22 July 2002

1. Abdominal Pain
2. Normal Weight Gain, Normal Growth
3. Many Ear Infections
4. Recurrent Pneumonia, Failure to Thrive
5. Diarrhea and Pain on Urination
6. Sore Throat, Antibiotics Causing Yeast Infection
7. Episodes of Temporary Blindness
8. Always Tired
9. Disclaimer

• Read Questions & Answers in Another Column

Abdominal Pain

-Worried Mom

Dear Worried Mom: The family history of abdominal pains may be useful information if it helps direct the diagnostic evaluation. Unfortunately, that does not appear to be the case since the diagnoses made in adult life on your relatives are not genetic and don't appear to have been the cause of their abdominal pains in childhood.

If your daughter can be helped simply by diet, then that should be the first thing you do before embarking on a major diagnostic workup. If she won't eat Fiber One, try to find other high fiber foods she will eat. The availability of more attractive children's cereals is irrelevant. She can eat high fiber foods all her life if she needs to. If she had diabetes, you would give her insulin shots and insist that she follow an appropriate diet. Your daughter is now failing to thrive because of her abdominal pains. If diet can solve her problem, then she needs to be on the appropriate diet. A nutritionist can help you find a variety of appropriate foods that she likes so that she can have choices just like everyone else.

Weight loss in a child certainly raises the specter of a significant, possibly serious cause of abdominal pain for your daughter. I only suggested an attempt at dietary management because you felt it helped in the past. If that does not work, your daughter needs a thorough diagnostic evaluation which, at this point, probably should be directed by a pediatric gastroenterologist.

Sincerely,
Dr. Warren

Thank You.

-TM

Dear TM: Children don't start to gain weight at some point. They gain weight continuously as they grow. Since children get wider while they get taller, each inch of height weighs more than the previous one so that between 4 and 6 years of age, children begin to gain 1 pound or more per inch of height.

Your granddaughter's weight is in the 75th percentile which is the high end of the average range, certainly not underweight. Since I don't know your granddaughter' height, I cannot judge if she is slim or stocky at that weight, but there's nothing unhealthy about being slim. There would be some concern if your granddaughter had not gained any weight in the past year or has lost. But if she was a chunky baby who has slimmed down after giving up bottles please don't think that she was healthier when she was overweight. The answer to that concern can't be estimated. Real numbers have to be plotted on a growth chart to see how a child is growing. The child's pediatrician should know if all is going well.

Sincerely,
Dr. Warren

PLEASE HELP.

-SC

Dear SC: Seven ear infections in the first year of life is a lot, but doesn't necessarily mean that the child requires tubes. That recommendation can only be made by a doctor who has seen your child. If the doctor's answers don't seem straight, ask for clarification. The doctor may be giving you a list of possibilities that would push him toward recommending surgery without making it clear where he feels things stand now. After your doctor sees your daughter, ask him not only what he thinks needs to be done now, but what his long term plan is.

If you can go see a specialist without a referral, consult an ENT for a second opinion. If you need a referral, or simply want to be sure that your doctor is involved (often a good idea), ask your doctor if he would refer you to an ENT for an opinion.

Please read my article Another Ear Infection!?!. It may enhance your understanding of ear infections so that you know what questions you want to ask your doctor.

Sincerely,
Dr. Warren

-KG

Dear KG: I wish I were the one who could provide all the answers when the specialists fail, but realistically, I am working without examining the patient, without access to the patients entire past medical history and all the diagnostic workup to date, without knowledge of what diagnoses have already been ruled out, and the reality is that I'm not more brilliant than any other physician. I could suggest possibilities which may have already been fully evaluated, but on the chance that they haven't here goes:

1. Has an H type TE fistula been ruled out?
2. TB could certainly cause paratracheal adenopathy, and should be ruled out, but it doesn't seem like the likely unifying diagnosis for your nephew's long term problems. Long standing, untreated TB since infancy should, in some ways, have made you nephew sicker. Therefore, other things like chronic granulomatous disease need to be considered. Sounds like a complete evaluation by an immunologist and/or oncologist might be useful.
3. Cardiac disease must certainly be considered in a child who has cyanotic episodes. When I was an intern I saw a child who was followed in the pulmonary clinic for recurrent pneumonia. I found a subtle abnormality of his cardiac exam which was then diagnosed on further evaluation to be an ASD. The pneumonias were the result of overcirculation to the lungs caused by the heart abnormality.
4. Children with asthma can have recurrent pneumonias. You didn't provide me with any details about the management of the child's wheezing. I have no reason to believe that it isn't being managed properly, but I at least have to ask if the child is on any appropriate maintenance anti-inflammatory medications such as Cromolyn or inhaled steroids.
5. An unlikely possibility, but one which must be considered, is that the cyanotic episodes represent seizures. Aspiration pneumonia could be a complication of a seizure that affects breathing.

