9 December 2002

1. Acid Reflux or Overfeeding?
2. Shriveled Nails
3. Signs of Liver Failure
4. Tooth Grinding
5. Speech Delay
6. Hypospadius
7. Recurrent Fevers
8. Persistent Croup
9. Disclaimer

• Read Questions & Answers in Another Column

Acid Reflux or Overfeeding?

Thanks

-NR

Dear NR: 24 pounds is enormous for a 4½ month old. Whether or not it is overweight depends on her height. There are a large number of medications available for treating reflux. Since these must be prescribed by a physician I will only say that the choice depends on what symptoms your baby is having and why you object to the Zantac. Advice regarding management of her symptoms also depends on what symptoms she is having and when. Given your baby's weight, I can't help but wonder if her problem is overfeeding rather than reflux.

Sincerely,
Dr. Warren

-BL

Dear BL: Nail dystrophy can be seen without any other disease. The cause is unknown. Treatment is cosmetic, i.e., trying to improve the appearance of the nails. I cannot say if this is what your son has since I haven't seen it. You should have your pediatrician check it at his next check up if everything else seems okay. You could also have it checked by a dermatologist.

Sincerely,
Dr. Warren

-Susan

Dear Susan: Your daughter will be monitored by her physicians so that you will not have to be looking for signs of liver failure. Liver failure is a late finding. By the time it occurs transplantation would be urgent. The following text about hepatic failure (liver failure) is quoted from Barnett's textbook of pediatrics.

Hepatic failure occurs when liver cell function is no longer able to sustain the minimal needs of the patient for synthesis and detoxification of a large number of chemical substances. The syndrome is characterized initially by mild confusion, slowness of thought, slurred speech, and poor handwriting (Stage I). This stage may be followed by more severe drowsiness and bizarre behavior as well as tremors and flapping of the hands when elevated (Stage II). Stage III is characterized by marked sleepiness, incoherent speech, mental confusion, and severe hand flap; stage IV, by complete coma and absence of hand flap. The EEG is abnormal during stages II, III, and IV. Other evidence of hepatic cellular insufficiency usually develops concomitantly with the onset of coma or pre-coma. Marked prolongation of prothromhin time occurs, as well as hypoglycemia and severe hyperbilirubinemia. Hypoalbuminemia occurs after several days. Previously elevated SGOT and SGPT values may decline abruptly with the onset of hepatic failure. The liver often decreases in size, heralding the loss of hepatic tissue and glycogen. Hepatic failure may occur with either acute hepatic damage such as viral hepatitis or toxic ingestions, or in chronic and progressive disorders of the liver, such as chronic active hepatitis. Ammonia levels in the circulating blood are usually elevated, assisting in diagnosis of hepatic failure. It is not certain whether ammonia accumulation alone or other toxic accumulations are responsible for the neurologic disturbance. The overall mortality in all patients with hepatic failure regardless of age and diagnosis is 90 percent.

Sincerely,
Dr. Warren

-Donnie

Dear Donnie: Tooth grinding may increase with tension, but some children simply grind their teeth for no special reason. There is a popular belief that tooth grinding is related to parasites, but this is not true.

Sincerely,
Dr. Warren

And thank you for this service!!

-Abby

Dear Abby: Speech delay may be anything from a normal variation in a healthy child to a primary language disorder to global developmental delays, or it may be seen in a child with hearing loss even if the child appears to understand speech. The next step is to have the child evaluated by a speech pathologist. After the evaluation, the speech pathologist will be able to tell you what kind of therapy is recommended and what you can expect from it.

Sincerely,
Dr. Warren

Thank you again for your kind attention.

-Abby

Dear Abby: A public health nurse is not the same as a speech pathologist. Her role in the evaluation process depends on her training and what kind of screening she will do when she sees you. Many states provide early intervention programs at no cost. These are often administered through the local health departments. If that is the case where you live, the public health nurse visit may be the first step in the process of providing services. Check with your doctor to find out why she is sending a public health nurse to be sure that this is a step in the direction you want to go.

Sincerely,
Dr. Warren

1. Prior to his birth my wife's sonography indicated that there was a PUJ obstruction. On birth a blood test , sonography and a renal scan were done and all reports indicated no major problem, we have however been advised to do one more sonography and periodically do so. Is this normal ?
2. He has a small degree of "hypospodais" and we have been told that corrective surgery would be necessary. What is the right age when this should be done?
3. There are a lot of conflicting view as regards the introduction of solid foods in his diet. What in your opinion is the right age when this should be done?

