8 July 2002

1. Potty Training, Encopresis
2. Contagion of RSV or Whooping Cough
3. Safety of Zinc Oxide
4. Fetal Distress and Learning Disabilities
5. Syndromes
6. Scarlet Fever
7. Normal Frequency of BMs, Giving Pedialyte
8. Red, Painful Gums
9. Disclaimer

• Read Questions & Answers in Another Column

Potty Training, Encopresis

-C

Dear C: Unless I'm misunderstanding what you're telling me, your daughter does not have encopresis. She is not constipated. She has bowel movements on the toilet bowl. And there is nothing to suggest that she is impacted with stool and is soiling because of leakage around an impaction. Why your daughter has decided she would rather go into a corner and have a BM in her pants rather than on the potty at this point, I can't tell you, but without constipation, the problem is purely behavioral.

I would suggest that you bring her to the potty after each meal and ask her to have a bowel movement. You can't make anything come out of her, and she knows it, so don't insist. Do praise her for cooperating about coming to the bathroom and sitting on the bowl. Praise her additionally for bowel movements in the bowl. You can try to motivate her with a calendar or wall chart on which she can put stars or stickers for every success. Express disappointment about soiled pants, but don't make a big deal because even negative attention can serve as positive reinforcement.

Finally, keep in mind that doing the right thing does not guarantee instant results. You have to keep doing it, recognizing that your daughter will get older and things will change, hopefully for the better.

Sincerely,
Dr. Warren

-KE

Dear KE: RSV and whooping cough are two very different illnesses, neither of which you want to expose your 7 week old if you can avoid it. Both infections cause coughing. RSV can cause croup an bronchiolitis with resultant barking cough, laryngitis, or wheezing. Whooping cough is generally prevented by immunization, but it's still around. When the patient with whooping cough starts to cough he coughs multiple times in a row, unable to take a breath until finally the spasm ends and the breath in causes a whoop.

If the child has whooping cough appropriate tests to confirm the diagnosis should be done and the health department notified. After a course of treatment with erythromycin, the child with whooping cough will not be any better but should no longer be contagious.

A child with RSV has a miserable cold and cough. Once the nasal mucus and cough have subsided the child should no longer be contagious. This stage should be reached within 1 to 2 weeks from the start of the illness.

Sincerely,
Dr. Warren

Question: Is long term exposure to Zinc Oxide a problem for our baby?

-HS

Dear HS: As far as I know long term exposure to zinc oxide applied externally is safe. No adverse reactions are listed in my pharmacology text. In my 22 years as a practicing pediatrician I have not seen a reaction to it.

Sincerely,
Dr. Warren

Thanks for your help.

-AG

Dear AG: If any aspect of anesthesia has an adverse affect on the mother at delivery such as low blood pressure or poor oxygenation, that can have an adverse effect on the fetus. If you were wide awake and suffered no adverse effect from your epidural, it is unlikely that it could have caused fetal distress. This opinion amounts to an educated guess since I have no experience administering epidurals and found nothing in the literature to indicate that fetal distress could occur as a complication.

Fetal distress is certainly a risk factor for learning disabilities and other subtle neurological problems, but there is no simple, direct cause and effect link. If a newborn who suffered fetal distress is significantly asphyxiated before, during, or after birth, the brain will suffer anything from subtle to major damage from lack of oxygen proportional to the length of time the brain was not well oxygenated. There may also be a significant genetic component to the development of learning disabilities. A combination of risk factors and genetics may act in concert. There is no one known cause of learning disabilities.

Sincerely,
Dr. Warren

She has one ear that is slightly rotated back. She has mild micrognathia. She does not have broad thumbs or toes that characterize this syndrome. Her weight as of today is 8lbs. 8 oz. We are breast-feeding. Weight gain is slow. Developmental assessment done by Early Child Intervention assessed her as on track (normal) in all areas except feeding at 3mos. She can push up, raise her head and roll over. She is cooing but has a quiet cry which has gotten louder with weight gain. Does this development seem normal and would I see this in a child that would have a syndrome characterized with moderate developmental delay?

The genetic testing did not show any deletions or additions of chromosomes. A special test for the above syndrome was also negative. The geneticist picked this syndrome due to postnatal growth delay.

We have been to a speech/ feeding therapist due to her high palate and are doing exercises that have increased her suck and lower jaw and lip strenghth. She can suck from a bottle very well.

I am only able to express three oz. of milk when I pump a feeding. She will drink more formula than this from a bottle. Do you think I should go to formula feedings to see if this increases her weight? I have two other children who have breast fed and are both on the small side. My five year-old weighs 35 lbs. and is only 42 inches tall. They have both been in the fifth percentile and sometimes right below since birth.

Please let me know what you think and how you would approach her weight gain. By the way, whenever we were waiting for test results and answers, she gained only 8 oz. in 21 days which I know had to do with my milk supply. Also, whenever we have had positive news, she has gained closer to 3/4 oz per day. On average in the past two months she has gained 1/2 oz per day. No gain recently with a cold but no loss either.

-LN

Dear LN: Occasionally we see a child who has so many features of a particular syndrome that we're convinced the child has the syndrome, and yet, one feature may not be the same as what is described. The child may have a forme fruste of the syndrome, i.e., partial expression. For instance, the child may be significantly more intelligent than most people with the syndrome. There have been a few, well documented cases of Downs Syndrome whose intelligence was well above most children with Downs.On the other hand, it sounds like your child is missing the defining features of the syndrome and the genetic test for it was negative. There are so many causes of poor growth, including other syndromes, that I would expect the geneticist to look further unless he has other reasons for picking that diagnosis.

