24 June 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
They told me it was obviously a viral thing since it hit so quickly. Her nose running, coughing, all indicating some kind of cold. But colds don't come with fever. Anyhow they told me to go ahead and continue the Motrin and Tylenol every two hours and keep the fever down. They gave her another dose of both tylenol and Motrin as well as a full blood work up and gave her a shot of an antibiotic (two shots - one in both leg simultaneously) They sent me home with instructions to follow up with the doctor if increased lethargy occurred or a rash.
Last night was long. Her breathing was very pronounced, very fast, and loud. The inhale was where you would here the crackling the most. Coughing once in a while, maybe every two hours at the most. Sounds like she needs to cough and get some stuff up. Took her to the doc today. Was informed that it sounds like croup. Although she is looking better now she understands that nights are the worst. She mentioned that maybe we should consider admitting her for observation. Where they would do a tent with a mist inside with some medicine included. She states this is usually a five day virus and the third day usually being the worst. Is this something I should consider? When she talks she sounds like a boy in puberty and her breathing is very loud.
Should I consider admitting her to be on the safe side? In all honesty what happens if we just let it take its course? Can you give me some ideas here? I don't mind taking her there but that would be quite traumatic being stuck in a tent.
Thank you so much for having this service. It's people out there like you who truly care.
-WD
Dear WD: The height of a fever does not tell you how sick a child is or what kind of illness a child has. Viruses can cause very high fevers. It's true that the common cold does not cause significant fevers in older children or adults, but there are many other upper respiratory viruses besides the common cold. Influenza is an upper respiratory virus which can make a person quite ill.
Since the height of the fever alone does not determine how sick a child is, we have to look at other things like activity level, appetite, vomiting, pain, breathing abnormalities, and/or other symptoms, to decide how sick a child is. Even though high fevers don't mean a child has a serious infection, illnesses like pneumonia, meningitis, and sepsis often cause children to run high fever and act quite ill. Such children require a thorough evaluation. Your description of your daughter lying motionless, staring into space, and responding minimally to you is very worrisome.
I don't know what tests the doctors in the emergency room ran in order to be sure your daughter had a virus infection, but it doesn't sound like they had the courage of their convictions since they gave her antibiotic injections. Viruses are not treated with antibiotics.
Rapid and labored breathing in a child with such a high fever and degree of illness would make me think first of pneumonia. Did your daughter have a chest x-ray? Croup doesn't generally cause such a high fever or degree of malaise, but it's possible. Children with croup generally have barking coughs and when they breathe in it makes a honking or crowing noise. Difficulty breathing with croup does tend to be worse during the night. Children who have difficulty breathing with croup may require treatment with steroids or hospitalization.
It might help if you read several of my articles. I would recommend the following ones:
The decision regarding admitting your child to the hospital depends on whether there are unresolved diagnostic issues which would be better handled as an inpatient, whether there are any treatments which require hospitalization such as intravenous fluids or medications or administration of frequent inhalation therapies, and finally, whether your daughter has any worrisome or potentially dangerous symptoms which require professional monitoring or might require urgent intervention. Your doctor who has evaluated her and is treating her should be the one to decide what is best.
Sincerely,
Dr. Warren
-Mr. & Mrs. A
Dear Mr. & Mrs. A: When a newborn is fussy for several hours each day and okay most of the rest of the day, that is typical of a fussy period. Fussy periods usually occur between 6 PM and 10 PM, but occasionally occur later. They need not occur at the exact same time every day, but are usually fairly predictable.
A newborn's cries are very different than an older baby's cries. For starters, there's no emotion in a newborn's cries. The newborn cries out of basic need - hunger, pain, a need for comfort. He puts his whole body into his cries and often grunts and strains as part of the process creating the impression that he is trying to have a bowel movement. Often gas is passed in the process. Just as often, the baby swallows air in the process which can cause gas pains. The newborn cries as if his life depends on it..... and in reality, it does. The only means the newborn has of making his needs known is to cry. If his cries could be ignored, the human species would not have survived.
