19 November 2001

1. Baby Hates Car Seat
2. Concern About Testicles
3. Thrush
4. Handling Suspected Child Neglect
5. Milk Allergy & Otitis Media Revisited
6. Lopsided Head
7. Ultrasound Can't Guarantee Healthy Newborns
8. Growth Charts
9. Disclaimer

• Read Questions & Answers in Another Column

Baby Hates Car Sear

Thank you for your help

-Christine

Dear Christine: For your baby's safety she must stay in the car seat for the duration of a trip no matter how much she cries. If you take her out before the trip is over, not only will you put her at risk, but you will encourage her to continue screaming because she will not learn that she has to stay in the car seat. If you are the one who is driving, make sure that she is seated where you can see her easily with a quick glance so that you can be sure that everything is okay. Talk to her or sing to her in an effort to calm her. But above all, learn to ignore her cries and concentrate on your driving. If you are not the driver, sit next to her and do your best to soothe her, entertain her, and distract her. Remember, if your baby was screaming because you wouldn't let her pick up a pretty, orange, hot charcoal ember, you wouldn't give in no matter how much she cried. This is a matter of safety. Your baby knows her immediate needs, but she doesn't know what's best for her. As her mother, you have to make the tough decisions. Over the course of her childhood she will cry about many of the decisions you make in her best interest. As one who adores children, I firmly believe in making children happy when we can, but only within the framework of doing what is right and best for the child. You have to remember who is in charge and why.

Sincerely,
Dr. Warren

                    |      |
                    |      |
Right testicle      |      |     |
                    |      |     |  Left testicle
                    \_____/|     |
                          /       |
                          |       | 
                          \______/

THANK YOU VERY MUCH, I WILL WAIT YOUR RESPONSE, AS SOON AS YOU CAN, BECAUSE I'M A LITTLE CONCERNED AND WORRIED ABOUT IT.

-G

Dear G: I was unable to find any reference to a condition called "elevator testicle" or "elevated testicle;" however, you should be aware that it is very common for the left testicle to hang lower than the right one. Since you are only 16, you should have had a fairly recent physical to make sure you are healthy and growing and developing properly. Unless this is a new condition, your doctor should have noticed and would have told you or your parents if he thought it was a problem. If both testicles are even in size with no abnormal swellings and you are not having any pain in the testicles, you probably have the normal amount of difference between the left and right side. If the right testicle is high in the scrotum or up against your abdominal wall, and cannot be pulled comfortably to the bottom of the scrotum, you may need attention for an incompletely descended testicle. Both testicles should hang freely in the scrotum, be equal in size, and not tender to gentle examination. If you are not sure, you should be examined by a doctor, but the place to start is to talk to your parents.

Sincerely,
Dr. Warren

1) Do you think it is necessary to see a doctor?

2) If I have a non completed descended testicle (the right) what would be the treatment, and will it have consecuences in my fertility?

3) Is my semen level normal for my age?

-G

Dear G: At 16 year of age, you should have regular checkups, and given your concerns, you ought to see your doctor to be sure if everything is developing normally. If the left testicle is significantly lower than the right and feels smaller, you may have a varicocoele on the left. This is a varicose vein around the testicle. A large varicocoele feels like a bag of worms. It is not dangerous, but may require treatment for pain, or if the testicles are not growing equally.

I was quite clear in my last response that you would only need to be concerned that your right testicle wasn't fully descended if it couldn't reach the bottom of your scrotum. If the testicle is hanging freely in the scrotum and is not high up against the abdominal wall, it is descended and you shouldn't worry about it. If the testicle is not descended, the treatment would be surgery. As long as you have one normal testicle, your fertility should not be affected. Given your description that your right testicle is at least as big as the left, I don't think that's a issue.

