28 January 2002
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
-KL
Dear KL: I suspect the problem with your daughter's sleep didn't start when you took her out of her crib. After all, your motivation for putting her into a bed so young was that she was trying to climb out of her crib. The difference is, that now she can get out and come to you. She will have to learn that she is expected to stay in her bed. She can only learn this through experience. You are on the right track by bringing her back to her bed. Be firm, yet reassuring and loving, and be consistent about getting her back into her bed as soon as she comes out so that she learns the rules about nighttime and sleep. If your daughter is very persistent, this could take many weeks. Don't give up, give in, or keep changing your response. And don't be worried about your daughter. The disturbance of her sleep isn't harming her. Nonetheless, she must learn an acceptable sleep pattern.
Sincerely,
Dr. Warren
-L
Dear L: If the lump is red and tender, it could be a boil or abscess. If the lump is not red or tender, it could be a cyst, most likely a sebaceous cyst. If the lump is actually under the skin, meaning it doesn't move with the skin, it could be just the tip of the iceberg. I'd need more details to know what internal organ it is on. The only way to know, is to have a doctor look at it. When you don't know what a lump is, it shouldn't be ignored.
Sincerely,
Dr. Warren
At the beginning, when she did this, we consulted our pediatrician, who was convinced it was a protein allergy. We took the necessary steps including changing her formula to Nutramigen.
As this continued, even after the formula change, the pediatrician was sure it was just gas. Again, we took the proper steps including changing her feeding position to a more upright position, buying new bottles to reduce the air intake and introducing her to children's Mylanta.
Then we were told to add cereal to her bottle because reflux was suspected and probable, due to her vomiting. To no avail, the ped. then opted for a barium swallow test. During the test we saw that she did have some reflux. Due to the reflux the Dr. then prescribed Propulsid which we started immediately after the test. She doesn't vomit anymore, but then again, it has only been a couple of days. We are optimistic that these measures will continue to help.
Now there is a problem of abdominal pain. By the way she cries, it seems to be severe. She cries most of the time and hardly ever sleeps (so it seems). She still scrunches up her body and acts as though she is still hungry, though when offered a bottle she refuses. She isn't satisfied with her pacifier either. We have tried every kind offered in our area.
We are very frustrated and at our wits end. I know that this will probably end with age, but can you offer any suggestions for the here and now.
She is still under the pediatricians care as we are awaiting the results of the test done earlier in the week. Anything you could offer will be very appreciated, as we have tried everything else.
Thank You.
-BS
Dear BS: Based on the amount of testing your baby had, apparently your doctor did not feel that this was just colic. If your baby is being treated for gastroesophageal reflux, even if the vomiting has stopped for the past few days, it could take time for the irritation in the esophagus to resolve. In fact, the cessation of the vomiting with the Propulsid does not necessarily mean there is no more reflux. Under the circumstances, I would recommend that you consult a pediatric gastroenterologist.
In the meanwhile, I would suggest that you take measures which are useful to deal with any long term screaming baby, whether it is caused by colic or something else. Medical evaluations take time and treatments take time to work and can't always eliminate all symptoms. During this difficult time period parents must have strategies to maintain their sanity. This is not a selfish matter. While you are doing the best to find out what's wrong with your child and care for your child, you must take care of yourself. It's in your child's interest to do so. Stressed out parents can't do a good job of soothing and comforting their child.
.1. Set up shifts for taking care of the baby so that you know you will have time for yourself. Take a bath, read a book, take a walk. When it's not your shift to take care of the baby, ignore the baby's cries and trust your spouse to handle it. Your spouse will be more at ease handling it and do a better job if he knows you trust him and that he doesn't have to answer to you. In fact, you both must be a source of support to each other, neither demanding that the other succeed in quieting the baby when it just isn't possible.
Sincerely,
Dr. Warren
-DB
Dear DB: The acute illness caused by a cold rarely lasts more than a week, but nasal congestion and coughing may persist several weeks. To relieve the nasal congestion, which also contributes to coughing, keep a vaporizer or humidifier going, use normal saline (salt water) drops in the baby's nose, and suction the nose with a bulb syringe. To suction a baby's nose, it is best to first put a drop of saline in the nostril. Then squeeze the bulb of the syringe and place the tip of the syringe into the nostril you want to suction. Gently pinch both nostrils closed with the syringe tip in one nostril so that the nose seals with the syringe. Finally, slowly release the bulb to suction mucus from up above.
