30 September 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
-W
Dear W: Children can learn new, undesirable sleep habits very quickly. One night in your bed may be all it takes for baby to decide he'd rather be there than alone. Please read my article, Helping Your Child to Sleep Through the Night.
Sincerely,
Dr. Warren
Looking back, now, I know that the symptoms began at least 8 - 9 months ago, probably longer. He is a child with great eating habits--wide variety, healthy foods. He is very advanced intellectually, (at least two grades, I'm told) and everything else about him is as it should be-in my eyes.
My concern is his health. Last winter he had croup, very badly. Since then, he has had sporadic fevers, mostly low grade, some worse than others, he complains of headaches very frequently, snores, has woken up in the night twice recently complaining that his throat felt too small to swallow. Now, along with all of this, months ago, he started to complain when I tried to lift his head up (gently) to rinse the shampoo out of his hair. He told me that it always hurts him to look up, and sometimes bend his neck to the right. I didn't think much of it -(thought that he didn't like rinsing). This problem has continued. I have noticed very apparent lumps on his neck, on the same side of the pain, further to the back. The strange thing is that his condition seems to suddenly flare up, at unforseen times. The lumpls swell, and he cries with the pain, not being able to move his neck. Then, after hours, usually at least a day, the swelling goes down somewhat, and the pain begins to subside. My son has become so used to having pain, that he says when it only hurts a little, he feels great, as long as he doesn't bend his head down toward his shoulder.
Twice, he complained that the pain was beginning to feel the same on the left side of the neck as well. When this happened, both sides swelled up to the point of his jaw bone, he was extremely pale, complaining that he wasn't sleepy, but he had no energy.
At his worst times, he begs me to bring him to a doctor. I've gone several times for the same reasons; 3 different doctors. Blood was drawn, however I was told all was normal. I was told that the liver and kidneys were tested, other than that, I'm not sure what else was done.
I'm at a loss. One doctor told me just to keep an eye on him, one doctor told me that absolutely nothing is wrong, and another doctor simply said that kids get strange things. I've been asking for an ultra sound on his neck, however no one seems to want to do it? The emergency room doctor told me that perhaps, eventually, we may consider having his lymph nodes removed.
I don't know what to do, Doctor. I don't know how to approach anything. It seems that the more questions I have, the less the doctors in my area are willing to help.
If these lumps are normal, isn't it possible that there may be something else causing problems? Certainly not everything can be on the surface? What if there is something under the lumps?
Please help me, if you can. I don't know how to help my son, and that is very hard to accept when he asks me to promise to make him better.
Thank you so much.
-CB
Dear CB: Of course there could be something more complex going on than the swollen, tender lumps in your son's neck, but they are certainly the most obvious and accessible finding that would point toward a diagnosis. It hardly seems likely that these lumps which are the most swollen and tender at the time your son has the most symptoms could be there coincidentally. Based on their location and your description of the recurrent swelling and tenderness, these are most likely inflamed lymph nodes.
Children get enough upper respiratory viruses each year that it is not unusual for them to have recurrent swelling of lymph nodes; however, this does not usually result in very large or tender swellings or pain in the neck. Children average 6 to 12 upper respiratory infections each year, many of which may cause fever, but if your child has more days with fever than without, or never goes more than a few days without fever, he needs a more thorough evaluation to determine what is going on. A biopsy of one of the swollen lymph nodes may be a helpful part of this evaluation.
At this point, if you have a pediatrician with whom you have a long term relationship, I would ask him to refer you to a variety of specialists to help arrive at a diagnosis. I would recommend evaluation by a pediatric infectious disease specialist, immunologist, and finally, if there are no answers from seeing these specialists, an oncologist. I didn't recommend an oncology evaluation first because the recurrent swelling and tenderness of the lymph nodes are more typical of inflammatory nodes rather than cancer.
If you do not have an ongoing relationship with a pediatrician, you should make an appointment to be seen in the pediatric clinic of a medical school teaching hospital. Do not go to an emergency room. Emergency rooms are for emergencies and cannot provide follow up or diagnostic evaluations for long term or chronic problems.