Lets put the whole issue of making a diagnosis of a particular syndrome in perspective. Syndromes are defined by features they have in common which are different from "normal" human features. In some ways, children with a particular syndrome may look more related to each other than to their families because of the unique features which define the syndrome. Other syndromes may be defined by abnormalities which are not evident on simple inspection. By defining and studying syndromes, physicians are able to make predictions about what to expect in terms of specific disabilities and abilities (both physical and mental), as well as being aware of certain problems yet to come, or to look for certain expected problems and treat them appropriately. Physicians have also been able to determine the cause of certain syndromes, find genetic markers and other tests to accurately diagnose the syndromes, and provide recurrence risks to help the parents make informed decisions about family planning.

Just as no two people are exactly alike, two people with a particular syndrome don't have to be exactly alike either. The purpose of making a diagnosis is to help people cope with what to expect. But the diagnosis should not be used to set limits on a child if the child shows unexpected abilities. On the other hand, having realistic expectations can avoid a lot of frustration.

The development you described sounds reasonable for a 4 month old, but at 4 months, there is a lot of intellectual and motor development yet to come. It would be hard for the parents of any 4 month old to predict their child's future potential. If your daughter is felt to be at risk, the best thing for her is to continue to be monitored by Early Intervention so that she will receive any services she needs.

Some mothers who nurse very well cannot pump much milk into a bottle. You can't use the amount you can pump as a guide to how well nursing is going. Your daughter may be small on the basis of genetics since your other children are also small. Weight gain generally represents height gain. If your daughter is short, feeding her formula won't make her grow better. If she is growing more than she is gaining, that would suggest that she is not adequately nourished. The determination of whether or not you need to change your daughter's feeding can only be made by examining her and evaluating her entire growth chart. This should be done with her pediatrician.

Sincerely,
Dr. Warren

Is there any advice that you can give to use to pass on to her mother. Unfortunately we live 90 miles away so we only get her every other weekend.

Thanking you in advance.

-DK

Dear DK: Some children are more susceptible to strep. In fact, some families are more susceptible. The function of the immune system differs from person to person, and it is genetic. While a strep infection is not a pleasant experience, treatment usually prevents complications. Having the infection twice in a short period of time may indicate that your step daughter was carrying strep in her throat after the last infection and had a relapse. Most relapses occur within 48 hours of stopping antibiotics, so that's not a high likelihood. Since she caught the strep from somebody else the first time, it may have made the rounds through her classroom and she was exposed again.

Scarlet fever occurs when the particular strain of strep is carrying a bacteriophage (a kind of virus which infects bacteria) which makes it produce erythrogenic toxin. The fact that your stepdaughter had scarlet fever twice simply means that both times she caught a strain which caused scarlet fever. That makes it very likely that the same strain simply made the rounds in her classroom. This does not have anything to do with your stepdaughter's response to strep. Aside from the rash and peeling, scarlet fever does not make a person any sicker than strep does. Years ago the erythrogenic toxin was more toxic and antibiotics were not available so scarlet fever was a more serious matter.

Strep strains appear to have cycles. At this time, strep is once again becoming more virulent (making people sicker). This cycle has nothing to do with antibiotics. We may see a change for the worse with scarlet fever, but at this point, scarlet fever is nothing more than strep with a rash.

Sincerely,
Dr. Warren

Thank You.

-NT

Dear NT: A healthy 3 month old may have bowel movements after every feeding, but many healthy nursing babies may also have them as infrequently as once weekly. As long as the stool is not hard, the baby's abdomen is not distended, the baby is happy, and the baby's appetite is good, the length of time between bowel movements is not crucial.

We recommend Pedialyte as a clear fluid for sick babies. Generally babies should not drink more than a quart of Pedialyte a day as that may be too much salt; however, a healthy baby who is eating well, would not take anywhere near that much. Giving a few ounces between feedings when the baby seems to want something is okay. But you wouldn't want to feed the baby enough Pedialyte to make the baby decrease his feedings.

Sincerely,
Dr. Warren

-D

Dear D: Hand, foot, and mouth disease, caused by coxsackie virus, is a summer illness characterized by fever, canker sores in the throat and on the tongue, and spots on the hands. The gums are not involved. There is no specific treatment. The illness runs its course within a week.

Herpes virus causes blisters in the mouth, on the lips, and does cause red, sore, bleeding gums. Usually the children are fairly sick with fever and miseries. I have seen this illness last up to two weeks. Supportive care aimed at preventing dehydration is the only treatment. Zovirax, an antiviral medication, might be indicated to treat an immunocompromised patient.

The whole issue of whether trench mouth represents a specific infection or is really more a gingivitis related to oral hygiene is controversial. According to the reference in which I found mention of Trench Mouth, it requires two organisms acting together (Borrelia vincentii and Bacillus fusiformis) to cause Trench Mouth. It used to be thought to be contagious, but now is not. It can only develop in situations of poor oral hygiene and inflammation of the mouth. These organisms don't cause disease in healthy mouths. Trench Mouth responds to conventional doses of penicillin; however, treatment also requires proper dental and oral hygiene.

You've told me what the dentist recommended. What was his diagnosis? What was the rationale for his recommended treatment? What did he tell you to expect regarding the course of this problem and its response to treatment? Imparting that kind of information to parents or patients is crucial in order for them to have faith in the treatment and to know when to contact the doctor about continuing or changing symptoms.

Sincerely,
Dr. Warren

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