I don't know if there are any standards for semen volume based on age. At the point in puberty when ejaculation first begins, the volume is smaller than later on. If there are any standards they would have to be based on pubertal development rather than age. While I'm quite certain that most adolescent boys are ejaculating quite regularly, I'm not sure how many have participated in research on their ejaculates. I'm quite certain the average teenage boy has not measured the volume of his ejaculate. Perhaps you're going a bit overboard here. At any rate, it might interest you to know that infertility is associated with a higher than normal ejaculate volume rather than a low volume.

Sincerely,
Dr. Warren

-TM

Dear TM: I haven't used Gentian Violet to treat thrush in almost 20 years. If thrush doesn't respond to Nystatin, the best bet would be to try Diflucan, a fairly new, systemic antifungal. The first thing, of course, is to be sure that what your infant has is thrush. Since you need a prescription to get Diflucan, I suggest you make an appointment to see the baby's pediatrician.

Sincerely,
Dr. Warren

She is 5.5 mths. old and weighs less than 10 lbs. She weighed 7.6 at birth. She has "grown" approx.. 2" since birth which makes her 10 lbs. look even smaller. I read through your article that stated that we often measure a child's growth by the weight but I and the rest of my family are genuinely concerned about her nutrition. For example, the mother has been known to "breastfeed" around 4:30 a.m., drop the baby off at my Mother's at 8:30 (not fed) and not return again until 4:00. She leaves no bottles except for the occasional juice. She has started her on cereal, fruit and vegetables. This has gone on for several months. This was also a major concern of ours with their first child. We never dreamed it would happen again but it has. I personally don't believe she has much milk...I have never believed it. I breast fed myself and I also work in the field of breast care and she does not display the usual signs of one who is lactating.

I have tried talking to my brother...the whole family has...but it is a terribly touchy subject. He is very protective and she is extremely defensive about it. We don't make it an issue all the time but it obviously comes up. Her Mother is obese as well as her sister and she often makes inferences to weight. She is fat gram crazy and gives her 2 y.o. skim milk and low fat snacks. For all our worrying he has faired well since he started day care. He has gained up to 23 lbs. which we believe is due to regular scheduled feedings.

What do we do? We have thought about feeding the baby on our own but are afraid of the repercussions if she has an allergic reaction. We have also talked of taking her to a pediatrician but have not for the same reasons.

They are a middle class family....we all have good jobs and are Christian people. The pediatrician they go to has been deemed a "quack" by many but again they are very defensive about anything you say. Could you please give some advice about how to handle this situation or at least some comforting information about whether she IS NOT malnourished?

Thank you.

-M

Dear M: I wish I could give you some reassurance that the child is not malnourished, but if she is indeed under 10 pounds at 5.5 months, she is failing to thrive. Without more growth data and other information, I cannot be sure that the failure to thrive is based on inadequate nutrition, but based on what you tell me, it is the most likely cause.

Your options are few, and some are not too pleasant.

1. You can hope at some point the child will begin to thrive as her sibling has, but you should be aware that inadequate nutrition now can have a permanent effect on brain development even if the child becomes adequately nourished later on.
2. You can tell your brother and his wife that if they don't do something to be sure that the child is adequately nourished you will call the authorities and have them investigated for child neglect. Then do it if they don't respond adequately. But first, you had better be sure that the child is truly failing to thrive as you believe. That will require that you get an independent evaluation by a pediatrician.
3. You can feed the child. I don't know how much time the baby spends with your mother, so I don't know how much of an impact that will have. Regardless of how much milk the mother may have, no infant goes from 4 AM to 4 PM without a feeding, and if the infant is in your care, you cannot be expected to participate in this form of maltreatment.

Sincerely,
Dr. Warren

I am ok with the amox., but my sister keeps insistanting it is an MILK ALLERGY and I should take him off of all dairy products. Her daughter had it and went to Dr. X Xxxx (who no longer has a practice!) My doctor does not think it is necessary. He said he would have other symptons! Would he?

Should I do it or should I demand an allergy test first?

Please advise - thanks.