Sincerely,
Dr. Warren
-RA
Dear RA: Object permanence refers to an aspect of child development. The early development of the human psyche is absolutely fascinating. Infants are born with no knowledge of the outside world. They have an inborn fascination with the human face. Mom's face is the right distance from her infant to be in focus during feedings and baby will stare intensely at her during the feeding, but baby has no knowledge that she still exists when he doesn't see her (object permanence) and will not look for her when she moves out of view. Neither does baby make any effort to focus on objects which are not in focus since he has no knowledge of their existence as being any different than he sees them. In the first few months he integrates all the information he has taken in through all his senses and learns to distinguish between the outside world, internal sensations, memories, and dreams. By the time he has put all this information together, he has developed object permanence. He knows that things exist even when he doesn't see them, especially Mom. Once that happens a baby begins to develop separation anxiety, stranger, anxiety, and cries out for Mom when he doesn't see her. The need for Mom becomes an independent need, separate and distinct from the fact that Mom takes care of baby's other needs like hunger and comfort.
Sincerely,
Dr. Warren
-Audrey
Dear Audrey: Sometimes it can be difficult to tell if a child has a viral infection or a bacterial infection. This is an important distinction because bacteria respond to treatment with antibiotics and viruses don't. Bacterial infections may sometimes be more serious than viral infections. For this reason, when a physician thinks a child looks sick and is not sure what infection the child has, a blood count may help to reassure that the illness is viral, or it may suggest that the illness is bacterial and therefore requires further evaluation or treatment. Unless the doctor tested for mononucleosis or some other specific infection, it is most likely that he did a complete blood count just to help him determine if your daughter's illness was viral or bacterial. This test does not provide any more specific information.
Sincerely,
Dr. Warren
What side effects should we expect? Is it safe?
Thanking you,
and May God bless You.
-Anxious Grandmother
Dear Anxious Grandmother: The biggest risk of bronchoscopy is the risk associated with general anesthesia, the same risk with other surgeries.
The following complications are listed as potential possibilities:
Respiratory depression/arrest, Transient hypotension, Seizures, Hyperexcited state, Laryngospasm, Syncope, Cardiac arrest.
Respiratory compromise, Obstruction, Perforation, Hemorrhage, Laryngospasm, Bronchospasm, Dysrhythmias, Syncope, Pneumonia, Hypoxemia, Pyrexia, Epistaxis.
Hemorrhage, Perforation, Mediastinal emphysema, Pneumothorax, Air embolism.
This information came from Sabiston: Textbook of Surgery, 15th ed., Copyright © 1997 W. B. Saunders Company .
Sincerely,
Dr. Warren
-Beth
Dear Beth: I do recommend the chickenpox vaccine. On theoretical grounds the vaccine should provide lifelong immunity just like having the disease does. The vaccine has been in use in Japan since 1974. So far there are no recommendations for boosters, but we will only know the final answer with continued surveillance of immunity levels. In the meanwhile, consider that if we successfully immunize all children against chickenpox, there will be nobody for adults with waning immunity to catch it from.
Sincerely,
Dr. Warren
-GS
Dear GS: In the dosage that Ritalin is given for treating ADHD it is not an addictive drug. Discontinuation will not result in any withdrawal. It can be stopped abruptly. If a child is doing well in school on Ritalin, the only way to know if the Ritalin is still necessary is to try the child off Ritalin. The timing of this is best decided based on the child's needs, status, and what is going on in school. If the child's concentration is significantly diminished by stopping the Ritalin, it can be resumed.
Most children tolerate Ritalin well. The most common side effects are abdominal pain, loss of appetite, and insomnia. Prolonged therapy may sometimes cause significant weight loss.
Sincerely,
Dr. Warren
My homework for this week is to bring back information as to why we get goosebumps and how it happens.
Can you please help me. I can't find any information and I don't know what web site I can go to that will answer my question.
Thank you.
-MJM
Dear MJM: Goosebumps or gooseflesh is actually piloerection. All mammals, including humans, have skin covered with hair. Most of the hair on human skin is fine and sometimes barely visible. When the hair in the follicle lifts up (piloerection) it makes the hair follicle stand out creating the appearance we call goosebumps. In animals who are covered with hair, the piloerection makes the hair puff out. By creating a fluffier layer of hair, the animal conserves heat. The human responds to cold with piloerection also, but humans don't have enough body hair for the response to effectively conserve heat.
The response is controlled by the autonomic nervous system just like sweating, heart rate, respiratory rate, and other functions over which we have no voluntary control.
Sincerely,
Dr. Warren
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