8 April 2002

1. Medications for Seizures
2. Writing Backwards
3. Bug Bites in Autumn?
4. Exposure to Loud Music
5. Toxicity of Amikacin
6. Cereal in the Bottle for Reflux
7. Infant Allergies
8. Hot Dogs for Every Meal, Beware About Giving Unsolicited Advice
9. Disclaimer

• Read Questions & Answers in Another Column

Medications for Seizures

-CJL

Dear CJL: The following information is quoted from Nelson's Textbook of Pediatrics:

The routine management of the normal infant who has simple febrile convulsions includes a careful search for the cause of the fever, active measures to control the fever including the use of antipyretics, and reassurance of the parents. Short-term anticonvulsant prophylaxis is not indicated. Prolonged anticonvulsant prophylaxis for the prevention of recurrent febrile convulsions is controversial and no longer recommended. Antiepileptics such as phenytoin (Dilantin) and carbamazepine (Tegretol) have no effect on febrile seizures. Phenobarbital has been ineffective in preventing recurrent febrile seizures and may decrease cognitive function in treated children compared with untreated children. Sodium valproate (Depakene, Depakote) is effective in the management of febrile seizures, but the potential risks of the drug do not justify its use in a disorder with an excellent prognosis irrespective of treatment. Oral diazepam (Valium) is recommended as an effective and safe method of reducing the risk of reoccurrence of febrile seizures. At the onset of each febrile illness, diazepam, 0.3 mg/kg q8h po (1 mg/kg/24 hr), is administered for the duration of the illness (usually 2-3 days). The side effects are usually minor, but symptoms of lethargy, irritability, and ataxia may be reduced by adjusting the dose.

I have reproduced the highlights of a table about anticonvulsants from Nelson's Textbook of Pediatrics below:

Common Anticonvulsant Drugs

Drug	Seizure Type	Side Effects and Toxicity
Carbamazepine (Tegretol)	Generalized tonic-clonic, Partial	Dizziness, drowsiness, diplopia, liver dysfunction, anemia, leukopenia
Clonazepam	Absence, Myoclonic, Infantile spasms, Partial	Drowsiness, irritability, behavioral abnormalities, depression, excessive salivation
Ethosuximide	Absence	Abdominal discomfort, skin rash, liver dysfunction, leukopenia
Gabapentin	Complex partial, Secondarily generalized	Somnolence, dizziness, ataxia, headache, tremor, vomiting, nystagmus, fatigue
Nitrazepam	Absence, Myoclonic, Infantile spasms	Similar to clonazepam
Paraldehyde	Generalized, status epilepticus
Phenobarbital	Generalized tonic-clonic, Partial	Hyperactivity, irritability, short attention span, temper tantrums, altered sleep pattern, Stevens-Johnson syndrome, depression of cognitive function
Phenytoin (Dilantin)	Generalized tonic-clonic, Partial	Hirsutism, gum hypertrophy, ataxia, skin rash, Stevens-Johnson syndrome
Primidone	Generalized tonic-clonic, Partial	Aggressive behavior, personality changes, similar to phenobarbital
Sodium valproate	Generalized tonic-clonic, Absence, Myoclonic, Partial	Weight gain, alopecia, hepatotoxicity, tremor

The newest medication I have heard of is Gabitril which is used for partial seizures and absence seizures. Reactions include dizziness, weakness, sleepiness, nausea, vomiting, nervousness, and impaired memory.

Sincerely,
Dr. Warren

-DA

Dear DA: Backwards writing is often referred to as mirror writing. It can be seen as part of dysgraphia or the broader category of learning disabilities or attention deficit disorder. If some of the letters are written backwards and out of order, that is perfectly normal for a kindergarten age child, so I don't think you need to be concerned about it.

Sincerely,
Dr. Warren

Thanks!

-CL

Dear CL: It is certainly possible for a child to appear covered with bug bites when no one else in the family is since the appearance of the bites is actually a reaction to the bite. Some children develop a reaction to insect bites called papular urticaria in which the bumps can persist a long time. However, if your son is suddenly covered with "bites" at a time when it is cold out and insects are not generally around, I can understand your questioning the diagnosis. Why not get another opinion from a dermatologist?

