year old forgets about it? Not a likely occurrence if he could decide after 1½ years without it that he could no longer live without it.

How, or if, to push elimination of the pacifier now is not really the issue since it is just a symptom. The older boy needs to see that there is a special place in Mom's life for an older child, and he has to see some advantage to being older. Younger twins can be very demanding. If he sees them getting attention, he tries to compete with them on their level. Face it, an overworked mother of twins can easily appreciate a mild mannered 4 year old who doesn't make too many demands on her, but the 4 year old will not likely recognize that appreciation as attention. Mom really needs to make a point of enthusiastically paying attention to his "big boy" accomplishments.

Sincerely,
Dr. Warren

Sincerely,
-Alex

Dear Alex: I regret that you did not share some of your concerns about the use of the Epi-Pen Jr. Perhaps I could have shed some light on it for you. It is true that epinephrine (adrenaline), the active ingredient in Epi-Pens, has some potent effects on the body; however, when it is used appropriately, it is being used in a situation where the potential or imminent danger to the patient significantly outweighs any of those side effects. Our biggest problem in prescribing Epi-Pens is to provide the parents and school nurses with detailed and specific enough instructions for them to know just when it should be used. Of course we don't want kids being shot with Epi-Pens willy-nilly, but neither do we want treatment to be delayed to the point where a serious allergic reaction has started and the child risks going into shock or cannot breathe.

In any event, in order for a school nurse to administer medications, she needs doctor's orders, but she also needs your permission. Except in a serious emergency where you cannot be reached the school does not have the right to administer treatments without contacting you. You should write a note to the nurse with your specific instructions on the use of the Epi-Pen. If you do not want it used at all, since you provided it, you should pick it up from the school nurse. If the school nurse does not agree to your parental rights you should contact the school principal. Your relationship with your physician or any plans you have to change physicians is irrelevant. The nurse has written orders which are not superseded by a change in physicians until she gets orders from the new physician; however, a written note from you stating what treatments you permit the school to undertake should be sufficient.

If your daughter is severely allergic to bee stings, while you may want to be sure that the school nurse has very specific instructions on when it is appropriate to administer an Epi-Pen, you would be unwise to refuse the school the right to administer potentially life saving treatment. If the nurse, teachers, or any school officials believe that your action is putting your child at risk, they are obligated by law to report the situation to the appropriate child welfare agency. Sometimes these well intentioned (and mandatory) reports can end up creating a nightmare for the equally well intentioned parents and their children. Therefore, I suggest that you have an honest discussion with the school nurse to deal with your concerns and settle the matter amicably. Also, keep in mind that the Epi-Pen is available as a safety precaution. The likelihood that it will be used before you meet your daughter's new pediatrician is very remote, but if this is causing a major anxiety for you, you should prevail upon your new physician to review the school's instructions for the use of the Epi-Pen for your daughter as soon as possible.

Sincerely,
Dr. Warren

Thank you again for reading the above-lengthily as it is. I hope that this additional information allows you a more defined picture of our situation. Again, I feel your expertise is more informative and valuable than what has been made available to us thus far. Your advice in this matter will be the determining factor on how we shall proceed. Thank you, sir, for just "talking" to us and for allowing this informational avenue to exist. You are very kind to correspond with us.

Most Sincerely,
-Alex

Dear Alex: I can't help wondering, with your attention focused on your concerns about the Epi-Pen Jr., just what degree of reaction your daughter had to bee sting. Anyone who had ever experienced a serious allergic reaction to bee sting would be so much more concerned about what would happen if the Epi-Pen were NOT given. So let's try to put this in perspective.

Bee stings can cause significant reactions even if you are not allergic. Bees inject venom. While it is nowhere near as potent as snake venom, you know that people who become ill from snake bite become ill because of the effects of the venom, not because they are allergic to snakes. If a large enough number of bees sting a person, as may happen when they are protecting their hive, the person could become seriously ill or even die - from the effects of the venom, not allergy. The venom of a single bee, or even a few bee stings is not so potent, but all bee stings cause local reaction which includes intense pain and local swelling. A large area of local reaction is not conclusive evidence of allergy to bee sting. Hives, wheezing, swelling of lips or tongue, or generalized itching are signs of allergy. Yellow jackets are more closely related to wasps than bees. While they are all related, if your daughter had a previous allergic reaction to bee sting, the lack of reaction is not proof of safety. At this point, given your concerns, you should consult an allergist and have your daughter tested for allergy to bee sting.

As a side note, you should review the procedures for avoiding getting stung. Don't wear perfumes which can attract bees. This includes sunscreens with fragrance. Avoid eating or drinking where there are bees. Especially avoid getting splashed by sweets like soda or juice. Avoid wearing brightly colored clothes where there may be bees. And stay away from garbage cans outdoors since they attract yellow jackets.

Epi-Pens are not dangerous. While we don't want them overused or used unnecessarily, it would be much better for a child to get an unnecessary dose of epinephrine than to have an anaphylactic reaction to bee sting or other allergen. Epinephrine raises the heart rate, blood pressure, and blood sugar, but the effects don't last more than 20 to 30 minutes and should pose no danger to a healthy child. In fact, since the duration of action of epinephrine is so short, the Epi-Pen is only considered an emergency measure to buy time to get a patient definitive medical care. No child should ever be given an injection with an Epi-Pen and be sent back to class. If there is a good enough reason to treat with an Epi-Pen, the patient should be brought immediately to an emergency room for further observation and care.

