11 November 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
My name is Kate-Lyn and I am 10. I live in Ontario, Canada. I am doing a science project on Diabetes because my father is a diabetic and was asking as many professionals around the world as I could, this question, What causes variations in a persons blood sugar level? What has the most impact on these differences? If you have time to answer these that would be great. Thanks for your time.
-Kate-Lyn
Dear Kate-Lyn: The biggest variable affecting blood sugar is diet. If diabetics didn't have to eat there would be no problem controlling their blood sugar. With each meal the blood sugar goes up and then comes back down as insulin helps to metabolize the sugar. When meals are taken irregularly and the amounts of calories and types of foods vary widely from day to day, it is difficult to determine a dose of insulin that will control the blood sugar properly. When diabetics adhere to an exchange list diet and avoid foods with sugar, it is much easier to arrive at a daily insulin regimen which will keep their blood sugar properly controlled.
Activity level is another important variable. Not only does activity burn sugar, but it enhances transport of glucose into the muscle cells where it is used. As a result, activity lowers the insulin requirement. As you can imagine from what I said about diet, if a diabetics activity level varies widely from day to day, it is harder to standardize his insulin dose.
Illness can play an unpredictable role in affecting blood sugar. When diabetics are sick, there blood sugar usually goes up from the stress, but on the other hand, their appetite may go down resulting in fewer calories being consumed, and if they have vomiting, they may not be able to consume calories.
Adjustments in insulin dose need to be made on days where the diet or activity level will be significantly different than the usual. During severe illness, diabetics should monitor their blood sugar carefully and may need to cover themselves with short acting regular insulin and avoid longer acting insulins.
Sincerely,
Dr. Warren
Also, can you suggest newly published studies on premature thelarche which I may be able to access for further information?
Thank you.
-mb
Dear MB: The following information on premature thelarche is quoted from Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company.
This term applies to a transient condition of isolated breast development that most often appears in the first 2 yr of life; in some girls breast development is present at birth and persists. Breast development may be unilateral or asymmetric and often fluctuates in degree. Growth and osseous maturation are normal or slightly advanced. The genitalia show no evidence of estrogenic stimulation. The condition is usually sporadic and is rarely familial. Breast development may regress after 2 yr, often persists for 3-5 yr, and is rarely progressive. Menarche occurs at the expected age, and reproduction is normal. Plasma levels of LH and estradiol are below the limits of the assays, but basal levels of FSH and their responses to GnRH stimulation are greater than those seen in normal controls. In contrast, children with true precocious puberty secrete predominantly LH. Ultrasound examination of the ovaries reveals normal size, but a few small (<9 mm) cysts are not uncommon.Please note the last sentence of the above quote: "Occurrence of thelarche in children older than 3 yr of age most often is caused by a condition other than benign precocious thelarche." It is, of course, possible that the breast tissue developed before 3 years of age and wasn't noticed; however, if it started beyond the age of 4, as I understood from your e-mail, your daughter should probably be evaluated by a pediatric endocrinologist. At the very least, she should have a bone age done and very careful monitoring of her growth as well as observation for any other signs of puberty.In some girls of the same age group, breast development may be associated with definite evidence of systemic estrogen effects, such as growth acceleration or bone age advancement. Pelvic sonography may reveal enlarged ovaries or uterus. This condition has been referred to as exaggerated or atypical thelarche. It differs from central sexual precocity because it is spontaneously regressive. GnRH stimulation elicits a robust FSH response and a minimal LH response. The pathogeneses of typical and exaggerated forms of thelarche are unclear, although a delay in the transition from the activated (neonatal-infantile) to the inactive (prepubertal) pituitary-ovarian axis may underlie both conditions.
Premature thelarche is a benign condition but may be the first sign of true or pseudoprecocious puberty, or it may be caused by exogenous exposure to estrogens. In addition to a detailed history, a bone age should be obtained. The serum concentrations of FSH, LH, and estradiol are generally low and not diagnostic. Pelvic ultrasound examination is rarely indicated. Continued observation is important because the condition cannot be readily distinguished from true precocious puberty. Regression and recurrence suggest functioning follicular cysts. Occurrence of thelarche in children older than 3 yr of age most often is caused by a condition other than benign precocious thelarche.
