3 December 2001

1. Sick Child Not Eating or Drinking
2. Croup
3. Food Allergy
4. Urinary Frequency and Difficulty Urinating
5. Hematoma
6. Penis Size, Masturbation
7. Abdominal Pain, Constipation
8. Nursing 3 Year Old Refuses Food
9. Disclaimer

• Read Questions & Answers in Another Column

Sick Child Not Eating or Drinking

It may also be helpful to know that two weeks ago my child had emergency surgery for a double hernia, from which he seemed to be recovering nicely.

Thanks.

-NH

Dear NH: I can understand your anxiety about your child's appetite, but sick children lose their appetites and forcing them to eat is looking to clean up vomit. In fact, I don't recommend forcing healthy children to eat. Encouraging and distracting them to get them to eat, sometimes. But forcing children to eat really doesn't work and results in unpleasant mealtimes and a poor attitude toward food.

Your main concern until your child fully recovers is to be sure that he doesn't become dehydrated. If he is not vomiting or having severe diarrhea, he should be able to meet his fluid needs by what he drinks. As long as he wets plenty of diapers and is acting well, you can be sure he isn't dehydrated.

While your son is sick, he is turning more toward what provides him comfort, namely nursing. Without your realizing it he may be taking more from your breasts than he was previously. Not only does this help meet his fluid needs, but it is an excellent source of nutrition. Unfortunately, you can't be sure how much he's getting and so it doesn't relieve your anxiety. Since a nursing doesn't provide a standard amount (there aren't 4 ounce and 8 ounce breasts), I can't tell you a specific amount to give him in addition, but thirst is a powerful drive. Your son will most likely meet his fluid needs unless pain or nausea prevent him from drinking. When children have sore throats, ices and ice pops can help to get fluids into them. Pedialyte makes an ice pop which has the added benefit of providing the appropriate salts to help prevent dehydration.

Your best bet is to not focus on how much you think your son is eating, but rather, on how he is acting. As long as he continues to get better and is acting happy, he is not dehydrating and his appetite will eventually return. If he starts to act sicker while he is recovering, it's time to see the doctor.

Young infants must be seen for low-grade temperature elevations because even a temperature of 100.5 could be a sign of a serious infection in a newborn. Your books don't provide a specific number for older infants and children because the number on the thermometer is not as important as how sick the child is acting. The fever itself is not the danger. The issue is what's causing the fever. Fevers higher than 104 have a greater risk of being associated with a serious infection, but some children routinely run high fevers and not all high fevers are associated with serious infections. For more information please read my article, Fever

Sincerely,
Dr. Warren

-NB

Dear NB: In some sense, the pediatrician who saw your daughter is correct, in that most croup in children is the result of a virus infection and must run its course. It will do that within a few days. There are some measures which can be taken to help a child with croup. Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) may be used to reduce fever and miseries just as it can be used for any other virus infection. Steam can relieve the symptoms of croup. If a child has been laboring to breathe with croup, but not severely enough to require emergency room attention, a short course of steroids to reduce the inflammation in the trachea can improve the symptoms and prevent an escalation of the symptoms. Croup can progress to the point of causing severe difficulty breathing which does require emergency care. This tends to happen in the middle of the night or the wee hours of the morning. Therefore, I would not consider your concerns "unsubstantial." For more information, please read my article about croup.

Sincerely,
Dr. Warren

Thank you very much.

-Carlos

Dear Carlos: I am somewhat flattered that another pediatrician would ask my advice, because in all honesty, my presence on the Web is a result of my willingness to help and take the time to explain things. I am not more brilliant or learned than other pediatricians.

As long as you are doing a blood test such as a RAST test for allergy, you can do it at any age since there is no risk to the patient other than getting poked for blood. If you want to do skin testing, you really should consult an allergist, but generally skin testing is reserved for inhalant type allergies rather than foods. The problem with RAST testing is that it is more useful for confirmation of clinically observed allergies or for sorting out what may have caused a reaction than it is for making a specific diagnosis. The correlation of symptoms with RAST testing is moderate. Some patients with positive RAST tests for certain foods may sometimes have no clinical symptoms on exposure to these foods.

Since allergy is a form of delayed hypersensitivity, which, by definition, requires prior exposure to result in sensitization, a negative test may not help you be sure that your child won't react to a food. If you have been careful to avoid any exposure to certain foods, your son's RAST test for those foods should be negative. On the first exposure to those foods, he may have no reaction, but he may become sensitized and have reactions on subsequent exposure.