Is your baby actually having pain? That's a question I can't answer by e-mail. Some babies are much fussier than others. Those same babies often have a lower tolerance for the discomfort associated with normal body functions like hunger and gas. If your baby is acting well, feeding well, gaining well, and fussy only several hours each day, the baby is probably fine. If the baby is always crying, he may just be a fussy baby, but you would need to have him checked by his pediatrician.
Sincerely,
Dr. Warren
From the beginning of this year she is having it every 30 days except the months of Apr, June & July, then in August it has started again with a cycle of 30 days and so on.
This is why we are concerned about it.
-R
Dear R: The list of possible causes of prolonged fever can include infection, inflammatory diseases like Juvenile Rheumatoid Arthritis and inflammatory bowel disease, cancers, and rare disorders of temperature control. Infections including such prolonged illnesses as mononucleosis simply don't last 6 years. Tuberculosis of such a prolonged duration without treatment would have made your daughter deathly ill. But most important, while these conditions can cause prolonged fever, they do not cause fever in cycles of 30 days. Even infections like malaria have cycles of 48 to 72 hours rather than 30 days. Thus if the source of your daughter's symptoms are infection, it would have to be recurrent rather than persistence of one infection all these years. If, on top of that, your daughter is generally healthy and thriving, she may just be having an exaggeration of the usual frequency of childhood virus infections. 6-12 upper respiratory infections a year is the norm for school age children. And non-infectious causes of fever don't cycle in the manner you describe.
The other possibility which comes to mind is that your daughter could have cyclic neutropenia. Patients with cyclic neutropenia have a drop in their neutrophil count approximately every 3 weeks. This makes them more susceptible to bacterial infection. This might be evident because of increased skin infections and mouth sores when the neutrophil count is low. If this has any bearing on your daughter's fevers, her white blood count, specifically her neutrophil count, should be low when she is ill. Familial Mediterranean Fever is a rare disorder which may cause recurrent fever, but not with a regular cycle. Since it is familial, there should be a family history or it. Significant abdominal pain is a usual feature.
The bottom line is that if your daughter appears to be ill, then any persistent or recurrent symptoms would require further evaluation. For recurrent fever, the specialists to see would include Infectious Disease, Rheumatology, and Hematology/Oncology.
Sincerely,
Dr. Warren
Any advice?
-JL
Dear JL: If the limp persists you daughter will need further evaluation. Since I don't know what part of her leg was x-rayed, I don't know what was definitely ruled out. A painless limp could be a symptom of Legg-Calve-Perthes disease which is a hip problem. An ankle x-ray wouldn't tell you one way or the other. If you saw your family doctor or pediatrician, I would suggest that he now refer you to an orthopedist.
The other possibility to consider if a child limps without pain and falls easily is a neurological problem. If the orthopedist finds nothing and the limp persists, a neurological evaluation would be in order.
Sincerely,
Dr. Warren
-CZ
Dear CZ: Sleeping with your 3 year old is not necessarily harmful. It depends on the circumstances. If he enjoys a special time with you but is willing to sleep in his own bed, I see no problem. If, on the other hand, he is only willing to sleep in your bed, you will eventually have to deal with getting him to sleep in his bed. Is there any possibility of a man in your life? If so, how will that affect the current sleeping arrangement? How is the current arrangement affecting your thinking about social life?
The psychological aspects of this are more complex. Only you can determine if you are fostering a pathologically close relationship with your son. Is his presence in your bed fulfilling a psychological need for you? At what age do you think he ought not be in your bed? How do you envision this separation happening? Answer these questions for yourself and you will have some idea whether or not there is a potential problem in this relationship.
Sincerely,
Dr. Warren
Thank-you for your advice.
