17 March 2003
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
-ET
Dear ET: A blocked or narrowed tear duct will not lead to any vision problems but will result in tearing eyes and may cause recurrent conjunctivitis (pink eye - infection). If the symptoms are not responding to treatment you should contact your pediatrician since he may want to change the treatment. If the problem persists the baby may need his tear ducts probed by an ophthalmologist.
Sincerely,
Dr. Warren
Because my son contracted the disease while his fetal brain cells were still shifting, it is still another reason why I am lead to believe the prenatal trauma contributed to his ongoing problems. It is also important to note that neither sides of the family has a history of psychoneurological deficits. With the advent of the drug Rhogam, it is very rare that fetuses are affected with Rh disease, so the studies on the subject are very limited. That did not stop me, however, in trying to access whatever information is available. Through much searching, I have obtained two interesting articles relating to my concerns. The first one by PA Gustafason ,"Bilirubin index: a new standard for intervention?", questions whether or not keeping bilirubin levels below 20mg./dL. guarantees the avoidance of kernicterus, lower IQs or neurologic abnormalities.
The other article written by Wood, "Bilirubin diffusibility", the author states:
"On the whole, it appears that in nonhemolytic jaundice there is no relationship between neonatal serum bilirubin levels and later IQ, in hemolytic jaundice the question remains open."Realizing I'm not a doctor, I am limited as to my ability to attain and evaluate the whatever information may be available on the long-term affects of prenatal hemolytic disease and postnatal hyperbilirubinemia. Though my son's rapidly rising, postnatal bilirubin level was curtailed at 17.4 through a total blood transfusion, and stabilized with intensive round the clock phototherapy, I don't think the experts can claim there is no connection between his psychoneurological deficits and the disease he struggled with prior to his birth? What do you think, Dr.Warren?
What is a blood brain barrier? And what is the difference between hemolytic jaundice and nonhemolytic jaundice? How will I ever know if the bilirubin was responsible?
If there is any other information that you know of which may be helpful, please let me know.
Thank you for taking the time out of your busy schedule to address my concerns. You must be a very special individual.
-SM
Dear SM: The blood brain barrier refers to the fact that certain molecules circulating in the blood stream are too large to cross into the central nervous system. While this has a protective effect, it is also the reason high doses of intravenous antibiotics are required to treat meningitis. The blood brain barrier is less effective in a newborn than an older child and becomes progressively more effective with passing time in the newborn period. As a result, an elevated bilirubin poses a greater risk in a one day old than a three day old.
Hemolytic jaundice results from the breakdown of red blood cells. Rh disease is a hemolytic disease. Severe hemolytic disease causes a rapid rise in the unconjugated bilirubin. Because it is unconjugated (not metabolized or bound to other molecules) it can diffuse more easily into the brain where it can do damage. Jaundice resulting from liver disorders or infection may have a higher conjugated component which carries less of a risk of causing kernicterus.
The younger the newborn when the bilirubin level rises, the less bilirubin is required to risk damage to the central nervous system. This has to do with the maturity of the nervous system and the competence of the blood brain barrier. If your son's bilirubin level had begun rising prenatally because of prenatal hemolytic disease, the fact that his bilirubin level peaked at 17.4 while receiving treatment might not be a true indicator of what his nervous system was exposed to.
Even though the exchange transfusion was necessary to prevent kernicterus, it is also not totally risk free. Infants often become acidotic [too much acid in the blood] and hypoxic [not enough oxygen in the blood] during exchange transfusions. Symptomatic hypoglycemia [low blood sugar] may occur before or during exchange transfusion in moderately to severely affected infants. It may also occur 1-3 hr after exchange. The brain needs oxygen and glucose to survive and is very sensitive to hypoxia and hypoglycemia.
Even though jaundice is the most obvious risk factor of hemolytic disease, let's not forget that hemolysis destroys red blood cells and can cause a profound anemia. Not only can this affect the blood's ability to carry oxygen to the brain, but if the anemia is severe enough it can affect all other systems. The immature brain is at risk from any bodily malfunction.
I understand your need for closure, but in the final analysis, there is no way to demonstrate whether or not jaundice has caused brain damage in a living person. Therefore you will never know for sure. While genetics is an important risk factor for ADHD, the fact that your son has other neurological injuries is a much greater risk factor. Since he was a sick newborn, other perinatal risk factors may have contributed to his neurological injuries, but it is also possible that, for reasons you will never know, this is the way his brain developed.