Sincerely,
Dr. Warren

-SC

Dear SC: There is nothing about the type of music a child hears which can cause any harm; however, if the volume is excessive, even classical music can cause permanent hearing loss. My advice: lower the volume or keep the child out of the room in which the music is playing.

Sincerely,
Dr. Warren

Thanks in advance.

-MN from China

Dear MN: The following information is extracted from information supplied by the manufacturer:

Since Amikacin is present in high concentrations in the renal excretory system, patients should be well hydrated to minimize chemical irritation of the renal tubules. Kidney function should be assessed by the usual methods prior to starting therapy and daily during the course of treatment. If signs or renal irritation appear (casts, white or red cells, or albumin), hydration should be increased. A reduction in dosage may be desirable if other evidence of renal dysfunction occurs such as decreased creatinine clearance; decreased urine specific gravity; increased BUN, creatinine, or oliguria increases or if a progressive decrease in urinary output occurs, treatment should be stopped.
Note: When patients are well hydrated and kidney function is normal the risk of nephrotoxic reactions with Amikacin is low if the dosage recommendations are not exceeded.

Nephrotoxicity: Elevation of serum creatinine, albuminuria, presence of red and white cells, casts, azotemia, and oliguria have been reported. Renal function changes are usually reversible when the drug is discontinued.

WARNING: Patients treated with parenteral aminoglycosides should be under close clinical observation because of the potential ototoxicity and nephrotoxicity associated with their use. Safety for treatment periods which are longer than 14 days has not been established.

Aminoglycosides are potentially nephrotoxic. The risk of nephrotoxicity is greater in patients with impaired renal function and in those who receive high doses or prolonged therapy.

Renal and eighth nerve function should be closely monitored especially in patients with known or suspected renal impairment at the onset of therapy and also in those whose renal function is initially normal but who develop signs of renal dysfunction during therapy. Serum concentrations of Amikacin should be monitored when feasible to assure adequate levels and to avoid potentially toxic levels. Urine should be examined for decreased specific gravity, increased excretion of proteins, and the presence of cells or casts. Blood urea nitrogen, serum creatinine, or creatinine clearance should be measured periodically. Serial audiograms should be obtained where feasible in patients old enough to be tested, particularly high risk patients. Evidence of ototoxicity (dizziness, vertigo, tinnitus, roaring in the ears, and hearing loss) or nephrotoxicity requires discontinuation of the drug or dosage adjustment.

The status of renal function should be estimated by measurement of the serum creatinine concentration or calculation of the endogenous creatinine clearance rate. The blood urea nitrogen (BUN) is much less reliable for this purpose. Reassessment of renal function should be made periodically during therapy. Whenever possible, Amikacin concentrations in serum should be measured to assure adequate but not excessive levels. It is desirable to measure both peak and tough serum concentrations intermittently during therapy. Peak concentrations (30 to 90 minutes after injection) above 35 mcg per ml and trough concentrations (just prior to the next dose) above 10 mcg per ml should be avoided. Dosage should be adjusted as indicated

Neurotoxicity-Ototoxicity: Toxic effects on the eighth cranial nerve can result in hearing loss, loss of balance, or both. Amikacin primarily affects auditory function. Cochlear damage includes high frequency deafness and usually occurs before clinical hearing loss can be detected.

The usual duration of treatment is 7 to 10 days. It is desirable to limit the duration of treatment to short term whenever feasible. The total daily dose by all routes of administration should not exceed 15 mg/kg/day. In difficult and complicated infections where treatment beyond 10 days is considered, the use of Amikacin should be reevaluated. It continued, Amikacin serum levels, and renal, auditory, and vestibular functions should be monitored. At the recommended dosage level, uncomplicated infections due to Amikacin-sensitive organisms should respond in 24 to 48 hours, If definite clinical response does not occur within 3 to 5 days, therapy should be stopped and the antibiotic susceptibility patterns of the invading organism should be rechecked. Failure of the infection to respond may be due to resistance of the organism or to the presence of septic foci requiring surgical drainage.

