28 October 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
Signed,
Desperate
Dear Desperate: Sounds to me like you'd like me to jump into the middle of a custody dispute without enough information to have any idea what's best for the child. After 20 years as a pediatrician I've learned never to fall into that trap. Yes the child's coughing could be asthma related and it could provoke vomiting, but how does that truth lead to the statement that the child's "mother does not want the child to be well.... [and is] constantly looking for problems within the daughter, causing more problems in the long run?" If the child is having infections that don't respond to medication she needs a more thorough evaluation by her pediatrician, or perhaps, the child's father needs to talk to the pediatrician to understand what is actually going on.
If you care about this child, don't get caught in the middle of an emotional, illogical crusade to discredit her mother. The child will not thank you down the road. The best thing you can do for her is to foster an environment which will preserve her relationship with all the adults in her life that love her including you, her father, and her mother.
Sincerely,
Dr. Warren
I am not saying problems don't exist. They do. What can be done to correct them is what I would like to know. I guarantee if this was my child she would not be sick all her life. I would not STOP until I found out what was causing the problems or what I could do to make her well for good. That is the way a GOOD mother works. You should know that. I would also like for you to know this child has been to the doctor over 459 times in three years. In my opinion, those are not very good odds. Only a severely ill child should be to the doctor this amount of times. This child has been to the doctor more in the 2½ years of her life than both of my children combined in their whole life. (age 6, and 9) Is this good? I think not. There has never been one single test done on this child. She is either told she has an ear infection or a cold. To be truthful she has a bad pediatrician.
This woman took her child away from her father at two weeks of age, she has been in mental hospitals, and lives with her manic depressed father. I know this is not good for the child....... This is not worth going into with you as you do not nor will you understand the complete situation. I asked for an opinion of illnesses and what causes them. I have not created anything that I have stated, I just know the truth about the whole matter......
Have a good day.
-Desperate
Dear Desperate: I don't doubt for a moment that you care about your step daughter and have only her best interests at heart, and yet I have seen time and again how people involved in custody disputes lose all perspective and look to blame everything that goes wrong with the child on the other parent. I implore you, for the child's ultimate best interest, to take a step back and look at what you are saying and doing, and resolve to find solutions that will maintain the child's relationship with all the parties that love her.
In the very same paragraph in which you state that if the child was yours she would not be sick all her life and you would not stop until you found the answer or made her well you criticize the fact that the child has been to the doctor so much. I can tell you that some of my patients are sick much more often than others and I often have to reassure their parents that it is not because of something they are doing wrong. Some kids have recurrent ear infections. Some have asthma with resultant chronic cough and recurrent bronchitis. Some are in daycare and are exposed repeatedly to colds and intestinal viruses. To advance your understanding of these issues I recommend that you go to the list of articles I have written and read the articles "Another Ear Infection!?!", "Upper Respiratory Infections (URIs)", and "What Is Asthma?"
I do not think you're a bad person at all, but I am worried that you are making the same kind of mistake many parents involved in custody battles make and the child will get caught in the middle. I got this impression from statements like this, "The mother does not want the child to become well. She constantly looks for problems within the daughter, causing more problems in the long run. The father is trying to get custody of the child, so that she can be properly cared for" which you said in your first e-mail to me.
You are right. I do not know everything that is going on. But if you think the child is being neglected or abused you do not need my advice. You need to bring your concerns to the appropriate authorities. One caution, the child's frequency of illness does not constitute evidence of poor care, especially since you have documented that the mother brings the child to the pediatrician.
Sincerely,
Dr. Warren
Thank You,
-Tara
Dear Tara: Although most teens are striving to become independent of their parents, spend most of their time socially away from their parents, would prefer to have their parents stay out things they consider their own personal affairs, and would definitely like to be free of parental efforts at control, most would not like to be rid of their parents. In fact, in spite of the fact that teens generally want their parents to stay out of their affairs, they still like to feel their parents' approval. In fact, this is a legacy that many of us carry into adulthood.