It is possible for your son to be highly allergic to cow's milk and yet not react to any other foods; however, his severe reaction to milk could indicate that he has an allergic tendency, and it might be a good idea to have epinephrine available. You might want to consider something like an Epi-pen Jr. so that somebody with no medical experience would be able to use it on your advice in an emergency.

If your wife does stop or decrease nursing before the baby is one year old and you must use formula, it would be best to use a hypoallergenic formula like Nutramigen or Alimentum rather than a soy. Even after one year of age a hypoallergenic formula may be a good source of nutrition for the highly allergic child. Highly allergenic foods like eggs and fish should not be introduced before 1 year of age. As an infant gets older, the risk of allergic reaction to these foods decreases because the intestines do not absorb molecules as large as in early infancy, and these larger molecules are more allergenic. A severely allergic child may sometimes develop a reaction just by touching the food to which he is allergic.

My best advice if your baby has a significant problem with allergy, is to consult an allergist and avoid being the one to make treatment decisions about your child.

Sincerely,
Dr. Warren

Nothing seems to work, do you have any suggestions?

Thanks

-Mr. & Mrs. E

Dear Mr. & Mrs. E: Even a happy child may experience stress symptoms. Some children develop a specific stress related to the bathroom, especially if they become anxious about restrictions of access to the bathroom in school. Sometimes the frequent urge can be a habit or tic.

On the other hand, your daughter may be experiencing bladder spasms. Therefore an evaluation by a pediatric urologist might be in order. If your daughter does not experience nighttime waking or bed wetting, it is less likely that she has bladder spasms, but it is still possible. If your daughter is experiencing any wetting, pain, or always has difficulty urinating, she should definitely have further evaluation.

It may help to keep a dairy of when she has symptoms and when she does not in order to get an idea of what might influence her symptoms.

External irritation should not cause an urge to urinate, but it may prevent her from emptying her bladder completely if she has a great deal of discomfort when she urinates. This could result in an increased frequency of urination and some difficulty initiating the urinary stream because of anxiety about the anticipated discomfort associated with urination. You should have your doctor determine the cause of the redness and recommend an appropriate treatment. In any event, Premarin is a hormone cream and may be irritating. You should not be using it for this situation and should not use it at all on your daughter unless specifically instructed to do so by a doctor.

Sincerely,
Dr. Warren

I saw the wrist the next morning and agreed with my friend that I should take her in to the doctor and have the wrist looked at. We both asked her if it hurt and she said only when people touch it. The doctor I saw is also in Tae Kwan Do and I asked him if this could have happened when we were practicing certain holds and releases that are all centered around the arms/hands/wrists and he said no (he is a black belt and is familiar with what we were doing). He said to wait a week and see how it went.

During the week of waiting, N would roll on her arm during her sleep causing her pain, the bruise has gone to two seperate yellow marks yet the "bump" is still there.

I recently took her back in, not pleased with how slow it was healing. The doctor looked at it, called his partner in who looked at it and then suggested an x-ray, no bone damage had been done. Now they want us to see a surgen which we will see tomorrow. Their current speculation is either a hemotoma or a hemagioma, I sort of understand what the two are. The bump and bruises are located right over a main vessel to the hand, possible surgery may be involved.

My main question is, how dangerous could this surgery be if its located right above a main vessel and how could she have bruised her wrist so much yet not know how it happened. My daughter is very honest and lets me know when she has hurt herself or if she's been doing something during the day (sports,playing etc) that has made her sore or tired. The doctors that saw her are stumped, I'm stumped also and would love to hear what you have to say.

Thanks so much for your time and this is great that we Mom's can get more information from our fingertips!

Sincerely,

-Lori

Dear Lori: Sometimes it is possible to develop a hematoma (bleeding under the skin) spontaneously or from a minor injury. If your daughter had multiple unexplained bruises, she would need further evaluation to make sure she doesn't have any clotting disorder. It is also possible for a small, previously unnoticed hemangioma (a benign growth of blood vessels) to become injured and bleed. The initial minor injury that provoked the bleed (if there was any injury at all) may not cause any significant pain and therefore go unnoticed, but the fresh blood under the skin is irritating and may cause an inflammatory response. In addition, once the clot organizes, it may leave a firm bump which is sensitive to pressure. If there is a good sized hematoma, it may take several months to fully resorb, and may leave a firm knot which is not tender or discolored which can persist many months more.

