23 December 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 daughter who is nine months and well, has just had a health screening and the doctor has expressed some concern about her hips because her "folds" on her legs appear asymmetrical? She is having a follow up visit and possible an x-ray. Should we be concerned? References ?
Many thanks.
-Julian
Dear Julian: Asymmetrical skin folds on the legs or at the buttocks may be a sign of a congenital dislocation of the hip. If a baby has congenitally dislocated hips, the earlier the diagnosis is made the easier it is to treat. X-rays and ultrasound studies of the hips can help determine if the femur (thigh bone) is properly located in the acetabulum (hip socket). If there is any question, it should be evaluated by an orthopedist since a diagnosis later in childhood could result in arthritis of the hip.
Sincerely,
Dr. Warren
-T
Dear T: Had you contacted me while your son was symptomatic I would have suggested seeing a gastroenterologist to have your son evaluated for gastroesophageal reflux. The episodic nature of the vomiting also has to make one consider the possibility of a seizure disorder. Some seizure are more likely to occur during sleep, but vomiting alone is not a usual manifestation of a seizure. Cyclic vomiting or abdominal migraine amy cause recurrent vomiting, but I'm not aware of the pattern being only during sleep.
If the symptoms recur, you should have further evaluation done. If there is no recurrence, it is possible that it was your child's response to an illness, but to be honest, with no daytime symptoms, I cannot point toward any specific diagnosis.
Sincerely,
Dr. Warren
Sincerely,
-T
Dear T: If a seizure occurs during sleep it may not always be obvious. Temporal lobe seizures, which may be more common during sleep, are often associated with repetitive movements which appear somewhat like purposeful movements such as blinking, lip smacking, or limb movements. If a seizure does not result in obvious seizure activity, it may still be associated with limpness and unresponsiveness afterward, but this may be difficult to distinguish from a child who doesn't rouse from sleep. Vomiting is not a common manifestation of seizures, but if the pattern is repetitive, seizure has to be considered. A sleep EEG may be helpful to establish the diagnosis.
Cyclic vomiting is related to migraine. Since I'm not sure of the diagnosis in your child's case, I can't be sure whether you should start with a neurological or gastrointestinal evaluation to reach a diagnosis. Cyclic vomiting probably falls more into the realm of a neurologist.
Sincerely,
Dr. Warren
-N
Dear N: Cerebral palsy generally results from brain damage either prenatally, at birth, or in early infancy. The exact mechanism remains unknown. Many children with CP have developmental delays, but some have normal or even above normal intelligence. The specific findings which make for a diagnosis of CP are abnormalities of motor function caused by damage to the motor cortex of the brain. As a result, many infants with CP are hypotonic (low muscle tone), but many of those develop the typical spasticity (tight muscles) of CP as their central nervous system matures. Other forms of CP may cause ataxia (an imbalance of gait or movement) or choreoathetosis (a constant writhing movement). The primary treatment for spasticity is PT, although surgical interventions are sometimes necessary. At this point, you son should be evaluated by a pediatric neurologist. The only changes in his management at this point would depend on the degree of spasticity your son has and if there is other evidence of abnormal movement.
Sincerely,
Dr. Warren
Thanks.
-AD
Dear AD: The frequency of your son's vomiting is often enough to make you wonder what's going on, and yet infrequent enough to question the value of further evaluation if he is eating well, growing well, and acting well. Although the pattern is not suggestive of gastroesophageal reflux, that diagnosis has to be considered in any infant who has recurrent vomiting. Since vomiting is usually an intestinal symptom, an evaluation by a pediatric gastroeterologist may be helpful.
Some children simply vomit more easily than others when they are ill, no matter what the illness is. That would go along with the possibility that these episodes are related to viral infections. The fact that your son recovers quickly and has symtpoms every two weeks makes that diagnosis less likely, but it is still plausible.
Cyclic vomiting and migraine are rare causes of recurrent vomiting in children. I am not aware of this diagnosis being made so young or going all the way back to 2 months of age. Cyclic vomiting and abdominal migraine are related disorders. You might try contacting the organization listed below. I found this information on the Web. I hope it is up to date.
Some additional information can be found in the NORD database.Cyclic Vomiting Syndrome Association (CVSA) 3585 Cedar Hill Road NW Canal Winchester OH 43110 Phone #: 614-837-2586 800 #: N/A e-mail: waitesd@cvsaonline.org Home page: http://www.cvsaonline.org
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
-MV
Dear MV: Your daughter probably has gastroenteritis, an intestinal infection. For full details on management please read my article Management of Gastroenteritis.