Most teens are still dependent on their parents financially and take for granted that they will have food, clothes, shelter, and a place of their own in their parents house (their house). This can generally be expected to continue until they have completed their education and leave home. Teens also depend on their parents to make decisions about health matters and to arrange medical care. As long as the teens are in school their parents will be contacted regarding any school related problems. Since adolescents take these parental functions for granted they are not generally concerned about their parents' availability to fulfill their parental responsibility, but there is a small part of their consciousness which realizes they still need their parents for some things. Those unfortunate teens whose parents do not responsibly handle their parental role rarely feel lucky to have no parental involvement.
Beyond meeting their kids basic needs, parents who take an active role sharing the part of their teens' lives which is available to them, and supporting their goals and dreams make a big difference in their teens' self esteem and potential for success. There are so many outside forces affecting teens that parents do not have the power to guarantee their happiness or safety, and they cannot completely control them. But supportive parents who keep the lines of communication open can be a lifeline in difficult times, and a source of happiness and inspiration in good times. Parents who believe teens are trouble and treat them accordingly can make their kids' lives miserable. Although my article Surviving Your Child's Adolescence deals mostly with behavioral issues, it expands on some of the concepts I have discussed regarding parent/teen relationships and may be worth your while to read.
As a pediatrician, I'm a firm believer in a teen's right to privacy. Unfortunately, many teens would simply not get certain medical care or discuss some of their concerns with their doctor if they thought their parents had to be told everything. On the other hand, most teens are woefully unaware how much they would benefit from their parents' support when they face a crisis. I will never violate the privacy of any of my adolescent patients, but I always try to show them how they can get their parents involved and offer to mediate if necessary.
Parents must be responsible for their teens actions. When their teens are headed for trouble they must set and enforce limits. (See the article mentioned above.) The family is the first line of defense in imparting values to kids and teens. If the parents cannot exercise any control over their teens, then they may need to seek relief through family court by filing a PINS petition (Persons In Need of Supervision). On the other hand, I cannot see how it makes sense to jail parents for their teen's antisocial or illegal acts. It sends a message to the teens that they are not responsible for their actions.
Sincerely,
Dr. Warren
Thank-you.
-JD
Dear JD: I do not know any physicians in the Cleveland area. At 6 years of age your son should have regular checkups at a pediatrician and so should have a pediatrician. If you have an insurance plan, you should obtain a list of participating providers in your area. If not, you should ask friends and neighbors for recommendations. Once you have some recommendations you should check to be sure that the pediatrician you choose is board certified by the American Academy of Pediatrics.
Sincerely,
Dr. Warren
-JS
Dear JS: The male and female genital tract both develop from the same embryological tissue. In the process of differentiation (cells forming a specific organ) and development certain portions must grow and others be absorbed in order to create either the male or female genitals. It is possible for some vestigial parts of a female genital tract to remain behind in a male child. Although I cannot quote any statistics, in my 20 years as a pediatrician I have had no such patients. Testicles may sometimes remain in the abdomen (undescended testes), but there is no mechanism by which an internal penis would form. There is one form of intersex, known as testicular feminization in which the organs are unresponsive to testosterone (the male hormone) so that the external genitalia are female even though the child is genetically male. In this situation the testicles will be in the abdomen, but because the child is male, it will not have ovaries or a uterus. These children are raised as females and cannot have children.
I suspect the explanation given to you has been somewhat simplified resulting in some confusion on your part. For starters, the child could not have been healthy for 3-1/2 months with any holes in his stomach, so I'm sure the holes you are referring to were elsewhere. Second, the vagina is not really an internal organ, so while the genital tract may not have been fully differentiated, it is probably a simplification to say that an internal vagina was removed.
Finally, if a baby is healthy and has no visible abnormalities of the genitals, I would suggest that parents not worry about the possibility that their child may have some rare abnormality of the internal portions of the genital tract.
Sincerely,
Dr. Warren
When should the size of the lymph node go down and should anymore tests be done?
I am very concerned about this. Thank you.
-Donna
Dear Donna: As long as the size of the lymph node is not increasing and the rest of her examination is normal, you don't need to be alarmed about an almond sized lymph node. This size inflammatory node is very common with childhood upper respiratory viruses. It may take several weeks before the lymph node starts to shrink in size, and it may become enlarged again with each upper respiratory infection
Sincerely,
Dr. Warren
From your experience, will you please set out some guidelines to help them with my granddaughter? They are not to put pressure on her to eat, as you advised in October, but how do you get her to eat. We are so concerned about her well being that I just had to write for your help.
