25 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
Thank You
-JR
Dear JR: It is difficult to do home screening of a newborn's hearing because you need a loud stimulus which can be repeated reliably in order to judge if there is a consistent response. A newborn's response could consist of sucking more rapidly or stopping sucking. Screening is now being implemented in nurseries across the country using a 100 dB white noise.
If there is a significant question about your daughter's hearing, your pediatrician could refer you to an audiologist who has experience screening newborns, or he could arrange for her to have a BAER (brainstem auditory evoked response).
Sincerely,
Dr. Warren
Dear Readers: Since this response was written technology has advanced and many nurseries are now running a hearing screening similar to the BAER mentioned above.
-KB
Dear KB: Erythema multiforme is a severe type of allergic rash in which the hives form targets, blisters, bruises, and generalized swelling. There may often be associated fever, joint pains, and constitutional symptoms. Steroids are used to decrease the inflammatory response which is part of the severe allergic reaction.
Sincerely,
Dr. Warren
Thank-you :-(
-Carole
Dear Carole: Mastoiditis, an infection in the mastoid bone behind the ear, is a complication of chronic or persistent ear infections. It causes fever, tenderness of the mastoid bone, and redness overlying the mastoid. It is the result of ear infections not clearing, and not the cause. It is fairly uncommon in children whose ear infections have been treated with antibiotics. For more information on ear infections, please read my article, Another Ear Infection!?!.
Red, itchy, swollen eyes may be allergy. If there is a pus discharge from the eyes, it's an infection. Infectious conjunctivitis and ear infections are often seen together.
Chronic anemia does not cause all these problems. The real question is, why does your daughter have chronic anemia? If she has immune deficits and abnormalities of white cells, she needs further evaluation to determine if there is one underlying cause. She should see a pediatric hematologist.
Sincerely,
Dr. Warren
-DM
Dear DM: Please read my article Managing the Difficult Child: Toddlers. The most important thing you can do is be consistent. Going from one approach to another trying to find one that works is confusing to your child. There is no approach that will quickly make him easier to deal with. He's a 3 year old, active child, who is reacting emotionally to the changes in his life caused by a new sibling. Obviously, with a new baby to care for, you could use his cooperation, but since he is only 3, he can't appreciate that. He will do whatever it takes to guarantee that he will still get your attention when he needs it. That means demanding that his needs be met the minute he sees you with the baby. Obviously he needs to learn to wait, but he also needs to be reassured.
There is no quick fix. Civilizing children is a full time job. Figure out what rules you need for your life and your son's life to run smoothly and, hopefully, pleasantly, and enforce them consistently.
Sincerely,
Dr. Warren
-LS
Dear LS: I don't know if your physician had a specific reason for refusing to do a TB test. Current recommendations for PPD screening is to only do it when there are possible risk factors for exposure to TB since false positive tests are possible. A TB screening test is not necessarily useful in the diagnostic evaluation of a cough. With regard to TB, cough is a symptom of active TB. Active TB should be visible on a chest x-ray. A chest x-ray is a reasonable and useful test to obtain on a patient with chronic cough even when TB is not a concern.
Active TB causes fever, night sweats, and weight loss. It is uncommon in healthy adolescents in the USA, but TB is not a disease of old age. While it is true that with advancing age the percentage of the population with positive TB skin tests increases, tuberculosis knows no age barriers. Your son's age does not protect him against TB.
Sincerely,
Dr. Warren
-Susan
Dear Susan: Oil can help soften the scales of cradle cap making them easier to remove, but oil left on the scalp will aggravate it. If you use oil you should use only a tiny amount, rub it into the scales well, brush the scales out of the hair, and wash the oil out completely. If this doesn't help, you can try a dandruff shampoo like Sebulex.
You can use 1% hydrocortisone cream (Cortaid) on the scales behind the ears. If this does not help, you will need to see your pediatrician.
Sincerely,
Dr. Warren
Thanks.
-Jeff
Dear Jeff: No education is ever wasted. If you explore your options in the pharmaceutical industry, and other industries which serve the medical community, you may find some career options you could follow with some additional training for the specific industry. If you are reluctant to work with patients but are willing to do a residency, you might also look into research or pathology as an option. You should also explore any career counseling available at your medical school. I have no experience with options for using a medical education outside of practicing medicine.
If you don't want to do pediatrics, or any kind of clinical medicine, I won't try to convince you otherwise. I understand that the responsibilities associated with practicing medicine are pretty scary. They're also pretty exciting. Since you were interested in clinical medicine, I wonder what about your clerkships changed your mind. Do you want to talk about it? I'm willing to listen.