Sincerely,
Dr. Warren
-T
Dear T: Sweating can be seen as a response to pain or not feeling well as well as a response to fever when the fever is coming down. If your child's apparent pain continues he should be rechecked. If he is perfectly okay all day and only has the problem at night, be suspicious of separation problems or bad dreams.
Decongestants can relieve stuffy noses but have never been shown to be beneficial for treating middle ear fluid. They have been classified by the FDA as ineffective for treating middle ear fluid. You should be aware that decongestants can make children cranky and they may cause overstimulation which interferes with sleep.
Sincerely,
Dr. Warren
-Julie
Dear Julie: Most children won't develop thrush from a short course of antibiotics, but neither will they develop diarrhea. It is possible for a perfectly healthy 2 year old who hasn't been on antibiotics to develop thrush. It's uncommon, but possible. There is no reason to think your son has a problem with his immunity if he developed thrush while on an antibiotic unless he has other kinds of uncommon infections. You should take your son to his regular pediatrician and have it checked. You are probably right that it is thrush. If so, it should be treated and you shouldn't worry.
Sincerely,
Dr. Warren
Sincerely,
Dr. Warren
-Anthony
Dear Anthony: Two conflicting opinions call for a third opinion. Whether or not to do anything depends on how extreme the tibial torsion is. Keeping a 16 month old in a Dennis Brown Bar would be a pain. Look for sleepless nights if you do it. If you trust the opinion of the orthopedist who assured you that everything would resolve without intervention, I'd go for that opinion, but if you feel uneasy, find a pediatric orthopedist at a university center for a third opinion.
Sincerely,
Dr. Warren
http://www.orthoseek.com/wbc/products/wbrace.html
http://www.orthoseek.com/articles/inttibtor.html
-Anthony
Dear Anthony: The information on the Wheaton Brace looks good, but I am unable to endorse it for any treatment since I cannot find any studies in any medical journals supporting either its efficacy (usefulness for the stated purpose) or safety. One thing I would keep in mind, is that the information on their web site gave strict criteria for who would need treatment. Just as I stated, they don't recommend treating mild tibial torsions.
Sincerely,
Dr. Warren
-CH
Dear CH: Most infants have some degree of bowed legs until 18 months. Since I can't see it, I can't make any judgment as to how extreme it is. At 18 months your son should be having regular checkups at his pediatrician, so you should ask his opinion at the next checkup. If your pediatrician's response is not satisfactory to you and you need more information, then you should consult a pediatric orthopedist.
Sincerely,
Dr. Warren
-CS
Dear CS: 20 months is not too young for most children to start potty training. The only important issue is to have realistic goals for a child that age and not put undue pressure on her. This is an excellent age for your daughter to be sitting on the potty regularly.
I'm not sure why the potty training at her father's is confusing her. You'll have to give me more details about what he is doing, what you're doing, and what problem she is experiencing for me to comment.
Sincerely,
Dr. Warren
Scott is 2,5 years old and did have a serious ear infection when he was much younger. It was only picked up recently by the ear specialist. A large plug of wax was removed and antibiotics cleared up the infection - do you think he may be holding his head to one side out of habit or is there more to it?
His balance is definitely not right and he is often falling over / bumping into things - mind you I am not surprised considering the way he holds his head.
I am worried about the growth of his spine and wonder if he now holds his head to the side out of habit?
Scott is a very happy and responsive child who eats well, but does tend to sleep quite a lot.
I would be most grateful if you would respond with some suggestions/answers and look forward to hearing from you.
Yours sincerely,
-AH
Dear AH: If your son's eyes and ears have been found to be normal his head tilt could be due to tight neck muscles or a neurological condition. Since you say his balance if not good, he should be evaluated by a pediatric neurologist. If his neurological evaluation is normal, then an orthopedic evaluation should be done to see if there is any spine or muscular problem and if he would benefit from physical therapy. I doubt this could be just a habit.
Sincerely,
Dr. Warren
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