-Marianne

Dear Marianne: It is certainly possible that allergies could contribute to ear infections. There are several letters posted in old Ask Dr. Warren columns about that which you should read. Allergy may sometimes affect the middle ear without causing nasal congestion. While allergy may contribute, milk has gotten a disproportionate share of the blame. Before you decide on trying a milk free diet, you could ask your doctor to do a RAST test for milk allergy. The RAST test is a blood test. The significance of RAST tests remains controversial since sometimes patients have positive RAST tests for foods which never cause them any symptoms they are aware of.

It is possible to put an 18 month old child on a milk free diet, but it is difficult. In order for your child to be adequately nourished (which is your prime concern) on a milk free diet, you will have to substitute a soy formula for his milk, eliminate cheese and yogurt, and read labels on foods to make sure they don't have milk or milk proteins such as casein, whey, lactalbumin, or lactoglobulin. As long as you are sure that you can nourish your child adequately, you can try a milk free diet, but it will take at least a few months before you will be able to tell if it makes a difference.

Sincerely,
Dr. Warren

I have noticied that she usually sleeps with the right side of her head toward the mattress, and rests her head when she is awake toward the right side also.

The Nurse Practioner in our pediatrician's office says her head size is okay and this probably a normal variation.

Is it possible the lopsidedness is related to her head position when sleeping and resting?

Thank you for your consideratrion of this question.

-DM

Dear DM: It is certainly possible for infants to have flattening of part of their heads from the way they lie. This may be increased if there is a congenital torticollis (tight neck muscle). If that is the case, it is essential to start stretching exercises of the neck or even physical therapy. If the shape of the head is severely distorted, it may be growing abnormally due to craniosynostosis. Craniosynostosis, is a fusion of one or more of the growth lines of the skull. When one of these is fused, the head can only grow along the other growth lines leading to an asymmetry of the head. It would be wise for the pediatrician to look at your baby's head.

Sincerely,
Dr. Warren

-R

Dear R: I believe you were referring to an ultrasound study when you asked about a UA. It is true that ultrasound studies can pick up certain birth defects, but not all. In addition, some findings may not be conclusive in time to consider a termination of pregnancy. I do not know what other birth defects your niece had, but a meningomyelocoele is compatible with life. I've had many patients with meningomyelocoele, and while they all had disabilities, they were happy children who filled their parents' lives with both grief and joy in the same way as their able-bodied peers.

It is unfortunate that your sister-in-law had to have a C-section only to end up losing her child, but unless the baby could have been saved by better medical care, I can't say the standard of care plays a role in the outcome. It's nice to have somebody to blame, but your sister-in-law's loss and her grief would likely have been the same with or without additional ultrasounds.

Sincerely,
Dr. Warren

I am currently stationed onboard the USS Xxxxx and do not have access to my "baby books" at home. My 15 month old just had a check up: his height was 31" and his weight was 23lbs 8oz. At birth, he was 20.5" and 8lbs.

The pediatrician assured my husband that the baby is perfectly healthy but my husband is still concerned for some reason. He believes that the baby is not gaining enough weight and has not looked up the % by age for me. The height and weight sound normal to me, but I would like to know what % he is in for his age group in each of these categories and are they indeed normal when put together? If I remember correctly, 20lbs and 30" is normal for a 12 month old?? So, 23 1/2lbs and 31" is good for a 15 month old I would think??

In the pictures that I have, he appears perfectly proportioned...I think my husband may be overly concerned because he is acting as a single parent right now and wants everything to be perfect!

Please let me know the %'s he falls into so that I can more accurately reassure my husband that all is well ! Thanks for your help....

-Liz

Dear Liz: Your baby's height and weight are both just below the 50th percentile. This is solidly in the middle of the normal range and should represent normal growth unless he was in a much higher percentile at his previous checkup. With his height and weight in the same percentile there is no question that your son's weight is appropriate for his height. Please reassure Dad and tell him that there are great parent support groups on the Web like Parent Soup, and he's welcome to visit "Ask Dr. Warren" anytime too.

Sincerely,
Dr. Warren

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