-SB, India

Dear SB: Hydronephrosis which is found prenatally on ultrasound may have resolved by the time the baby is born. Follow up is advised, but if the ultra sound is normal, nothing more needs to be done.

The best age for hypospadias repair is between 6 and 18 months, but it may be done as early as 3 months.

Solid foods should not be introduced before 4 months. Please read my article, Feeding Your Infant.

Sincerely,
Dr. Warren

I have just two more questions to trouble you with regarding his hypospadias condition:

1. You have said that the best age to repair this is between 6 and 18 months then , but will he not be too small or young to undergo this surgery?
2. Is this corrective operation required to be done in two stages or can it be done in a single surgery? His condition as told to us by the doctor here is a very slight degree but he still indicated that the surgery may have to be done in two stages to cater for the urine tube at one stage and for the sperm tube at the second stage. The doctor also told us to check the trajectory length of the baby' s urine. We have seen this and it is about 6 - 8 inches trajectory.

Many thanks for your trouble and look forward to receiving a reply,

Yours sincerely,
-SB

Dear SB: The reason that hypospadias surgery should be done at 6 to 18 months is that it is generally desirable to do genital surgery before a child is old enough for his genital abnormalities or the surgery to have a large emotional impact. A child that age is not too small to have this surgery done by an experienced pediatric urologist.

Sometimes when the surgery is done, if there is a chordee, the urethral opening turns out to be lower than it originally appeared and the surgery may require more than one stage. Only the surgeon who has examined your son can tell you the likelihood of doing the surgery in one or two stages.

I have not written any articles on hypospadias and can only suggest that you use an internet search engine making sure to spell hypospadias correctly.

Sincerely,
Dr. Warren

-C

Dear C: Infection is one of the most common causes of fever in children, but it is not the only cause. The evaluation of fever of unknown origin includes looking not only for occult infection, but also, inflammatory diseases like JRA, lupus, and inflammatory bowel disease. Unfortunately, prolonged fever of unknown origin can also be seen with childhood cancers like leukemia and lymphoma.

The possibilities are so numerous, and the evaluation for all these possibilities so complex, that one usually looks for some guidance in the symptomatology: abdominal pains or bloody stools to suggest inflammatory bowel disease; unusual rashes, swollen joints, blood in the urine, involvement of multiple organ systems to suggest collagen vascular diseases like lupus or JRA; localized pain to suggest a localized chronic infection; urinary symptoms or foul urine to suggest urine infection; etc.

An elevated white blood count suggests a bacterial infection, but an elevation of the white count can also be seen with inflammatory diseases. If your daughter's fevers are infection related, the question to be resolved is whether each episode represents a new infection, or if she has a chronic infection which has not responded adequately to treatment. If your daughter has recurrent infection, an evaluation by an immunologist might help pinpoint the reason this is happening. Some children are prone to recurrent ear infections or urine infections even though they have normal immunity, but these infections can easily be diagnosed by examination or simple tests. Bacteria rarely cause chronic infection, but if there is a focus of infection in an internal organ the gallium scan should help locate it.

If the fevers are persistent or recurrent with a frequency of every two weeks and infection is ruled out, then your daughter will need further evaluation by a rheumatologist and oncologist. If the fevers are less frequent and generally run a course of 5 days or less, in spite of the elevations of your daughter's white count, you may be experiencing nothing more than the usual childhood infections.

Sincerely,
Dr. Warren

-SD

Dear SD: Temperatures between 94-96 degrees are not characteristic of any infectious illnesses, but below normal temperatures may sometimes occur as part of the temperature instability associated with illness. Most cases of croup improve within 3-5 days. On occasion it takes longer. Since there are no medications which specifically treat croup or shorten the illness, there is nothing to do but wait. It gets better. If the child's breathing is affected, even if the breathing is not severely labored, a course of steroids would be appropriate to reduce the inflammation in the airways. Any time an illness runs longer than expected, it is reasonable to have your doctor reevaluate in case the findings, and therefore the recommended treatment, changes. If a symptom such as hoarseness persists several weeks or more beyond the usual course of croup then the larynx and trachea should be evaluated by an ENT.

Sincerely,
Dr. Warren

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