12 May 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
Thanks,
Bev
Dear Bev: As a general rule, babies should be walking independently by 16 months, so your daughter's motor development is mildly delayed. It so happens that my two daughters didn't walk until 18 months, and they're both fine. But you also have to consider that your baby's prematurity puts her at risk. It's great that she's doing as well as she is, but you have every reason to want to give her the best chance of success. With the combination of the risk of extreme prematurity and mild motor delays your daughter should be evaluated for early intervention to make sure she gets any services to which she is entitled.
Sincerely,
Dr. Warren
Thank You.
-Rose
Dear Rose: Your fiancé's condition is known as situs inversus. Sometimes situs inversus can be associated with significant heart abnormalities. Otherwise, the person with situs inversus may be perfectly healthy, but is at risk for misdiagnosis of medical conditions such as appendicitis which, in the case of situs inversus, causes pain on the left instead of the right.
Situs inversus can be associated with immotile cilia syndrome (also known as Kartagener syndrome or primary ciliary dyskinesia) which is a rare inherited disorder in which patients have chronic sinusitis, and airways disease leading to bronchiectasis. Other than that I didn't find any information regarding inheritance of situs inversus.
Sincerely,
Dr. Warren
If you were told not to expect your niece's brain to grow, brain growth is certainly a good sign. Unquestionably, absence of brain growth is bad. Given the variability of head size and brain size in the normal population, I didn't think the size could be pinpointed accurately enough to make a statement that it is smaller than the expected by 7 weeks. Perhaps this is something that is being done at the center where your niece is being cared for.
Since I have had patients with head sizes below the third percentile (and therefore smaller than the normal range) who had normal intelligence, and I have never had a neurologist talk to me about brain size in reference to any of my patients, I'm not sure how the information is used prognostically, but if the brain is abnormally small, it's certainly one more indication of trouble. If an MRI or CT image shows not only small size but also atrophy of brain tissue, that is even worse.
I hope I haven't confused things further. When I answer e-mail, I have a printout of the e-mail right in front of me. Even then, my answers sometimes lead to more questions.
Sincerely,
Dr. Warren
-CB
Dear CB: I suspect what you're calling Pallid Infantile Syncope is the same thing as Pallid Spells or Pallid Breath-Holding Spells. Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company says the following about Pallid Spells:
A breath-holding spell can be a frightening experience for the parent because the infant becomes lifeless and unresponsive owing to cerebral anoxia at the height of the attack. There are two major types of breath-holding spells: the more common cyanotic form and the pallid form.I hope this is the information you were seeking since I did not find any other reference to Pallid Spells.A cyanotic breath-holding spell is usually predictable and is always provoked by upsetting or scolding an infant. The episode is heralded by a brief, shrill cry followed by forced expiration and apnea. There is rapid onset of generalized cyanosis and a loss of consciousness that may be associated with repeated generalized clonic jerks, opisthotonus, and bradycardia. The interictal EEG is normal. A breath-holding spell can occur repeatedly within a few hours or it can recur sporadically, but it is always stereotyped. Breath-holding spells are rare prior to 6 months of age; they peak at about 2 years of age, and they abate by 5 years of age. The management of breath-holding spells concentrates on the support and reassurance of the parents. Some parents feel that, whatever the physician recommends, they must splash cold water on the face, turn the child upside down, or initiate mouth-to-mouth resuscitation and even cardiopulmonary resuscitation. A thorough examination followed by an explanation of the mechanism of breath-holding spells is reassuring for most parents. The counseling session should emphasize the need for both parents to be consistent and not reinforce the child's behavior after the child recovers from the spell. This may be accomplished by placing the child safely in bed and by refusing to cuddle, play, or hold the child for a given period of time when recovery is complete.