It is possible for infants to have nasal congestion from allergies. This happens most often with formula fed infants; however, if the baby is exposed frequently to cats and/or dogs, she could develop an allergy to either.
I'm not sure if you had a question about chiropractic care for a 4 month old or if you were inviting comment by bringing it up. The only thing I would ask is "Why does the doctor need to adjust her so frequently?" Is there some problem that requires such frequent chiropractic care, or is this his recommended routine for all his patients? Aside from the fact that such frequent visits must be costly, unless the doctor assures you that you arrive to an empty waiting room, you are risking exposure to infectious disease. Of course this is true in a pediatric office as well, but no pediatrician sees healthy children every week.
Sincerely,
Dr. Warren
-DL
Dear DL: Severe eczema can be caused by allergies, in which case, it is called atopic dermatitis. If dietary changes have not helped your nephew's condition and both the dermatologist and your pediatrician are convinced the cause is allergy, you should consult an allergist.
Severe atopic dermatitis can be difficult to treat. Even when you eliminate dietary allergens, the highly allergic child may still react to environmental allergens. Since you didn't tell me what formulas you did try, I just want to point out that soy formulas are not hypoallergenic even though they may help for the child who is milk allergic. Hypoallergenic formulas include Alimentum and Nutramigen. If a child doesn't do well on one hypoallergenic formula, you may need to try another. The trial must be long enough to allow the reaction to the previous formula to subside.
In spite of the best efforts at eliminating allergens from the atopic child's diet, if he has eczema, he will still need attention to proper skin care. Avoid soap and excessive drying. Moisturize. Use anti-inflammatory creams as prescribed by the doctor. An antihistamine such as diphenhydramine (Benadryl) or hydroxyzine (Atarax) may be necessary to control itching. Consult with the dermatologist frequently about measures to control the rash.
Sincerely,
Dr. Warren
-FS
Dear FS: Pityriasis rubra pilaris (PRP) is a rare, chronic disease of unknown etiology which causes thick, smooth, yellow palms and soles, redness of the skin, frequently with well-defined "skip spots" of normal skin surrounded by a background of redness and red bumps of the hair follicles on the backs of fingers, elbows, and knees at the part closest to the body. PRP may occur at any age, but most cases occur in the first and fifth or sixth decades of life. PRP has been divided into adult and childhood forms.
Childhood PRP begins on the scalp and face and simulates seborrheic dermatitis (cradle cap). The disease becomes more widespread and horny bumps of the hair follicles develop. The childhood form tends to recur for years, which is not characteristic of the adult form. The circumscribed form is characterized by red-orange plaques, usually on the elbows and knees, consisting of sharply demarcated areas of stiff hair follicles and redness. The 3-year remission rate is 32%.
The distinctive clinical picture is the most valuable diagnostic feature. The disease looks like psoriasis when localized to the scalp, elbows, and knees. A definitive diagnosis can be made by biopsy.
Frequent use of lubricants such as Lac-Hydrin (12% lactic acid) and Eucerin or Vaseline keeps the skin supple. Lac-Hydrin applied to the feet and covered with a plastic bag at bedtime is an effective approach for removing scale. Application of heavy moisturizers, such as equal parts Aquaphor and Unibase, followed by occlusion with a plastic suit for several hours makes the skin supple. Dovonex (calcipotriol, a vitamin D3 analog), the new topical agent approved for psoriasis, may be effective for PRP.
Retinoids (vitamin A analogs) are the most effective systemic agents. Isotretinoin provides symptomatic improvement of redness, itching, scaling, swelling, and horny bumps in 4 weeks, while significant improvement or clearing takes 16 to 24 weeks. Remission or maintained improvement persists after stopping therapy in many patients.
The antimetabolites offer an alternative to retinoids. Daily methotrexate is more effective than the standard weekly regimen used for psoriasis and may be more effective than retinoids. Improvement may be noted in the second or third week, and there may be marked improvement in 10 to 12 weeks, at which time the dose can be tapered. Megadose vitamin A given for 5 to 14 days clears the skin in days in some reports but has been less effective in others.
