14 April 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
-RC
Dear RC: I don't know if there is standard agreement on the ages for the categories you gave. The neonatal period extends from birth to 8 or 12 weeks depending on who you read. Keeping in mind the neonatal period as a distinct period, it may be tempting to start infancy after the neonatal period, but a newborn is also considered an infant. In fact, legal papers refer to all children as infants. Most people start referring to babies as toddlers rather than infants when they start to walk. That would start the toddler phase generally by 15 months, but many people would call any baby under 2 an infant. Most people would consider a 3 year old a child rather than a toddler or infant, but for the purposes of medical insurance coding, an examination on a child between 1 and 4 is coded the same. Adolescence is usually synonymous with the teen years, while adulthood is considered to start between 18 and 21 depending on who is defining it and why. Most 18-21 year olds are still cared for as adolescents, but some health insurance policies declare you an adult at 19. It's all rather arbitrary.
Sincerely,
Dr. Warren
-Terry
Dear Terry: Your daughter may very well have an enlarged rectum and colon. They get stretched and get used to staying stretched by being chronically filled with stool. Since her rectum has accommodated to being stretched, she does not feel the urge until it is full of an enormous, hard stool. If your daughter had these large, infrequent bowel movements since earliest infancy, she may need medical evaluation by a gastroenterologist to make sure she does not have any medical condition contributing to constipation. Your description of your daughter getting on and off the potty as a toddler and complaining that her bottom hurts is typical stool withholding behavior.
The management of your daughter's large stools and constipation involves not only trying to keep her stool soft as described in my articles, but also getting her to move her bowels regularly so that her rectum and colon can shrink down. If you have only read the q&a's about constipation on my Web site, be sure to read my article, Fecal Soiling. After 9 years of significant constipation, it would probably be reasonable for you daughter to have an evaluation by a pediatric gastroenterologist before embarking on any treatment regimen.
Sincerely,
Dr. Warren
Thanks.
-M
Dear M: Whether or not to be concerned depends on the size of the swollen lymph node, if it's growing, and if there are more of them. A small (pea sized) lymph node may persist even when your child is not sick just because of the frequency of upper respiratory infections. Once a lymph node has been activated, it doesn't disappear quickly when you become well.
Sincerely,
Dr. Warren
-JC
Dear JC: Milk always curdles in the stomach as part of digestion whether or not you have fever. It's perfectly okay to drink milk when you have fever as long as you're not nauseated or vomiting. Milk is food, and sits in the stomach. A person with fever needs lots of fluids, so it may be better to drink clear fluids rather than fill the stomach with milk and then lose the desire to drink.
Sincerely,
Dr. Warren
-RS
Dear RS: Although hepatitis and meningitis are important diagnoses to consider in a sick child with undiagnosed cause of fever, neither illness will cause recurrent fever over a period of a month. An environmental toxin would be an extraordinarily rare cause of fever. The tip off to an environmental toxin is that multiple people are exposed so that the cases with similar symptoms cluster. This can be the case with certain infectious agents too. If your granddaughter is the only one sick, a toxin is not a possibility unless there is a likelihood that she is the only one repeatedly exposed.
Even though 4 febrile illnesses within a month is excessive, it is possible that these are just separate illnesses. That possibility is greatest if your granddaughter has a source of exposure such as daycare or an older sibling.
If all of the fevers within the past month represent one persistent or recurrent illness, then your granddaughter requires a thorough evaluation for fever of unknown origin. The possibilities include not only a variety of infectious diseases, but also inflammatory disorders like Juvenile Rheumatoid Arthritis and inflammatory bowel disease, and also childhood cancers. Whether or not any of these are possibilities depends on your granddaughter's clinical presentation. Before considering any of the rarer, more serious disorders, the more likely infectious causes must be ruled out unless her examination suggests otherwise. Since I don't know what tests have already been done, I cannot advise further other than to point out that a urine culture must be done since a urine infection can only be ruled in or out by a culture, and urinary tract infections may cause recurrent fever.
Sincerely,
Dr. Warren
-YP
Dear YP: If you are able to get your son to eat, and none of the day care providers you bring him to can, it would appear that you need to spend some time observing how meals are handled in the daycare setting before picking a place. There is no magic that will get a kid to eat if he doesn't want to. Putting excessive pressure on a child to eat will usually result in decreased eating, but not spending the time necessary to feed a child is also not going to work. The only things I can suggest, since your son eats for you, is to plan on his having at least one meal with you before you go to work, and another meal with you when you get home. I understand that puts an additional burden on you, but it will also forge your relationship with your son if it is done right. You can also provide a high calorie nutritionally fortified supplement like Pediasure for when he is in daycare.
Sincerely,
Dr. Warren
Thank you.
-DP
Dear DP: Most children who complain of an occasional ankle pain have twisted it during play and only feel the discomfort later when they are not busy. If the pain is recurrent or your son has a limp, he will need to be evaluated by an orthopedist. If the ankle is red, hot, or swollen when he complains, that would also be a reason to see a doctor.
Sincerely,
Dr. Warren
Thank you.
-BH
Dear BH: According to Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company
renal vein thrombosis in infants is associated with polycythemia, shock, dehydration, diabetic mothers, asphyxia, sepsis, and coagulopathies such as antithrombin III or protein C deficiencies.From what you have told me, your son has one remaining normal kidney. Fortunately, human beings can lead perfectly normal lives with only one of a paired organ. The only restriction would be avoidance of competitive contact sports or potentially dangerous activities in which there is a significant risk of injury since your son does not have a spare.For unilateral renal vein thrombosis, treatment is supportive and involves correction of fluid and electrolyte abnormalities and treatment of infection. In infants, the thrombosed kidney undergoes progressive atrophy, ultimately leaving a small scarred kidney. Nephrectomy should not be performed in the acute phase, and later only if hypertension or chronic infection develops.
Sincerely,
Dr. Warren
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