Sincerely
-RS
Dear RS: Since I have no personal experience treating this type of severe eating disorder, I would be reluctant to say anything which would interfere with compliance with the specialist's recommendations. Hunger is a strong drive, but after a number of days without calories a person will become ketotic from burning body fat and this will decrease the appetite. Thirst is an even stronger drive. Even if your granddaughter were not to eat at all during the 10 day trial she would be able to make up the nutritional loss when her caloric intake resumed, but if she does not drink at all in the 10 days she will become dehydrated. In order to meet her fluid needs, in the absence of any food which may contain liquid, she would need about 1 quart per day of fluids. This would have to contain some electrolyte rather than being plain water since, if she isn't eating, she wouldn't be getting any salts. Pedialyte or Kaolectrolyte are appropriate rehydration fluids.
I am not suggesting that your granddaughter start taking electrolyte solution now; however, if she is only given what she will take by mouth, it is crucial that she be monitored closely for signs of dehydration. This can be done by following her weight every day or two and monitoring her urine output. If the doctor is committed to the 10 day program, he may want her to get intravenous fluids at some point during the course to prevent dehydration while avoiding filling the stomach with fluid via the feeding tube.
Discovering that food can satisfy hunger is certainly a useful part of retraining your granddaughter's eating habits. Since hunger should kick in within a few hours of not eating, should the more extreme 10 day trial fail, perhaps the doctor might want to try more frequent shorter trials with electrolyte solution by feeding tube during the intervening 6 months.
Sincerely,
Dr. Warren
-G
Dear G: It doesn't sound like anything major to me, but since I didn't see it and your pediatrician did, why not find out what the neurologist he spoke with thought.
Sincerely,
Dr. Warren
The baby is being fed mother's milk through a tube which has been inserted directly into his stomach. Also the food pipe which is having a blind end, has been brought out from the side of the neck so that the saliva which he gulps can come out automatically from the side opening without going into the air pipe and choking him.
The operation which he underwent in his stomach is named as "Gastrostomy" and the procedure which he underwent in his neck is termed as "End oesaphagostomy".
Since he has started growing and playing, inadvertently he pulls the tube or the tube (which is around 8 inches long outside his stomach) gets entangled with his hands or legs and comes out. Already they had to insert the tube twice in the past one month or so. Every reinsertion of the tube is a very painful process for him as well as for his mother and others nursing him. There is, I believe, an alternative to this.
Instead of the tube, a button is fitted to his stomach and along with the button, we get a tube separately which is to be inserted into the button everytime we have to feed the baby. It appears this button and the corresponding tube is available.
Doctors attending to him recommend that an operation will be performed after the child is one year old to cure the defect.
Doctor, I will be grateful to if I could get your response as I am really interested in taking the pain off of the kid.
Thanking you.
Yours faithfully,
-Visu
Dear Visu: I am not sure what kind of details you would need about the button. Yes, it is possible to insert a button into a gastrostomy to allow easy insertion of the gastrostomy tube. If the surgeons in your country have no knowledge or experience with these buttons I'm sure they could get the necessary information by contacting British or American surgeons.
Unless infants are medically unstable, the primary repair of esophageal atresia is generally done at birth in the USA. The only time an esophagostomy and gastrostomy is done is if the esophageal segment is too short to make an anastomosis of the segments. Since I don't know the specific details of your nephew's condition, I am not in a position to make any recommendations; however, waiting a year is undesirable since, if the infant is unable to eat by mouth for the whole year, he may have a significant feeding disorder (refusal of food) by the time the surgery is done.
If the infant is not being attended by pediatric surgeons in India and travel to another country is a possibility, I would certainly recommend a consultation with a pediatric surgeon in the USA, Canada, Great Britain, France, Germany, or Israel as soon as possible. I'm sure there are other countries where good pediatric surgeons are available as well.
Generally the procedure for repair involves pulling the two ends of the esophagus together and sewing them together. If the segments cannot be brought together, it may be necessary to use a loop of bowel between them. The main complications are possible stricture and gastroesophageal reflux.
Sincerely,
Dr. Warren
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