10 June 2002

1. Pregnant Woman Exposed to Shingles
2. Giardia
3. Student Complaint
4. No BM for a Day
5. Immune to Antibiotics
6. Cradle Cap vs. Ringworm
7. Periodic Fever
8. Toddler Refuses Solids
9. Disclaimer

• Read Questions & Answers in Another Column

Pregnant Woman Exposed to Shingles

-KL

Dear KL: Shingles is caused by Herpes zoster which is also known as Varicella zoster. It is the same virus that causes chicken pox. Shingles occurs when a person who has had chicken pox has a recurrence of the virus along a nerve root. Chicken pox is highly contagious because it is spread through the respiratory tract. Shingles is not highly contagious because the only live virus is in the blisters. It can only spread by direct contact with the virus.

Chicken pox virus does not have a high likelihood of causing birth defects. In addition, the fetus can't be affected by the virus unless the mother catches it. If the expectant mother has had chicken pox, then she should be immune to the virus and there should be no risk to her unborn child. If she is not immune, she would have to develop chicken pox for there to be any risk to her child. An inapparent infection would be highly unlikely.

Sincerely,
Dr. Warren

Best Regards.

-PR

Dear PR: Giardia lamblia is a parasite. It may cause diarrhea or gas. Symptoms may be persistent or recurrent. If there are no symptoms, treatment is not necessary. Giardia can be treated with medications: quinacrine hydrochloride, metronidazole, and furazolidone. Treatment should be prescribed by a physician.

Sincerely,
Dr. Warren

Sincerely,
-A 14 Year Old Aspiring Neurosurgeon

Dear Aspiring Neurosurgeon: It is clear that I have angered you, and I certainly understand why.... and yet I cannot fathom that you think I have hurt you or anyone else so grievously as to doubt that I am the least bit decent. While you are certainly entitled to the opinion you have formed of me in your anger, you do not know me. If I were to list all my good qualities and try to convince you that you were wrong, you would have to take my word for it, and I would sound quite egotistical. Suffice it to say that those who do know me do not share your opinion of me. That includes my office staff, most of whom have enjoyed working with me for more than 10 years and many for more than 20 years. That also includes my patients who appreciate the time I take to answer their questions and deal with their concerns even in the middle of the night.

I am not above taking constructive criticism. I have often worried that some of my responses might sound a bit harsh. I have never had a complaint from any of the students to whom those responses were sent, but I will take from your letter as a constructive criticism that indeed some kids will see me as unkind and unavailable. What you don't know is just how many students received a response that simply directed them to the information they sought. There is little point in my publishing each of those on my web site. The letters that were posted which upset you were chosen for a specific reason, and I'll come back to that.

I'm not sure why you refer to my web site as a "fan" site. "Ask Dr. Warren" started as an advice column 6 years ago. It was, and has remained a free public service. It is not supported by advertising or any other funding. It has no staff other than me. I read and answer the e-mail in my free time. Some answers require considerable research and thought because I am often asked questions outside the scope of my expertise and experience. If you have looked at much of my web site you would have seen that I often express considerable regret over my inability to provide the answers some of my readers seek by e-mail. I have stated on more than one occasion that I am not a professor and not more knowledgeable than other pediatricians (not exactly evidence that I lack humility). My web site exists solely because I am willing to take the time to share my knowledge and insights with others.

