13 May 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
As the Internet grows, many people are able to exchange information about topics of common interest. It is astounding to find that those affected by P.E. describe the exact same symptoms of the condition. Sadly enough, most articles also make a note of a physician like yourself, with judgmental remarks and outdated info to back things up. How much longer before doctors like you recognize that there are in fact physical symptoms associated with the condition, regardless of how difficult they are to prove scientifically?
As a new 'age physician' (having a web site etc.) it's particularly important for you to stay on top of discussions, and not just the ones initiated by other physicians. A good doctor takes the time to listen and learn. By doing so you can avoid having to make statements that others can criticize. Feel free to check out my personal P.E. site. It is not unlike hundreds of others on the web: http://www.pectusinfo.com/ And if you still prefer doctor talk, visit http://www.emedicine.com/ped/topic2558.htm for a good start.
Good Luck!
-(unsigned)
Dear Sir: Since you read the comments regarding my original post about pectus excavatum, might I not also assume that you read my response to the gentleman's criticisms? Both are posted on my web site. While your concerns that physicians should not minimize the impact of pectus excavatum on patients are legitimate, I fail to see why you feel that my response did not cover that adequately.
I did review your web site, and in posting your letter with my response, will be happy to include the links to your site and the other site you recommended so that my readers may benefit from your input, but in all fairness to my readers, I must point out that you and the other gentleman who objected to my original post regarding pectus excavatum have your own personal agenda due to your own personal experience with pectus excavatum. I am sorry that your doctor's reassurances that pectus excavatum was not serious ended up being a disservice to you, but I will not remove all reassurances from my web site and leave the impression that all patients with pectus excavatum should consider surgical correction. There is a balance necessary in providing advice to patients. When physicians provide reassurances, they must be careful not to leave the patient feeling that his complaint is being dismissed. Nonetheless, providing reassurances is a large part of what physicians do to make patients feel better. It is also a large part of what I do on my web site.
If you will reread my original response you will find that the words "corrective surgery for P.E. is strictly cosmetic" do not appear in it. Since Michelle had been told that surgery might be necessary, I'll agree that I missed the boat in not providing more information regarding the surgical treatment; however, my original reaction to her question was that she was very anxious about her grandson's condition and that she needed to be reassured that he wasn't in any danger. My personal experience with a family member and the few patients I have had with pectus excavatum who have not had nor considered surgery, is that they did well. Surgery is a big deal, and I think it is legitimate for patients contemplating surgery to know whether or not the surgery is necessary. Therefore, it is legitimate for me to reassure parents that surgery is not always necessary just because a child has pectus excavatum.
That does not mean everyone with pectus excavatum does well. Certainly patients who have decreased exercise tolerance or significantly narrowed chests should be evaluated for surgery. So should any patient who expresses a desire for treatment. Since the optimal age for surgery both socially and physically is prior to adolescence, any parent who feels that his child's chest looks too caved in should explore the surgical options before the child starts to complain about his appearance.
Not withstanding the improved pulmonary function that some patients have experienced after surgery for pectus excavatum, the bottom line is that the majority of patients seek medical attention because of concerns about their appearance. That is a legitimate medical concern and does not minimize the condition. A child with a facial or limb deformity does not have to prove decreased health as a result in order for his surgery to be considered legitimate. Pectus excavatum is a deformity of the chest and should be treated IF the parents or child want treatment. Overstating the effects of pectus excavatum on the heart and lungs in order to justify the surgery will unnecessarily frighten parents and patients who are not having significant symptoms. It also perpetuates the mind set that surgery can only be justified if there is a significant health risk to the patient if he doesn't have surgery. As always, my advice to patients is to consider the risks, benefits, and alternative treatments before making any medical decision.