Sincerely,
Dr. Warren

-KK

Dear KK: Urine infections can only be diagnosed or ruled out by doing a urine culture. Since some of the organisms that cause urinary tract infection can be resistant to Biaxin (and very likely would be if it developed on Biaxin) you need to see your doctor and have a culture done.

Diarrhea is not usually a symptom of urinary tract infection, although UTI may be a cause of chronic diarrhea in infants. It is possible that your son may be having diarrhea from being on antibiotics. He may also have some skin irritation from prolonged antibiotic use resulting in some urinary symptoms. The onset of the symptoms is most consistent with a gastroenteritis (intestinal virus); however, since your son has been on antibiotics so much, if he is very ill, your doctor will have to check his stool for Clostridium difficile.

You are certainly welcome to turn to me for advice, but any chronically ill child, such as one with a diagnosed immune deficiency syndrome, needs the ongoing care and advice of a knowledgeable specialist. If you don't have an immunologist involved in your son's care, you should consider consulting one.

Sincerely,
Dr. Warren

Please help us.

-From a concerned mother

Dear Concerned Mother: Yeast infections in the mouth or diaper area can occur as a complication of antibiotic therapy. Broader spectrum antibiotics like amoxicillin are more likely to cause such complications than narrow spectrum antibiotics like penicillin. The yeast infection is not a serious complication and can be treated with medication.

Strep throat may certainly be treated with a single injection of LA Bicillin (a long acting penicillin) in a non-allergic patient. Viral sore throats and colds will not benefit from antibiotic therapy, so it is important to determine if a throat infection is strep by doing a culture or a rapid strep test prior to initiating treatment. This will avoid your daughter taking any unnecessary antibiotics and suffering any unnecessary side effects. It will also decrease the environmental pressure that causes resistant organisms to develop from overuse of antibiotics.

Sincerely,
Dr. Warren

1. ) when she got up to go to the bathroom in the morning
2. ) on the bus going to the symphony
3. ) while listening to the symphony
4. ) on the way home from the symphony

The doctor said to "observe" her for a few days..... Since I teach blind skiing I am a bit concerned and am kind of looking at other ways to go! (or who to go check out for advice doctor wise). Any and all suggestions would be appreciated.

She's 10 physically active and in good shape and healthy.

Thanks.... We are getting very worried.

-Anita

Dear Anita: Without more information I can't be sure what's going on. In fact, without seeing your stepdaughter, I might not be able to make a judgment even with more information. But four possibilities do come to mind:

1. She may be experiencing near syncopal episodes (almost fainting). People often experience decreased or lost vision just before fainting. If this is the case, an evaluation by a cardiologist including tilt table testing is in order since a diagnosis can result in the prescription of effective treatment.
2. Migraine may be preceded by an aura which may consist of visual aberrations. Even if the doctor feels that a brain tumor has been ruled out, a neurological evaluation may be in order.
3. Neurological evaluation may be in order for other reasons as well. Multiple sclerosis can present with intermittent and changing neurological signs. I have never heard of MS presenting in a child, but if these symptoms are not related to blood pressure changes such as near syncopal episodes, their cause is likely neurological, unless....
4. The cause could be psychological. This diagnosis should not be entertained just because no physical cause can be found. I have seen stress cause some pretty unusual symptoms, but you can't consider that diagnosis in the absence of stress.

Sincerely,
Dr. Warren

Thank you.

-AS

Dear AS: You may be right to be concerned about your niece's constant fatigue, but you have to decide whether you have enough of a reason to be concerned to pursue the matter when her father is not concerned. Apparently the matter has been discussed with the child's doctor who feels she's fine. When you see your niece on the weekend you may be seeing her after a very busy week of activities and school. If she has the energy for that, there's nothing wrong with her crashing on her days off. She may be one of those people who loves some extra time in bed in the morning. Finally, no matter how close you are with your brother, it's not reasonable to assume you are privy to everything going on in his life. Maybe the doctor said something your brother isn't ready to share, or maybe there is something going on with your niece that your brother feels isn't anyone else's business. Since your brother is aware of your concern and has answered it, unless you have reason to think he is a negligent parent, you have to respect his privacy and his handling of his own affairs.

Sincerely,
Dr. Warren

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

ask Dr. Warren a question?!?