Sincerely,
Dr. Warren
-Jeff
Dear Jeff: You certainly face some tough decisions since this is your whole future we're talking about. But don't forget, you will always have your MD degree which qualifies you to enter a residency program any time in your life if you decide to change careers or specialties. It is realistic to realize, however, that most of us don't choose to go back and do something else because of the big investment we make (emotionally, financially, and physically) in our original choice. Therefore, you need to figure out what your priorities and goals are and look at the long-term picture as well as the immediate future.
It's true that you won't become wealthy as a pediatrician, but you can still make a respectable living. The jobs that make people rich are primarily in the business world, and except for those who get lucky with investments, wealth and advancement comes primarily to workaholics who spend less time with their families than the average pediatrician. A dedicated pediatrician can still have a family life. In private practice, the best bet is to join a group which limits night call and weekends. I've been in practice with the same partner for 23 years. That means I'm on call half the nights and half the weekends, but when I'm off, my time is my own. And we also share weekend call with other pediatricians in our area, so that on some weekends I'm on second call. Sure, some nights on I get a lot of calls, but even on call nights can be quiet. I just didn't pursue many interests that didn't include my family. I've had to miss a few things, but I've been there for my wife and kids. Since I'm self employed, my partner and I decide how much vacation time we take. When he's away, somehow all hell breaks loose. But when I get my vacation, I'm totally free.
Private practice isn't the only way to be a pediatrician. If you're willing to earn a little less, you can work in a clinic with set hours. You can even find a job with no weekends or night call. Being a pediatrician isn't the way to get wealthy, but it is rewarding, and you can probably find a way to do it that fits your life style. You just have to look at the big picture and figure out if that's what you want for your future. There are better ways to earn money, but they can also consume your life. And you want your life to be about more than earning money.
Yes, residency is a big commitment, and you're only young once, but just like the situation in practice, you do get nights off, weekends off, and vacations. It's true you can't be off as much time as some other jobs, but I don't know anyone who would trade an extra ski trip for his whole future. You don't have to give up your personal life to be a resident, and you'll become friends with a whole bunch of other people in the same boat. Residency is three to five years - not too much of a sacrifice to invest in your future since, while it may cut into your personal life, it doesn't eliminate it.
I'm not out to convince you to commit to something you'll regret, but when you're 30 and looking at where your life is now, the sacrifices made for residency will not seem like a big loss to you unless you really don't want to be a pediatrician. Medical school is also a big time commitment, and yet you've managed it and still have a personal life. You've focused so strongly on your concerns about the downside of residency and a career in pediatrics that you've lost sight of the fact that you will ultimately control how you spend your time during your future. If your goal is to be chief resident and become a hot shot famous physician you'll have to devote a lot more time to study and being around for procedures during residency than if you have lesser ambitions.
So there you have it. Residency and life as a pediatrician is not a piece of cake, but there's an upside and a downside to all career choices. You have lots of options. Don't let fear of the unknown prevent you from exploring them now that you've gone this far. Figure out what your priorities are, but don't lose sight of long term goals. Talk to some people currently in residency programs to get a more realistic sense of what to expect. And remember, no decision is written in stone. You have to honor your commitments, but you can always leave a residency program without completing three years if you really don't like it. And even though it may be tougher later on, you could get into a residency program later. I'd go for the first choice while you have the momentum, but you have to decide for yourself.
Sincerely,
Dr. Warren
Do you think it is safe to try the protein drink or really start to diet. He too, is aware of his belly and is embarrassed of it. The summertime is really hard because he doesn't want to go without a shirt. I'd like to try to help him over this winter so that he won't be so self-conscious this summer.
Thank you for any advice you can give.
-SE
Dear SE: Protein drinks cannot help a person lose weight unless they are substituted for meals. They are not appropriate for children. No child can be hungry all the time. Children (and adults) often use the word hunger when they mean appetite. Even overweight children should be allowed some treats, but there is no way to control weight without decreasing caloric intake and increasing activity to burn more calories. At 7 years of age, your son is depending on you to set limits. You do it for everything else. You have to do it for food. Don't tell him it's because he's fat. Just tell him when he's had enough, or when it's not yet time for a snack. And don't cave in to the whine, "But ma, I'm hungry!!!" Help him to learn the difference between hunger and appetite. Please read my article, Childhood Obesity.
Sincerely,
Dr. Warren
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