I am not sure what main vessel the lumps are located over, but it is highly unlikely that the hematoma has anything to do with an artery since the artery is between the bones, not really subject to injury, and arterial bleeding would have caused an enormous hemorrhage. If there is any malformation of veins or capillaries causing the hematoma, it would not be difficult to control the bleeding should surgery be necessary. In fact, with proper care, arterial bleeding is also controlled. Surgeons always have to deal with the blood supply to any organ on which they operate. But I think we're jumping the gun here. There would be no reason to do surgery on a hematoma or a hemangioma unless there were uncontrolled bleeding or continuing enlargement. If the consultation with the surgeon is due to the doctors being unsure what the lump is, I wouldn't expect the surgeon to rush to do surgery without further evaluation.

My advice would be not to rush into anything. Since I haven't seen your child, I want you to understand that I am not in a position to recommend surgery or recommend against it, but a slowly resolving hematoma does not require surgical intervention. If anyone recommends surgery, make sure you understand why he thinks surgery is necessary, what the risks and benefits of the procedure would be, and what the risks of not doing surgery would be. If exploratory surgery is recommended to determine a diagnosis, make sure you explore other diagnostic options before you agree to surgery. The bottom line is that surgeons have a lot of experience with lumps. Going for an opinion does not mean surgery is the necessary answer. I have certainly, on occasion, asked my surgical colleagues for an opinion about a lump without necessarily anticipating surgery.

Sincerely,
Dr. Warren

Thank you very much for your time. Please email me back as soon as possible. This is very important to me. Thanks.

-Dustin

Dear Dustin: Your penis should not be swollen from masturbation unless you are doing something to irritate it. I am assuming that you are not talking about your erection when you say your penis is swollen. Even after your erection goes away your penis will be larger than its usual state for a few minutes. If your penis is not red, sore, or swollen in one particular location, and the swelling you are talking about always goes away, you are probably talking about the normal changes that occur to the penis associated with masturbation and erection.

There are lots of charlatans out there selling devices and creams that promise to enlarge the penis, but none of these work. When you have an erection your penis will be fully extended, but when the erection subsides, it will always go back down to its usual flaccid length. There is nothing that can keep your penis stretched.

You are only 14, and while I don't know where you are in pubertal development, at 14 it is likely that your penis hasn't finished growing. I would suggest you be patient and let nature do its job.

Sincerely,
Dr. Warren

-VS

Dear VS: In only eight weeks, it is hard to believe that the baby has had laxatives, juice, and colic medication. Without more details about what you have used, it's hard for me to comment, but I would say that it may be necessary to stick with an approach long enough to give the baby time to adjust to it.

Although I'm a firm believer in giving infants iron fortified formulas, and have found that most infants don't become constipated from the iron, I would try a baby this severely constipated off iron for a while. In addition, because Enfamil has more whey than Similac, it sometimes results in a softer stool. After giving a formula switch some time, if necessary, add the prune juice regularly to the diet. Sometimes it may require several approaches until you find the right combination, so you must stay in close contact with the pediatrician, but remember, each change need at least a week before you can evaluate its efficacy and decide if it's time to change strategy.

Sincerely,
Dr. Warren

Thank you

-B

Dear B: There are certainly some issues which need to be addressed regarding a 3 year old who refuses most food and is still nursing when her mother is 7 months pregnant, but if the child is gaining and growing adequately, I'm not sure on what you base your conclusion that she is not getting any real nourishment. Mother's milk is very nourishing, and based on the fact that the child is thriving, we have to assume she's getting enough of her mother's milk.

Parental attitudes toward food can certainly affect a child's diet, but Mom being a picky eater cannot make the child gag on foods she doesn't like starting in early infancy. So I suggest we just stick to the facts here.

Fact #1: Mom has a baby coming soon, and if she's planning to nurse the baby, she's waited a bit long to wean the older sister. Some advocates of nursing may disagree with me, but I think the new baby deserves the full benefit of mother's milk, and it's time for the 3 year old to move on.

Fact #2: As long as the child's nutritional needs are met by nursing, given her current attitude toward food, she has no reason to try other foods.

Fact #3: Healthy attitudes toward eating cannot be developed by forcing children to eat. Neither do they develop when mealtime is stressful. The child should be presented with a variety of good foods at each meal and be encouraged, but not pressured, to try different things.

Fact #4: As long as the child is healthy and thriving, if Mom has not asked you for advice, it's not up to you to tell her Facts #1,2, or 3.