Since you feel uncomfortable about the qualifications of the medical personnel in your school and seem to be at odds with the nurse, you should bring your concerns to the school principal. But since your daughter is in their care and they do have doctor's orders, for your daughter's safety as well as to avoid a nasty confrontation, you should not attempt to tie their hands in an emergency. Review the information I have presented you with the principal, the nurse, and the certified medical technician, and help them to understand your concerns and the need for not overreacting, but make sure they don't get the message that you will prevent them from doing what must be done in an emergency. Also, be sure that you have a way to be reached at all times, such as a beeper, and make sure that they know they must contact you immediately, even if they decide that the Epi-Pen must be used before you arrive at the school. In addition, don't forget that your daughter must get medical attention as soon as possible after receiving an Epi-Pen treatment. Perhaps you can take some comfort in knowing that, in the event your daughter receives an Epi-Pen injection, she should be seeing a doctor shortly afterward.

Sincerely,
Dr. Warren

He has been diagnosed with: GERD, severe esophagitis, stomach migraines, C. difficile, irritable bowel and now toddlers' diarrhea. He was placed on lots of medication the most recent was Prevacid and Bethanecol. He continued to have several problems and nobody can figure it out. The doctors sent us to Chapel Hill hospital last week and they switched his medicines and are running test but we are getting no where.

Here is his symptoms:

• swallowing
• burping with vomit
• diarrhea
• undigested foods in his stools and foul smelling stool
• jelly like stools
• severe cramping
• loss of weight
• high fevers and colds frequently

My question.... What is it?

-I

Dear I: I wish that I could give you a diagnosis when others have failed, but to make a diagnosis one must examine a patient and run tests. I am not more brilliant than other doctors, so I cannot make a diagnosis on less information.

My initial thought when I first read the symptoms was GERD. It's not always easy to treat and may take a while to find the right combination of medications. With appropriate testing, it should be possible to document whether or not your son has GERD. C. difficile is a diagnosis which can only be made by testing. Some children who are very ill may have more than one problem. C. difficile is a complication of antibiotic treatment. Your son may have had it, but that doesn't mean it's all he has.

If your son's stool is unusual and he is not gaining weight, a complete stool analysis should be done to see what foods he is not absorbing correctly. The inability to digest certain foods can make a child quite ill. Fat malabsorption can occur with cystic fibrosis leading to foul smelling stools and poor weight gain. These children often have respiratory problems including pneumonia, but they usually have good appetites and don't have abdominal pain.

It's hard to put fevers and frequent colds together with your son's complaints, but inflammatory bowel disease can cause fevers. On the other hand, your son may need an immunologic workup if he has an unusual frequency of infections or unusual infections. It's hard to say if that could get to the root of his GI problems through the back door.

I once had a patient who was sensitive to grains, particularly oats. During his infancy, every time he ate oatmeal he would vomit profusely, become cold and clammy, and become unresponsive for several hours. We never did find out why, and he outgrew it.

Sincerely,
Dr. Warren

Thanks.

-PK

Dear PK: Constipation is a functional problem related to the point at which a person has an urge to have a bowel movement and how long the stool is held in the rectum. The longer stool is held in the rectum, the harder it gets. A person who tends to be constipated may be constipated for his entire life. There are ways to help constipation, but strictly speaking, I cannot offer you a cure.

If a young child is having pain related to bowel movements, he will hold in the bowel movement, aggravating the constipation and making the pain worse. This becomes a vicious cycle. Laxatives are occasionally useful to induce a bowel movement, but they are not desirable to use long term. If medication is necessary, the best management for constipation is to use stool softeners like Colace, bulk formers like Metamucil or Fibercon, and lubricants such as mineral oil. Sometimes a mild stimulant combined with a bulk former such as Senokot is helpful. Prior to using medication, and continuing even if medication is needed, constipation should be managed with appropriate diet. Processed starches like white rice should be avoided. All starches should be whole grain. Fruits and vegetables should be eaten for fiber, but bananas should be avoided. Fluids, especially fruit juice, should be encouraged.

The lump you describe could be a hemorrhoid, but it would take some pretty severe constipation to cause hemorrhoids in a 21 month old. I am concerned that you might be seeing rectal prolapse. If possible, your doctor should see the lump to which you are referring, or your daughter should see a pediatric gastroenterologist.

Sincerely,
Dr. Warren

Could he have problems associated with it throughout his life? In addition, he was diagnosed with croup (at 9 months) , which lasted 3 weeks. Is that caused by a weakness in his lungs?

I would appreciate it if you can enlighten me, even a little.

Sincerely
-MC

Dear MC: According to Diseases of the Newborn written by A. Schaffer, M.D. an M Avery, M.D., there are two primary mechanisms which generally cause an infant to be born with pneumonia.

1. After prolonged rupture of membranes the amniotic fluid may become contaminated by organisms from the mother's genital tract. Since the fetus is continually swallowing amniotic fluid, organisms can enter the fetus through the mouth, nose, or GI tract. These organisms may cause infection in the newborn which may spread to the lungs causing pneumonia. If the labor is difficult, the fetus may gasp during delivery and aspirate contaminated amniotic fluid directly into the lungs.
2. Infections may cross the placenta and enter the fetal circulation, settling in the lungs, thereby causing pneumonia. If you had bacteremia (bacteria in your blood stream) when you were ill, that is a possibility. Although it is less common, viruses can also cross the placenta and cause pneumonia.

Sincerely,
Dr. Warren

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