Sincerely,
Dr. Warren
-J
Dear J: Certain parts of the nervous system develop at the same time from related tissue as certain parts of the skin. As a result, certain neurological conditions such as neurofibromatosis and tuberous sclerosis cause characteristic changes in the skin. This needs to be evaluated, but it does not mean with certainty that your son has a neurological disorder.
Sincerely,
Dr. Warren
Then she e-mails me that this (HYPOXIC ISCHEMIC ENCEPHALOPATHY) is what he has, but she can't explain it.
I hold great love and concern for this boy and want to be a part of his life. To understand whats happening is a help for me. Any info you can point me to would be greatly appreciated.
-SV
Dear SV: Brain tissue is highly dependent on glucose and oxygen to survive. As a result, brain tissue dies if it is deprived of oxygen or blood flow as happens during a cardiorespiratory arrest. The longer the person isn't breathing or his blood isn't flowing to his brain, the more injury there will be. Hypoxic means not enough oxygen. Ischemic means not enough blood flow. Encephalopathy means brain damage. The brain damage that results from hypoxia and ischemia is permanent. Your nephew needs appropriate therapy from physical therapists, occupational therapists, speech therapists, and educational specialists in order to maximize his potential.
Sincerely,
Dr. Warren
-JT
Dear JT: The condition you are treating is called labial adhesions. Estrogen creams are effective for opening labial adhesions. They cause local irritation and therefore should not be used for more than two weeks. Used in that short a course, the estrogen is not dangerous. Some girls have recurrent labial adhesions. In that situation, the best thing to do is leave them alone unless the adhesions are obstructing urine flow or, in the older child, resulting in leakage of urine which has pooled in the vagina. Once these girls reach adolescence their own hormones should cause the adhesions to resolve.
Sincerely,
Dr. Warren
-Traci
Dear Traci: If your daughter were a happy baby who was gaining weight well, I would point out to you that some healthy babies spit up so much they appear to be vomiting; however, your daughter's distress before she vomits indicates that she is symptomatic for something more than spitting. The story is most suggestive of gastroesophageal reflux. That possibility is not ruled out by the fact that her condition was not improved by general measures aimed at alleviating reflux. Since there are medications which can help a child with severe symptoms of reflux, your daughter should be evaluated by a pediatric gastroenterologist.
Sincerely,
Dr. Warren
Thanks for your time.
-Shawn
Dear Shawn : Do your parents know about your pains? I would imagine your parents would want you to see a doctor for recurring pains that have been so severe. You could be having pains originating in the trigeminal nerve (trigeminal neuralgia, also known as tic douleureux). You could also get shooting pains from jaw or dental problems. Pain going down into your back, neck, and chest could be muscle spasms. There are many possibilities. The fact that the pain keeps coming back doesn't have to mean it's serious, but it certainly demands to not be ignored.
Sincerely,
Dr. Warren
The problem is: baby is not having bowel movements and has an extremely extended navel.The baby spits up milk and develops gas then the Mother has been using a q-tip to start bowel movement. Baby cannot have movement without help. The baby is on breast milk and soy milk formula. He has been on another formula but developed a lot of gas. The parents have taken him to two different Drs. and both say colic but the baby has not been physically examined. There is concern he could have impacted bowels or obstruction.
Thank you.
-Grandma
Dear Grandma: Neither bowel impaction nor obstruction will respond to rectal stimulation with a Q-tip. In fact, a bowel obstruction would make the baby quite ill. I am absolutely puzzled by your statement that two physicians diagnosed colic without examining the baby. Even a healthy two month old requires regular examinations. Can't the baby's mother get the baby examined?
Abdominal distention associated with vomiting or pain can certainly indicate a problem, but a protruding navel simply means the baby has an umbilical hernia. It has nothing to do with the baby's bowel habits and is of no consequence.
Is it true that the baby cannot have a bowel movement without help? Or is it perhaps that nobody has waited long enough to allow the baby to establish a natural rhythm. Babies don't have to have bowel movements every day. Healthy nursing babies can sometimes go 4 to 5 days between bowel movements. As long as the stool remains soft, the baby is eating well, growing well, and happy, that's perfectly okay. If indeed the baby cannot have a bowel movement without help, the baby needs evaluation by a pediatric gastroenterologist to make sure he does not have Hirschsprung's disease. If he does, the treatment is surgical.
Sincerely,
Dr. Warren
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