-L
Dear L: Certain foods tend to be binding. White rice and bananas are at the top of the list. The amount of iron in the cereal is not likely to cause constipation. Some people find iron constipating while others get diarrhea, and many have no intestinal symptoms at all. Since eliminating the rice seems to have solved your problem, your best bet is to stay away from the rice. He may do better with barley or oat.
On the other hand, any solid food may change the consistency of the baby's stool enough to cause what you experienced. Your son may simply need time to adjust to the change in his diet. Of course, at 5 months, there's no rush to get him on cereal. Another approach may be to start fruit (not bananas) before cereal so that the fiber can help keep the stool soft.
The current opinion on nursing and iron is that nursing baby's don't need an iron supplement because the lactoferrin found in human milk enhances the transport of iron across the intestines. For this reason, if you offer a formula supplement while nursing, it should not be iron fortified. If you switch from nursing to formula, the formula should be iron fortified. Your baby's problem with the rice cereal does not imply that he will have a problem with iron fortified formula.
Sincerely,
Dr. Warren
However, recently, our son experienced a seizure that was different and extremely frightening. While he was sleeping, his diaphram began to contract violently and rapidly. He would "hiccup"approximately 8 times in succession, quit breathing for 20 to 30 seconds, and then begin hiccuping again. The noise from the hiccups was so loud that my husband was alterted of the seizure from accross the house. The seizure continued for 15 minutes, my husband gently shook my son, he began to cry, and the seizure continued for another 5 minutes. We took our son to the emergency room. Blood tests, urine tests, and a chest x-ray indicated that he was "normal".
We have scheduled an appointment with a pediatric neurologist. Unfortunately, the earliest our son may be seen by the doctor is in two months.
Because my son is only four months old, and he quits breathing during his seizures for a period of time, I am concerned that something extreme may happen before the specialist can see him.
Has anyone experienced this? Is there any advise as to what we should do during this two-month waiting period. I've requested a montor, so when we are asleep we know when he quits breathing. Whether or not we get it is up to our insurance. Please help us or direct us to someone who can. Thank you for your help in this matter.
-HS
Dear HS: What you're telling me is so extraordinary that I hope there has been some misunderstanding about what your doctor really thinks is going on. Seizures are not a normal part of infancy which an infant should just mature out of due to increased myelination of nerve endings. Seizures in infancy could indicate a serious metabolic disturbance or neurological condition which requires thorough evaluation and ongoing management by a neurologist.
Your pediatrician knows you and your child, whereas I don't. He may have reason to believe that what you are describing is not actually a seizure and not a cause for serious concern. In that case, he should provide you with an adequate explanation and appropriate reassurance so that you know how to deal with your situation.
If your pediatrician believes that your infant is having apneas (brief periods without breathing), or seizures, then he should admit the baby to the hospital and arrange for monitoring and neurological evaluation there. If he is unsure, but thinks there is a significant risk, at the very least, he should speak to the neurologist and arrange for a earlier appointment.
Sincerely,
Dr. Warren
Thank you
-SS
Dear SS: A scant amount of clear to gray mucousy discharge from the vagina may be normal for a little girl. Some increased discharge is normal with puberty, which is not strictly age dependent since some girls are menstruating by 11 while others have no pubertal development before 14 and all are within the normal range.
The discharge with a yeast infection is white and cottage cheesy and is generally associated with itching. Little girls don't get vaginal yeast infections because the vaginal lining doesn't support the growth of the yeast until after puberty. External creams are not useful for treating internal infections, so if your daughter were mature enough to have a yeast infection, she would need to be treated accordingly.
Yellow discharge implies inflammation or infection. Improper wiping with toilet paper shreds left in the vagina is a prime culprit. A non specific vaginitis can be helped by using a bland ointment like A&D and taking sitz baths (sitting in warm water, no soap or additives) 3 to 4 times daily.
Should the symptoms persist, your daughter will need to see a doctor again. In that case, you might want to look for a woman gynecologist who has experience with children, or at least adolescents.
Sincerely,
Dr. Warren
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