It sounds like your daughter's symptoms are improving, so she is probably on the mend and should respond to appropriate dietary management; however, a week is a long time for a child to be vomiting. Unless she has been holding down reasonable amounts of fluids during this time, she should be checked by her pediatrician to be sure she is not dehydrated. If her recovery does not continue or she is running any high fever at this point, that would also indicate a need to se a doctor.
Sincerely,
Dr. Warren
About two weeks ago, at around 10:30 PM, after being asleep for about 2.5 hours, he woke up screaming (crying). Not his usual cry when he wakes up, at which we then feed him some formula and then get him back to sleep. This time, it was loud and a little eery sounding - almost like he was scared! My wife picked him up and he seemed very disoriented, not able to focus with him eyes and kind of appeared weak. I went downstairs to get some formula, and my wife put him on the changing table to begin to change his diaper. I wasn't there, but she said he began to twitch (legs, arms, and even his head appeared to be moving involuntarily. She immediately picked him up and called his name, which he did not respond to. She began to panic and came down the stairs crying. I then took him into my arms and he still seemed disoriented and kind of moved around in my arms in an "unbalanced" way. (Sorry but this is the best way I can describe it ). After about twenty seconds of talking to him he seemed to be normal. We called 911, went to the hospital and had the following tests done over a two day period: Urine test, blood test, normal doctor exam (throat, nose, mouth, ears, heart rate etc.), the first day. Then they suggested that we have an EEG and KATSCAN (spelling ?) done. These both came back negative. At this point we "chalked" it up to the fact that his bad cold was creating an excess amount of phlegm and when my wife put him down to change his diaper, he was actually choking (gasping for air). So his leg, arms, and head movements we indicative of a breathing distress.
Now it has been two weeks, he has slowly gotten back to normal. Everything seemed fine....Then, last night, exactly two weeks to the hour (around 9:30 PM this time). It happened again, but not quite as severe. He woke up screaming, and then seemed disoriented. I noticed while my wife was holding him that he had what appeared to be a twitch in his left arm. Again, we brought him downstairs and opened the front door to get some fresh air. After a minute or so, he seemed his old self and was laughing and smiling in response to my smiling while mommy held him and vice versa. We gave him some formula, he fell asleep after a while, and everything today seems normal.
What could possibly be going on here ? This has happened only the two times, that we are aware of and it seems strange that it happened around the same time at night and while sleeping. Could we be misinterpreting the twitches as just normal movement for a baby who has just woken up and is disoriented ? If so, then why does he wake up screaming sometimes ? Could it be a nightmare that scared him at this early age ? Also, why is he disoriented sometimes and then most of the time he is not ?
We have an appointment scheduled with a pediatric neurologist just to be sure, but the hospital told us that they did not see anything wrong with the initial test results.
We appreciate your opinion on what could possibly be going on here.
-Mr. and Mrs. Worried
Dear Mr. and Mrs. Worried: You could be describing a night terror. A night terror is similar to a nightmare, but different. When children have nightmares, we don't become aware of them until the child awakens crying or tells us of a bad dream. The child who cries out during a night terror is still asleep. As a result, he looks at his parents with wide eyes an no sign that he recognizes them. Since the child having a night terror cannot recognize his surroundings or his parents, he may flail or strike out at a parent who tries to comfort him. Night terrors end when the child either wakes up or falls back into a deeper stage of sleep. On awakening, the child will have a vague uneasiness, but no recollection of the night terror. The fact that both episodes occurred around the same time favors the possibility that this was a night terror. The fact that your child is only 7½ month old goes against that diagnosis since night terrors occur primarily in preschool age children.
On awakening, before becoming fully awake, just as when drifting off to sleep, children may have some twitchy or jumpy movements. If there is twitching of one or more extremities which is repetitive and rhythmic, that is more consistent with a seizure. While it is good that all the tests were negative, a normal EEG does not rule out the possibility of a seizure. Therefore, you should see the pediatric neurologist as scheduled.
Sincerely,
Dr. Warren
Thank you.
-AA
Dear AA: Growth does not cease with the onset of menstruation. Menstruation starts around mid-puberty which is when an adolescent usually has her peak growth. After the start of menstruation, growth usually continues for two to three years or more. Not all children go through puberty in the same manner. Since your impression is that your daughter's body habitus does not look mature, in spite of the fact that she has started menstruating, she may not yet have reached her peak growth. On the basis of family history and statistics, the odds are that your daughter's height will be close to yours, but there are many factors affecting growth. At this stage, the most significant factor affecting her growth will be the rate at which she progresses through puberty.
Sincerely,
Dr. Warren
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