Of course excessive doses of vitamin A may be toxic. Possible toxic effects include the following:
Sincerely,
Dr. Warren
Thanks.
-TH
Dear TH: I'm not sure if I can add anything to all the specialists opinions, but since I don't know how much testing any of them did, and how much they relied on the medical history you provided them, my first recommendation is to be sure that you are not chasing your tail as a result of an incorrect diagnosis of UTI. Under the circumstances you need to be sure that the diagnosis of UTI is made on the basis of a reliable urine culture result. UTI cannot be diagnosed on the basis of symptoms or a urinalysis. Sometimes it can even be difficult to be sure of the diagnosis from a culture unless it is properly collected with adequate cleaning and with the specimen immediately refrigerated or put into a stabilization tube. If there is any doubt, the culture should be obtained by catheterization of the bladder using sterile technique.
Redness of the vaginal area would indicate that your daughter has vaginitis, a nonspecific inflammation of the vagina. Unfortunately, little girls with vaginitis may be diagnosed as having UTI because it can be difficult to get an adequately clean specimen for culture from a girl with vaginitis.
Both vaginitis and UTIs may be caused by improper wiping technique, synthetic underwear, and bubble baths. Girls and women should wipe from front to back once, and discard the paper, taking a new paper for the next wipe. They should never wipe back and forth. Little girls should wear only cotton underpants since synthetics are not absorbent. Bubble baths are absolutely forbidden. If your daughter takes baths instead of showers, she should rinse all soap from the vaginal area by showering afterward or sitting in a fresh bath without soap.
If your daughter has vaginitis, sitz baths should relieve her symptoms. A sitz bath consists of putting her bottom into a basin of warm water or sitting in a tub of warm water (enough to cover the vagina area) for several minutes. Nothing should be added to the water, especially soap. This should be done at least 3 or 4 times a day.
If none of these measures help, you should consult a pediatric gynecologist for a closer look at the vaginal area and that end of the urinary tract to be sure there isn't any unusual medical reason for these recurrent problems.
Sincerely,
Dr. Warren
Thankyou.
-Desperate mom Andrea, and dad Dave
Dear Andrea and Dave: Since I haven't seen your son's circumcision, I can't give you a definitive answer, but most often, when circumcised boys appear to have foreskin covering the head of the penis, these boys have a heavy pubic fat pad in which the penis is slightly to completely buried. Even in the situation where the fat pad does not bury the penis, it may cause skin from the shaft of the penis to push up onto, or even over the head of the penis just like a foreskin.
What you must consider to understand this anatomically, is that the foreskin is continuous with the skin covering the shaft of the penis, sort of like a thin, redundant fold of skin. The circumcision is done by crushing two layers of skin together to fuse them and then removing the excess. If too much skin is removed, a portion of the penile shaft will be denuded of skin and will heal with a wider scar which may sometimes cause difficulty. If too little skin is removed, the penis may not appear fully circumcised, but the foreskin is fully open allowing it to be pulled back at an early age. Even if just the right amount of skin is removed, since the foreskin is continuous with the skin of the penile shaft, under some circumstances, as mentioned above, the skin may push up over the penis making it appear uncircumcised.
The penis does not grow appreciably during childhood until puberty. If the appearance of your son's penis is a result of the skin being pushed up over the penis by the pubic fat pad, when his penis lengthens during puberty, the uncircumcised appearance will go away. I suppose you could say he would "grow into his circumcision." If the appearance is due to a larger amount of foreskin being left than the average circumcision, that skin will grow with the penis and your son may not "grow into his circumcision."
I am sympathetic to your concerns about the appearance of your son's penis; however, I should tell you (and hopefully reassure you) that there is no medical reason that your son needs to be circumcised. Given a choice, it is better to have too much foreskin left than too little, and your son's circumcision may be quite satisfactory in spite of his current appearance. At one year of age, circumcision would not be as simple a procedure as in a newborn. It would require general anesthesia and stitches. Under the circumstances, even if you want your son to be recircumcised, you can always decide when is the best time. It is elective, essentially cosmetic, surgery. For an opinion on the risks, benefits, and the need for another circumcision, consult a pediatric urologist.
Sincerely,
Dr. Warren
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