When I started, I had no idea how overwhelming the response would be. I have answered thousands of e-mails. Over the years I have had many readers who chose to write to me again and again establishing an e-mail relationship with me. I never anticipated the student interview as part of what I would be asked to do, but they came as well... a few at first, and then as others got the idea, they multiplied. Some came from students who clearly had an interest in my response, but many were simply school assignments. Sometimes it was clear that the student hadn't even read the questions or thought about whether or not they were applicable to the field of pediatrics. Some came addressed, "Dear Sir or Madam!" Many came with the exact same questions as previous interviews. Not only would it have taken an inordinate amount of time for me to rewrite an original response each time, but it would have consumed a lot of time for me to find each of the appropriate interviews and copy the answer for the student. The best way for me to cope with the large volume of repeat questions was to organize student pages and establish rules and requirements for submitting questions. That was not a selfish move purely for my own benefit. It was intended not only to encourage students to learn how to do research on a web site, but also to make them think about their assignments rather than just look for a quick and easy way to get a grade. As a side benefit, it would leave me more time to devote to the new and unique questions. Students are not the only ones who have been asked to review previous answers before asking a question. I have also asked people seeking advice to search my web site for answers first as well. Student interviews are often much more time consuming than medical questions since they may contain multiple questions. They often don't include specific personal details that medical question do which benefit from a more personal response, so I thought it quite reasonable not to provide a personal response to every interview request when most students could find the answers they needed with a little effort. The truth is that I would be much happier if I could just answer every single question that comes my way. I really like pleasing people, but aside from preserving my own sanity, to best fulfill my obligation to my readers, I must place some limits on how and when I answer questions. So the rules were established. Imagine my surprise when I continued to get interview requests addressed to "Dear Sir or Madam" which contained 10 to 20 previously answered questions or including some questions that could not possibly apply to pediatrics, some even addressed to an alternate e-mail address when my web site clearly stated that I was unavailable.

It was never my intention to be harsh with these students, but it seemed to me that I had more of a responsibility than to simply fill in their blanks. In fact, based on the rules that I had established, I didn't have to answer those e-mails at all. Maybe education is different now than it was when I attended school, but learning how to do work and to analyze and understand information was considered just as important as gathering and learning the data. I thought those points were worth getting across to students who simply didn't bother to follow instructions. Looking for shortcuts is not the way to success.

The interviews which were posted were chosen for a variety of reasons. Some contained questions and answers which were not previously posted. At the risk of sounding like a horrible person, a conclusion which you apparently drew, I chose to publish many of the interviews which included a discussion of student responsibilities, the importance of following directions, and the need to understand the interview questions before they're asked. Not only did I want students who read those interviews to learn the value of following instructions and doing real research, but also to understand the difference between doing an assignment just for a grade or to fulfill a requirement, and doing an assignment to actually learn from it. In addition, I hoped to be taken seriously about not answering the same questions again and again, presented without forethought. Apparently some students got the message and were not the least bit offended. Check out interview #1 on Student Extra # 3. Tina asks a bunch of questions I've previously answered, discovers that I've previously answered them and fires off a revised e-mail which includes only the questions she still needs answered, and finally writes,

"Dear Dr. Warren: It's Van and Tina...(we e-mailed you some questions and then we found some of the answers to our question on your website... remember?)... Anyways.... we just wanted to THANK YOU SO MUCH and tell you HOW COOL YOU ARE for answering all those questions for those high school kids like us who are in desperate need of answers for a project. We've tried so many physicians but none of them would take the time to answer our question. Even though you are busy and have a hectic schedual and more important things to accomplish, you take time to answer the questions. I feel that this is a very rare thing to come across someone who is so passionate about what you are doing. When I become a pediatrician I will let the world know that Warren Silberstien was my inspiration. Thanks again.=) "

I fully realize that I am not the only busy physician.... never suggested otherwise. That was your conclusion. In fact, one of the reasons Dr. Warren receives such a huge amount of e-mail is that so many of my readers believe that their doctors can't or won't take the time to answer their questions. I also realize that I don't have to provide the service I do on my web site, yet I do it anyway, a factor which I would think would weigh in favor of considering me a decent human being. Like I said, I'm sorry I offended you, and do understand what you find offensive. This is obviously important to you since you shared it with your mother and took the time to write to me. I suspect, however, that you did not review a significant portion of my web site with your mother before finding her support for your conclusions. As a professional, I'm sure your mother is aware of the dangers of making snap judgments and drawing conclusions from scant and incomplete data. One of the biggest difficulties I face in providing e-mail advice is that I often have little to go on and don't benefit from the nuances and give and take of a face to face encounter. As a result, sometimes my responses miss the mark and even ruffle a few feathers. I do my best to correct errors in a timely fashion. I believe I've published all complaints on my web site. There have been very few. To the best of my knowledge, I have not harmed anyone with my advice. I have helped many and have received hundreds of e-mails thanking me for my help. I may not do the job perfectly, but considering the balance of good I do, it doesn't strike me as reasonable to stop because I occasionally blow it or because I don't please everyone.