Sincerely,
Dr. Warren

• Fact 1: Mother asked me to write this letter!
• Fact 2: This child is not thriving as she shakes all the time and is sick constantly. She is irritable and cranky and as for nursing she has never been given the opportunity to be weaned. This is one way mom can keep her quiet.
• Fact 3: Mother does not cook meals at all. If they eat they eat out. She refuses any kind of homecooked meals from anywhere. Taco Bell and McDonalds are her big meals. When they go to these places the child is NOT offered any food at all. She takes chips or crackers for her and when asked if maybe you could offer the child some mom says "Why, she won't eat it anyway."
• Fact 4: It was not inferred that the child gagged because mom is picky but I do believe that when being given baby food the child hears from the mom that this stuff gags her or is nasty they do pick up on that.
• Fact 5: As mom is anorexic and most days lives on chips and pop herself I don't feel her milk is very nourishing.
• Fact 6: I feel this is very much my business as I have raised and supported this child from before she was born and still do.

-B

Dear B: I am sorry that you didn't find my advice helpful. I try to give the most complete answer I can based on the small amount of information I usually get in the e-mail queries I receive. It's not like having a conversation with a patient since I often can't sense how the writer feels and he can't steer me in the right direction if I have missed the mark. Still, after two years on the Web, and after thousands of e-mails answered, while I'm sure I haven't given everybody the perfect answer, yours is the first real complaint I've had, and judging from the tone of your response, I apparently struck a raw nerve.

Since I never claimed to be more brilliant than Dr. Spock, and you feel that you, as a nurse, already knew what I had to say, part of the problem appears to be that in spite of what you know and I and Dr. Spock might say, this 3 year old is still being offered the breast instead of food. If you're looking for a quick fix when common sense gives you difficult answers, you won't find one.

As to some of the things you took issue with in my response, your initial e-mail did not state anything about the child being in ill health. It also said that she is at an adequate weight, which would lead me to conclude that she is thriving. If the child is not doing well (and even if she is) she should be seeing a pediatrician for evaluation. He can determine if her nutritional state is adequate, and if he finds that her health has been adversely affected by her diet, his opinion will carry more weight than mine. This is important, because it sounds like the child's mother has been resistant to suggestions that she change what she is doing. In fact, your comments about the mother are what led me to think that your input was not solicited, which is why I said you shouldn't offer advice IF it wasn't requested. But there was an "if" in the statement, so if your input was requested, I haven't said anything to suggest it isn't your business.

I get a lot of e-mail from friends and relatives looking for me to provide ammunition to support their point of view when they disagree with how a child is being handled. I have to be very careful how I answer those questions, providing useful information when appropriate without taking a stand against the parents (or one parent in divorce cases). When a child is not doing well because of neglect, mistreatment, or poor parenting, I think we all have an obligation to intervene on the child's behalf, and hopefully befriend, help, and educate the parent(s) in the process. But when a child is doing well, I feel that parents need as much support as they can get, and they don't need the interference of well meaning relatives who think their way is the best way.

Sincerely,
Dr. Warren

I hope you understand my frustration with this problem and my deep concern. I am sure you are doing a fine job on the internet with addressing issues that people would otherwise not be able to find help with. If at any time you can provide me with any data or information as to a child that appears to have a phobia towards food I would appreciate it if you could provide me with that. This is not a case of taking sides or a custody thing. We are just trying to be sure that this little girl is helped.

-B

Dear B: Some children do develop an aversion to food, but since the child eats some foods, presumably her swallowing mechanism is normal. A child who has a limited repertoire of foods may have a problem not only with the taste of some foods, but also with certain textures. For a thorough evaluation and a therapy program aimed at increasing the child's repertoire of foods, I would recommend consulting a speech pathologist who specializes in, or at least has experience with, feeding disorders. Since these kinds of problems are common in autistic children (I'm not saying your child is autistic) a therapist who works with these kids might have the experience you need.

That having been said, if your daughter is seeking to make some changes and wants some advice, I suggest she read my first answer to you. As long as the child continues to nurse instead of eating, she has no reason to eat. And with a new baby on the way, stopping the nursing is overdue. The environment in which your granddaughter learns to eat must be pressure free, but she still needs the opportunity. That means, a variety of good foods must be presented to the child at mealtime, whether she eats them or not. But you have to be reasonable. Offering too much food or too many choices can be overwhelming. And if the child doesn't eat at mealtime, the meal should end within a reasonable time. The next opportunity to eat should be at the next meal, not continuously. Conversation at the meal should not focus on the child's eating. By good food, I don't mean fast food. The child has to have fresh food in her own house, or at least, the place where she spends the most time. No significant changes will occur over night, so persistence is the key.

Sincerely,
Dr. Warren

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