Sincerely,
Dr. Warren

And now he's getting constipated. Does the old Ivory soap method work (warm water and ivory soap as a sort of enema) and can it hurt him? And is the constipation related to the cereal?

I'm sure we're being overly caution parents but we can't help but be really worried when he cries so much. We'd appreciate it if you could give the pacifier to the parents in this case. hehehe

-K

Dear K: The cereal in the formula may be causing constipation. This may in turn be causing gas pains. You can use a glycerin suppository if absolutely necessary to induce a bowel movement. When the stool is extremely hard, Baby-Lax, a liquid glycerin may work better. But it's best to try to let the baby develop his own rhythm rather than using these things frequently. A few ounces of prune juice a day may help to keep the stool soft. Don't use any kind of enema unless instructed to use it by your doctor. A soap suds enema could be very irritating to your little baby's intestines.

If the constipation is controlled and your infant still seems to have colic, it may be the result of reflux or formula intolerance. You could try a hypoallergenic formula like Alimentum or Nutramigen. If that was the cause of the vomiting, you might even be able to eliminate the cereal in the bottle. If your infant has a lot of reflux, even though thickening the formula with cereal has decreased his vomiting, he may still have irritation of his esophagus from acid. For further evaluation and treatment, he may need to see a pediatric gastroenterologist.

Sincerely,
Dr. Warren

-RS

Dear RS: Sounds like there's a little confusion and misunderstanding regarding your doctor's answer, not necessarily at your end. Young infants have very little sinus development, but they do have sinuses, and although it is rare, they can have sinus infections. But that has nothing to do with allergy. Your sinuses don't have to be developed to have allergies. An allergic reaction is a kind of immune response. Very young infants have less reactive immune systems that adults, but they certainly can develop allergies. Inhalant allergies such as allergies to pollen and dust are uncommon because most infants haven't had enough exposure to develop an allergic response. On the other hand, we certainly see infants who have eczema or chronic congestion due to allergy to their feedings.

Sincerely,
Dr. Warren

Thank you for taking the time to respond. We appreciate your expertise and kindness.

Sincerely,
-Alex

Dear Alex: Hot dogs are high in fat, high in salt, and indeed, they have nitrites. They were never intended to be the mainstay of anyone's diet; however, since they are made from meat, they do provide complete protein, and they certainly provide calories. If the child drinks many bottles of milk, the milk will also provide all of her basic nutrients. Such a diet won't be balanced, and lacks fiber, but it will meet your granddaughter's most basic growth needs.

Now that you have this information, a strong word of caution about what to do with it. Any person who has ever offered another advice intended to be helpful, but not all advice is received as if it is a gift. If you think back, I'm sure you can remember times in your life when you received unsolicited advice that made you bristle. No matter how pure the intentions of a person giving advice, if it's unsolicited and suggests that the recipient needs to change his ways, it implies that the person giving the advice thinks his way of doing things is better than the ways of the person he is advising. Put simply, unsolicited advice, especially from in-laws or parents of adults, can backfire. You could be told never to offer any input regarding your granddaughter.

Before you offer any advice, make sure you've walked in the mother's shoes a while. Do you really know what the child eats all the time, or have you just heard things or made assumptions based on what you've seen? Perhaps some of your concerns are unnecessary. Do you know for a fact that the mother hasn't tried to feed this child other foods? Perhaps she's given up trying because the child refuses to eat anything else. Many children who are offered a healthy diet have less than optimal nutrition because they refuse to eat certain foods. That doesn't mean we should let children malnourish themselves, but you can't criticize what the mother is doing if you don't know all the facts, and unfortunately, unsolicited advice often comes across as criticism.

Perhaps the mother would benefit from cooking lessons, offered in friendship. Maybe she desperately needs a break and you could spend time caring for your granddaughter (and offer her some nutritious alternatives to cold hot dogs while you care for her). Maybe the mother would be receptive to an ear to listen to her concerns about dealing with her daughter. You'd be amazed at what kind of relationship you can develop with people when you're really willing to listen without saying too much. And when you really understand what's going on in someone's life and they trust and depend on you, it becomes much easier to offer advice that's taken as the gift it is intended to be.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

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