6 January 2003

1. Student Complaint #2
2. An Online Dermatology Atlas
3. Oppositional Defiant Disorder
4. Penile Discharge
5. Recurrent Labial Adhesions
6. Severe Hypoxic Brain Damage
7. Pigeon Toed
8. Amitriptyline for Abdominal Pain?
9. Disclaimer

• Read Questions & Answers in Another Column

Student Complaint #2

-Mike

Dear Mike: You should be glad to know, and probably not the least bit surprised, that you were not the only one to complain about some of my answers to student questions. You can find the previous letter (and my response) titled Student Complaint in my June 10, 2002 column, question #3.

If you read through to the end of my response, I think you will find the apology you demanded. I hope it satisfies you. You will also find that I made that angry young man a promise. I've changed... seen the light, so to speak. I have been careful in my responses to all student inquiries to be kind and considerate.

It amazes me that both you and the other young man who wrote to me felt the best solution is for me to just cash in my chips and get out. Is that how young people think these days... the best solution to a problem is to get rid of it, no compromises, throw out the good with the bad? Actually, I have too much faith in young people to believe that.

Okay, you're entitled to be angry, but ... "I think u should quit your job and retire." First of all, my web site is not my job. I spend 50 or more hours a week in direct patient care (office visits, telephone calls, emergencies, hospitals, clinics). I answer e-mails in my "spare" time. As a result, I must limit the questions I answer. The best way to serve everyone is to avoid spending time on duplicates. It has nothing to do with how much I like kids, no matter how poorly I came across. I adore kids, and most of them know it, even the ones I've given shots to.

As to your assertion that "Some kids asking questions may not understand all the rules you put on you web site," frankly, I have a higher opinion of youngsters than that, after all, these questions are not being submitted by 6 year olds. Here's an exact quote of the rules: "Students who have been assigned to interview a pediatrician should not send their entire assignment, but only questions that are unique and different from questions previously answered." Those instructions are followed by links to different interviews. So which part of "the rules" do you think is hard to understand. My web site is not publicized. Anyone who is capable of finding my web site for an assignment is also capable of searching it.

As to your suggestion, "You should consider shutting down ur website if you cant treat young people nicely...." It was never my intention not to be nice, but in any event, I'm able to see the error of my ways, I've promised to do better, and I've honored my promise. I still think the many letters which have been helpful to so many, including youngsters who felt they had no place else to turn with personal, medical, or embarrassing questions (I don't just do student interviews), vastly overshadow the "offensive answers" on my web site, arguing strongly in favor of my keeping the site running. If I should find the time to review and redo the student pages, I will decide if some of the responses should be edited to avoid scaring or offending some kids; however, considering the large number of interview requests I get, if I think I'm primarily scaring away the questions from those kids who can't be bothered with making the effort to find answers on my site and send only unique questions, I'm not so sure that I want to change anything.

Finally, there are a lot of factors influencing the declining numbers of people entering medical school and pediatrics, not the least of which includes the significant changes in the practice of medicine today due to the current means of health care delivery, all a result of greed and abuses in the health care industry and the response of an equally greedy insurance industry. I don't have a big enough ego to accept your assertion that "We need pediatricians, if they go short I will blame you and your stupid website." If I had anywhere near that kind of power, I can assure you I'd aim to use it to benefit mankind.

Sincerely,
Dr. Warren

The Dermatlas is compiled, reviewed, scored and updated by physicians of the Johns Hopkins University. Currently 2815 clinical and histological images, 14 CME cases and 721 diagnoses are included in this fast growing collection of dermatology images.

-Bernard A. Cohen, M.D. and Christoph U. Lehmann, M.D.
Departments of Dermatology and Pediatrics
Johns Hopkins University School of Medicine
600 N. Wolfe Street, Brady 208
Baltimore, MD 21287-3200

Dear Readers: Check this site out. It looks pretty good.

Sincerely,
Dr. Warren

-P

Dear P: As a general rule, you can depend on school districts to provide services that children need based on test results, but since funding is an issue, the school district uses very strict criteria to determine who qualifies for services an who doesn't. Therefore, if you're going to find yourself in a battle with the school district to get services for your son that you believe he needs, it behooves you to have an independent psychological evaluation of your son and to have his treating psychologist support your efforts in getting services for your son.

The teen years can be difficult with normal, healthy adolescents. The combination of adolescence, depression, and oppositional defiant disorder can make for some very difficult behavior problems in school and at home, and may even lead to some brushes with the law. This is not ordinary teenage stuff. I urge you to get professional counseling for your son and yourself.

Sincerely,
Dr. Warren

-Peter

Dear Peter: I can't give a complete answer to your question because I'm missing information such as, whether or not you're circumcised, whether the discharge is always present, whether or not the discharge is colored, what the consistency of the discharge is (thick, thin), and whether or not the discharge actually comes out of your penis through the urethra (the opening of the penis) or whether the discharge is just around the penis.

The area surrounding the head of the penis and under the foreskin is richly supplied with glands that produce lubricants for the penis. Lubricants are also produced inside the urethra and by internal male glands in response to sexual activity. These secretions come out through the penis. Any kind of sexual activity increases the amount of secretion by these glands. The odor of these secretions is sometimes fishy.