Pallid breath-holding spells are much less common than cyanotic breath-holding spells, but they share several characteristics. Pallid spells are typically initiated by a painful experience, such as falling and striking the head or a sudden startle. The child stops breathing, rapidly loses consciousness, becomes pale and hypotonic, and may have a tonic seizure. Bradycardia with periods of asystole of longer than 2 seconds may be recorded. The interictal EEG is normal. Pallid spells can in some cases be induced spontaneously in the laboratory by ocular compression that produces the oculocardiac reflex by afferent stimulation of the trigeminal nerve and by efferent inhibition of the heart by way of the vagus nerve. This procedure should not be attempted by an inexperienced physician, and appropriate resuscitation equipment should be readily available. Most children respond to conservative measures as outlined for cyanotic spells, but a trial of an anticholinergic, oral atropine sulfate 0.01 mg/kg/24 hr in divided doses with a maximum daily dose of 0.4 mg, which increases the heart rate by blocking the vagus nerve, may be considered in refractory cases. Atropine should not be prescribed during very hot weather as an episode of hyperpyrexia may be initiated.
Sincerely,
Dr. Warren
-Mr. & Mrs. A
Dear Mr. & Mrs. A: If your daughter has a truly imperforate hymen, she should see a pediatric urologist. If there is no opening at all in the hymen, vaginal secretions cannot get out, and therefore have to fill the vaginal vault and uterus. Over a period of time the distention of the vagina and uterus with fluid can be felt as a mass in the abdomen, and may cause bulging of the hymen which will protrude out of the vagina. The pediatric urologist can explain the procedure necessary to correct the problem. If the hymen is not truly imperforate, he can set your mind at ease.
Sincerely,
Dr. Warren
-SD
Dear SD: If you have mild back pain, try rest, ibuprofen, and heat. If you're in a lot of pain, see a chiropractor.
Sincerely,
Dr. Warren
Thank you.
-Frustrated in Ma.
Dear Frustrated: You need to stick with one specialist and have him review all the records and sort it out. After all those tests there really shouldn't be a question about whether or not there is a blockage or what kind of blockage there is, if there is one. If you live in or around Boston, I'd suggest seeing a gastroenterologist affiliated with Harvard Medical School.
Sincerely,
Dr. Warren
Thankyou.
-DA
Dear DA: The normal range extends from the 3rd percentile to the 97th percentile. The 50th percentile has the largest number of kids and could be considered the "average."
| AGE | 10% | 50% | 90% |
| 6 yr. | 43.8 | 46.3 | 48.6 |
| 6˝ yr. | 44.9 | 47.6 | 50.0 |
| 7 yr. | 46.0 | 48.9 | 51.4 |
| 7˝ yr. | 47.2 | 50.0 | 52.7 |
| 8 yr. | 48.5 | 51.2 | 54.0 |
| 8˝ yr. | 49.5 | 52.3 | 55.1 |
| 9 yr. | 50.5 | 53.3 | 56.1 |
| 9˝ yr. | 51.4 | 54.3 | 57.1 |
| 10 yr. | 52.3 | 55.2 | 58.1 |
| 10˝ yr. | 53.3 | 56.0 | 58.9 |
| 11 yr. | 54.3 | 56.8 | 59.8 |
| AGE | 10% | 50% | 90% |
| 6 yr. | 43.5 | 45.6 | 48.1 |
| 6˝ yr. | 44.8 | 46.9 | 49.4 |
| 7 yr. | 46.0 | 48.19 | 50.7 |
| 7˝ yr. | 47.0 | 49.3 | 51.9 |
| 8 yr. | 48.1 | 50.4 | 53.0 |
| 8˝ yr. | 49.0 | 51.4 | 54.1 |
| 9 yr. | 50.0 | 52.3 | 55.3 |
| 9˝ yr. | 50.9 | 53.5 | 56.4 |
| 10 yr. | 51.8 | 54.6 | 57.5 |
| 10˝ yr. | 52.9 | 55.8 | 58.9 |
| 11 yr. | 53.9 | 57.0 | 60.4 |
Sincerely,
Dr. Warren
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