Now I have some advice for you. Your e-mail had some constructive criticism in it, but it was full of unwarranted personal attacks on me which actually detracted from your expression of your legitimate concerns. When you want someone to focus on your complaints you'll achieve your goal more effectively if you don't put him on the defensive. Just discuss the substance of what concerns you (Dr. Warren. Are you aware that some students feel attacked and inferior by the manner in which you answer requests for information you've previously answered?) and make reasonable suggestions for changes if you have any (not "just stop the program altogether."). I had to get past feeling hurt and feeling the need to convince you that I'm a decent human being (something you wouldn't really get to appreciate because we will likely never meet) in order to focus on what changes I should make to answer your concerns. You might like to review my response to you and my web site a bit more with your mother so she can help you reconcile your feelings with the data that does not support your point of view. You have a legitimate gripe. It isn't necessary for you to find me a despicable person for you to be angry about something I've done.

You are choosing a difficult career as a neurosurgeon. Many of the patients you deal with will be seriously ill. In spite of your best efforts some patients will have undesirable outcomes. Most will understand and appreciate the efforts you've made on their behalf. In spite of that, you will second guess yourself and ask yourself again and again what you could have done differently. If you are a physician with a conscience and a heart you cannot help but take every less than wonderful outcome personally, but then you will go on. Some patients will demand perfection from you and guarantees of good outcomes that you can't guarantee. When the results are less than optimal they will blame you. Will you quit as you've suggested I should, or will you look at the good you do and find a way to go on so you can continue to do good? Most physicians entered the profession for the noblest of reasons. Some do lose their way, become arrogant, self impressed, forget that they serve their patients and why they chose to do so. You won't make medicine a more noble profession by refusing to join it because of those few bad apples (who are not necessarily beyond redemption). Neither will you serve your own purposes by not pursuing your dream. While I can assure you that I am not at all stuck up, even if I were, how could you allow that to change your goals in life?!? You would do well to review your e-mail to me and see just how much of it is emotional spouting off. Think about how you could remove that stuff and write a much more effective letter. If you do that it will serve you well. It's good to have principles and take a stand. I hope you'll continue to do it, but don't lose sight of the best way to achieve you goals including working within the system. Save your emotional venting for friends and family.

To you and other students who might take offense at my tactics, I offer my sincerest apologies. On reviewing my student pages I am amazed myself at just how many negative comments there are. That kind of makes both your point and mine. There are an awful lot of students who didn't follow, understand, or even read the rules, but if I haven't made my point by now, I'm not going to accomplish anything by beating students over the head with it. From now on students who send questions previously answered will get a response pointing them toward the information they seek unless I have time to answer their query directly, no commentary, no complaints, just information on how to find their answers. Students who have questions I haven't answered mixed with lots of questions I've answered will get answers to the new questions and the same kind directions to search for the others as mentioned above. I will be careful to avoid any hint of negativity in my response. But the letters already posted will remain as they are, warts and all. They serve a purpose.

Sincerely,
Dr. Warren

-MM

Dear MM: As long as your baby has been having normal bowel movements it's perfectly okay if he skips a day. Some babies go even longer. If the stool becomes hard, the baby's belly becomes swollen, the baby becomes irritable, or the baby loses his appetite or feeds poorly, the you need to call your doctor.

Sincerely,
Dr. Warren

Also, we have been told she will outgrow this, but her ears drain continually. She has been on Augmentin for the past two months and I feel that if the antibiotics aren't working then it's time to try another direction.

I would appreciate any opinions or advice you can offer.

-JB

Dear JB: If your daughter has draining ears, the she is a candidate for treatment with Floxin Otic drops, the newest antibiotic for treating ear infections. Since the drop is not taken systemically, that also avoids some of your concerns about antibiotic resistance. Floxin is not related to any antibiotics currently used to treat ear infections. Unfortunately, the drops can only be used to treat ear infections with draining ears or tubes since the drops can't get into the middle ear when the drum is intact.