Okay, now we've both had our say, and I hope you can see that my position is not just one of "judgmental remarks and outdated info." In fact, my remarks, no matter how incomplete or misguided you may think they are, are not in the least bit judgmental. That's something you read into them because of your own experience. And perhaps I'm reading into your response, but it amazes me that you found the initial comments on my statements regarding pectus excavatum "quite harsh," and yet, after reading my response which covered both sides of the issue, you still write, "A good doctor takes the time to listen and learn." implying that I am not such a good doctor.
The best I can offer, since I will not remove Michelle's letter or my response to her, is to add a note to my readers immediately following it indicating that several readers considered my response unsatisfactory and include links to those postings so that anyone reading my original response regarding pectus excavatum will look further to see the additional information.
Sincerely,
Dr. Warren
Like many others I have been active in promoting awareness and building support for people with Pectus Excavatum. I understand that P.E. severity varies from one patient to the next and that desire and need for correction should be based on individual assessments. I also acknowledge that there is significant lack of scientific evidence for P.E. and what is available is controversial. I was not attempting to single you out among many that share your view on the topic. Instead I took the liberty of using your comment as an example and a reminder of what P.E. patients hear from doctors time after time: 'only cosmetic'.
These days it's an achievement if the doctor is neutral about correction, even if it's 'only cosmetic'. It is an indication that he has at least acknowledged that P.E. is not normal. And that having P.E. may prevent a patient from living a normal life. While this is a step in the right direction, it is a far cry from doctors actually associating symptoms with the condition.
Let me give you an example. Just two days ago I discussed my son's exercise-induced asthma with his Pulmonary Function Specialist. While this doctor has been supportive all along and in fact he had referred us to a surgeon for correction(being neutral despite viewing it as cosmetic) he was still unable to make connections between my son's P.E. and the physical symptoms. We have no history of asthma in our family. My son has never had any indication of asthma(usually apparent in the first couple of years of life). Yet, as he reached puberty and his pectus went from a small dent to a P.E. severity index of 4.64 he has began to have breathing difficulties. At age 14 with about 4 years left to grow, do you think we can afford to wait for some scientific evidence? Perhaps it's already too late and surgery will not improve his pulmonary function. But is it not possible that correction may prevent some further damage?
It is astounding that so many people with P.E. (moderate to severe cases) describe the same symptoms time after time. When you do some reading on line of personal P.E. sites, you can discover this for yourself. These people have never met and are not collaborating to make the same story up. The symptoms are quite real. How can doctors dismiss this? Is it ignorance or deliberate disregard? Perhaps they only read medical journals or are not computer literate.
On the positive side, the surgeon we have been referred to, is quite knowledgeable. While he claims no miracle, he is willing and able to provide a patient list with positive results of correction. He is not alone. Increasing number of pediatric surgeons have taken on the task of not only performing correction, but also of educating others still in the dark. A mother with a prepuberty P.E. child should be warned that there may be some significant changes in the condition during the teenage years and it may be best to prevent things or at least to be informed about them.
I understand that not all P.E. is like my son's but let me assure you that many are. I hope that you can understand why things get sensitive. Again I appreciate your note and wish you all the best with your e-practice. Taking the time to correspond rather than ignoring negative feedback is part of what I would consider good e-medicine practice.
Best regards,
Zsuzsanna
-TE
Dear TE: Any antibiotic can cause a loss of appetite. Septra is among the ones that is usually well tolerated, but each patient's response is different. The loss of appetite may also be due to a progression of the urinary tract infection, in which case, it should improve after a few days on the medication.
There are many antibiotics which are effective against urinary tract infections. The choice depends on what organism is growing in the urine and what antibiotics it is sensitive to. Amoxicillin is still a good choice for an uncomplicated urine infection, especially a first infection. It is also possible that your daughter may find another brand of Septra acceptable.
Sincerely,
Dr. Warren
-JK
Dear JK: Molluscum contagiosum is a kind of wart. As the name implies, it is contagious and can be picked up from another person. It can also spread once it takes hold on a person. Molluscum contagiosum may sometimes disappear on its own, but sometimes it persists and spreads necessitating removal of the mollusca. This can usually be done by a dermatologist.