If the bumps you describe on the penis are around the head of the penis, it is possible that they are glands filled with secretions. If the bumps are only on the shaft of the penis, especially if they have hairs in them, they are probably enlarged hair follicles or oil glands. Of course, without seeing the bumps, I cannot tell you what they are, so if they are making you nervous, you should see a doctor for peace of mind; however, you are not describing any sexually transmitted disease. In particular, you are not describing symptoms of AIDS.

Sincerely,
Dr. Warren

Thanks for your help, you have made me less uncomfortable.

-Peter

Dear Peter: Although it is likely that sexual activity increases the amount of penile secretions, I cannot promise you that the secretions will go away if you have no sexual activity. Genital secretions are a fact of adult life. I can't see why you would feel obliged to stop masturbating because of an increase in normal secretions. If the smell bothers you, deal with it by bathing. If you use proper hygiene, I assure you nobody smells it but you.

Sincerely,
Dr. Warren

-Lisa

Dear Lisa: Labial adhesions will not affect the urinary tract unless they are severe enough to interfere with urine flow. Since you experienced this once with your daughter, it behooves you to watch for thick adhesions which obstruct the urethral opening. As long as that doesn't happen (it rarely does), labial adhesions are nothing more than a nuisance. Since labial adhesions clear up with estrogens, it stands to reason that they will resolve with puberty.

Since estrogen creams can be irritating and cannot be used long term, I asked my pediatric urology colleagues how they felt about treating recurrent labial adhesions. They were in agreement with me that as long as the adhesions were not causing a problem such as obstructing urine flow, they could be left alone.

Sincerely,
Dr. Warren

Yours Faithfully,
-IA

Dear IA: According to the information you have given me, your son has suffered significant brain damage as a result of not getting enough oxygen to his brain either before, during, and/or immediately after delivery. At this time, there are no treatments which will reverse the damage to his brain. You will need to get your son involved in early intervention programs with physical therapy, occupational therapy, and speech therapy as soon as possible in order to maximize his potential for improvement. You also need to have your son evaluated periodically by a developmental specialist who will counsel you regarding realistic expectations for your son.

This type of information should have been conveyed to you by your baby's doctors. If I am the first to be telling you this bad news, I apologize for being so blunt. You should not give up hope since I cannot tell you what your son's potential is. But you can help him best by proceeding with a clear understanding of what degree of disability your son has. You need to talk to his doctors.

Sincerely,
Dr. Warren

Thanks.

-EB

Dear EB: The correct term for pigeon toed is intoeing. This may be caused by internal tibial torsion, metatarsus adductus, or a combination of the two. Treatment depends on the age of the child and the severity of the intoeing. Severe turns require evaluation and treatment by an orthopedist. Young infants with mildly in turned feet can have their feet rotated and stretched into the outward direction with each diaper change. Older children should be discouraged from sitting on the floor with their feet under them since this tends to accentuate the turn of the foot.

Sincerely,
Dr. Warren

-BG

Dear BG: Amitriptyline Hydrochloride is a tricyclic antidepressant. According to GenRx the only official listed indication for using it is the treatment of depression. In view of the lack of experience with the use of this drug in children, it is not recommended at the present time for patients under 12 years of age. Possible side effects include constipation, nausea, epigastric distress, vomiting, anorexia, and diarrhea.

In the Journal of Pediatrics Volume 133 • Number 4 • October 1998, Copyright © 1998 Mosby-Year Book, Inc., in an article titled Recurrent abdominal pain and the biopsychosocial model of medical practice it stated,

Drug therapy plays an adjunctive role in Irritable Bowel Syndrome treatment, with tricyclic antidepressants or anticholinergic drugs used first at the preference of the clinician. Tricyclic antidepressants such as imipramine or amitriptyline (dose: 0.2 to 0.4 mg/kg per day, 10 to 50 mg/day, generally at bedtime) may be used to decrease pain and diarrhea, possibly through their anticholinergic, as well as central analgesic, effects. These drugs have been used for treatment of chronic visceral pain, but there are only anecdotal reports of their use in children with chronic abdominal pain. Amitriptyline has greater sedative and anticholinergic effects than imipramine and therefore may be a better choice for those who have difficulty sleeping or a diarrheal component to their disorder. Imipramine may be better than amitriptyline for children with a tendency to constipation, because at doses commonly used for visceral pain, constipation is rarely exacerbated.

So what do these conflicting views mean? Unfortunately, medications which may be useful for children are often denied to them because they haven't been adequately studied in children. Since you are seeing a specialist, he has some experience with the newer uses for this medication, but it is not a standard pediatric medication for treating abdominal pain, therefore, I cannot give you advice based on my experience. All medications have side effects, and amitriptyline has a fairly long list. Your son may not experience any adverse reactions if he takes the medication. Therefore, you have to decide how crucial it is to proceed with treatment of your son's symptoms. If his quality of life or his ability to function are significantly impaired by his symptoms and all the standard approaches have been exhausted, then you have to consider trying a newer approach. If your son is doing reasonably well with his symptoms, you have to decide if he can manage with his symptoms without medication as opposed to aiming to make him symptom free with medication.

I think you need to discuss your concerns fully with your gastroenterologist. Since he is treating your son for abdominal pain, he may feel that you expect him to make your son pain free. You need to form a therapeutic alliance with your doctor where he understands what you expect from him and what risks you're willing to take in order to achieve your goal. You need to periodically adjust your therapeutic goals based on a mutual understanding of what you will accept and he can offer, and what benefits and risks there are to each treatment option. You may be surprised to find out how much what you ask for determines the treatment options offered by your physician.

Sincerely,
Dr. Warren

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