Even though chronic ear infections may be difficult to clear, the difficulty revolves around the condition being treated. The anatomy of some children's ears just makes them more prone to ear infections and harder to treat. Children DO NOT become immune to antibiotics. The antibiotics do no do anything to the patient. Antibiotics kill bacteria. Bacteria can become resistant to antibiotics. The general over use of antibiotics has increased the number of resistant organisms in the environment. If your daughter should develop any infection while on an antibiotic, it is more likely to be a resistant organism, but if your daughter catches an infection from someone in your community, your daughter's risk of having an infection with a multiply antibiotic resistant organism is no higher than everyone else's risk in your community.

Sincerely,
Dr. Warren

Help.

Regards,
-JD

Dear JD: Cradle cap can be a recurrent condition. The treatment is aimed largely at reducing the scales. Anti-inflammatory lotions can be used to reduce the scaling and redness, but repeated treatment will be necessary since the medication is not a cure. If the scaling is due to tinea capitis, you should not use anti-inflammatory medications. Antifungal creams are not very useful for treating tinea capitis since the fungus gets into the hair follicle. Treatment requires medication by mouth. Since the correct diagnosis can't be made without seeing the scalp rash, and treatment depends on the diagnosis, you will need to see your daughter's pediatrician.

Sincerely,
Dr. Warren

I have a daughter aged 6 years, she is getting a periodic fever every 30 days. it is being her case since she was 9 months old. the accompanying symptoms are :

• stomach pain
• laziness
• headache
• bedwetting 3 days before getting the fever.
• Fever for 3 days, striking high every 3 hours
• irritated tonsils but not infected

-RM

There are no ordinary childhood illnesses which cause fever regularly with a cycle of 30 days. Since you say this has been going on for more than 5 years, I would certainly want to know what kind of evaluation has been done and how your child is doing in terms of general health and growth before I tried to make any diagnosis.

Urinary tract infections could be recurrent (but not with a regular cycle of every 30 days), cause abdominal pain, malaise, fever, and bed wetting. They would not cause irritation of the tonsils. Has your daughter had urine cultures done?

Sincerely,
Dr. Warren

To help you making your diagnosis please find here below more details about her case.

She used to get the monthly fever since she was 9 months old, with an interval of 6 months at the age of four and 3 months this year. The evaluation done so far is that she has weak immune system making her more exposed to viruses. Moreover she proved to be allergic coughing and spitting out during her illness for around 10 days. She has undergone some physical therapy (back massages) in this regard.

The results of urine tests were satisfactory revealing that nothing was wrong. Her urine becomes aching during her illness only. The frequency of her heart beat is fast somehow but they said it is the case of many children.

I hope the above answers all your questions, and waiting to be informed about your diagnosis if any.

-RM

Parents often think of the many infectious illnesses young children have as being one recurrent or persistent illness. In reality, the situation you describe does not have any periodicity. When your daughter was younger she had a high frequency of fevers averaging once each month, but probably not with a regular cycle of every 30 days. As she became older the frequency of these illnesses decreased to between 2 and 4 each year, which is not a high frequency of febrile illness for a child.

Some of the recurrent symptoms your daughter has may not be specific symptoms of a specific illness, but rather, may be her body's response to becoming ill. If urinary tract infection has been ruled out as the cause of your daughter's bed wetting, then this must be her response to not feeling well. The other symptoms such as headache, stomach pain and malaise may all be seen in response to fever from a variety of different illnesses.

Unless the frequency of your daughter's fevers increases beyond the current 4 times each year, I think each fever can be treated as a new and unrelated illness. Treatment, or the need for further evaluation should be based on the specific symptoms, doctor's findings, and the course of each illness.

Sincerely,
Dr. Warren

-RMA

Dear RMA: If your daughter is drinking reasonable amounts of milk, it will meet her basic nutritional needs. If your daughter's pediatrician has found her growth and weight gain to be satisfactory, you don't need to be worried. Keep offering your daughter foods, but don't make a big deal about it. If you pressure her she will resist. Otherwise, she will eventually develop more of an appetite for food.

For additional advice and information, read my article, Nutrition Without Tears.

Sincerely,
Dr. Warren

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