Sincerely,
Dr. Warren
-BK
Dear BK: When infants start using jargon (talking using the rhythm and sounds of real speech without using real words) they are heading in the direction of acquiring speech. Most children are saying words by 15 months, but some do not. My two daughters didn't say a word until 18 months, but they sure speak now. If your baby understands speech, that is reassuring. If she doesn't respond appropriately to speech and follow simple directions, then it's time for further evaluation.
Between now and two years of age, your daughter should acquire a lot of words and start putting some together into phrases. If that doesn't happen, there doesn't have to be something wrong, but it would the be wise to have a speech and hearing evaluation and start some early intervention speech therapy.
Sincerely,
Dr. Warren
-D
Dear D: You would have to ask the doctor what he had in mind when he told you not to give your daughter milk. Perhaps he meant that she would eat more if she took fewer bottles, but I can't imagine that he feels milk is causing her to grow slowly. The amount of milk your daughter is drinking may not be a problem, because it provides nutrients and calories. But try to avoid letting her nurse her bottle all day long as this will interfere with eating and promote cavities.
You could try a high caloric, fortified feeding like Pediasure in place of milk to see if it will help increase your daughter's caloric intake and boost her growth.
Sincerely,
Dr. Warren
He has seen two speech pathologists and a behavioral expert. Treatments vary and all progress is slow at best. He can swallow although he doesn't like it. He does not have hypersensitivity to textures in his mouth. His pediatrician feels at this point it is behavioral. It seems like a battle of wits and he is winning. Please advise. Nothing is working.
-DF
Dear DF: Eating comes naturally to infants when they are born, but when an infant is fed long term by NG tube or gastrostomy because of any condition which prevents him from eating, his instinct will be lost because the satisfaction of hunger is not associated with eating. After 5 months of not eating, it's going to take a while for your infant to learn that eating is a way to satisfy hunger. It will also be necessary for him to be a little hungry.
At first, he won't be able to take enough to meet his caloric needs, so you will have to tube feed him after he eats. Try to delay tube feeding until after eating each time. If you try a variety of age appropriate foods, his interest in taste may stimulate some eating. As he learns that eating is pleasurable, hopefully you can increase his intake enough to eliminate the tube. This may require some high caloric feeds at first until he gets used to taking larger volumes.
This is a complex problem which will take time, persistence, and patience. Your son will need monitoring of his nutrition and growth, and you will need feedback and support from a doctor managing his condition.
Sincerely,
Dr. Warren
-Jessica
Dear Jessica: At 68 inches, for a 15 year old girl your height is in the 95th percentile. The 95th percentile for weight would be 170 pounds. The 75th percentile, which should be slim for a young lady whose height is in the 95th percentile, is 132 pounds. Therefore, your weight should be between 132 pounds and 170 pounds, depending on your body build.
Read some of the tips in my article on obesity. Even though you're not a little kid, some of the information will pertain to you. If you need to lose weight, increase your activity level, cut down on any calories you drink, limit the quantity and frequency of your snacks, choose low fat alternatives for most of your foods, and limit portion sizes.
Sincerely,
Dr. Warren
-Sincerely,
Kris
Dear Kris: I have been unable to locate any information on the internet or in any of my books about any oculo-auriculo-vertebral conditions. The name implies involvement of the eyes, ears, and spine. In an attempt to clarify this further, I researched the term shectrum, but could find no reference to it in the medical literature or my medical dictionary.
I regret that I cannot provide additional help. You will have to go back to the source of the term, namely the doctor who provided the diagnosis. I understand that it is sometimes difficult to get information from doctors. That accounts for the popularity of my Web site. If the doctor could provide a little more information or put the name in writing for you so you can be sure you've got it right, I'd be happy to provide any additional information I can find.
Sincerely,
Dr. Warren
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