11 August 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
-Chana
Dear Chana: There is no cure for migraine, but there are treatments which can prevent and alleviate symptoms. Dietary management such as avoiding chocolate, hard cheese like cheddar, and caffeine, can help prevent migraines. An antihistamine called cyproheptadine (Periactin) can also sometimes prevent migraines.
Children's migraines can be alleviated by acetaminophen (Tylenol) or ibuprofen (Motrin, Advil). More severe migraines may require prescription medications. Some medications used for treating adults are not yet approved for young children.
Sincerely,
Dr. Warren
When my son went off meds after reflux, I started a crying log to show pediatrician (cried 30-60 times a day) for at least 6-8 weeks. Doctor thought he would grow out of it. (Perhaps because test showed only episode of moderate reflux - volume of 0.7 mls in 60 min?
Biopsy for celiac disease was negative (after 2 month return to gluten diet) but gastro did see redness in esophagus. At post-biopsy meeting she recommended only that we keep him on gluten and dairy-free diet. Allergist seemed surprised that gastro did not persue reflux angle.
Has had no stool or urine analysis. (no occult blood, etc. aside from parasite test - results not back)
CBC counts were mostly within normal range last August.
HCT slightly low at .348 L/L. Monos slightly high at .88 X10^9/L
IGE low at 20.16 G/L (Allergist doesn't feel therefore that food allergies are problem)
IGA was 0.17 G/L
I have always been concerned by how much he drinks. (I have mentioned it to every doctor I have seen.) He seems to panic without it and can drink 12 ounces in minutes. (Could be be mildly hypoglycemic? "Allergic-type reactions" seems to happen late morning and mid-afternoon. Abdominal problems started long before he drank juice. )
Other relevant info:
No one has recommended an immunologist. I know nothing about disaccharidase deficiencies but will look it up. Does pancreatic insufficiency make any sense? I have read an enormous amount but the information is very technical and it's hard to know if it relates to my son. While it was productive for my neurologist to suggest I learn all I can about NF, it can also be quite frightening and I feel that if I could rule out the link between NF and his problems (by finding a likely cause), I would be able to rest easier.
Any suggestions you have would be enormously helpful. I really appreciate the time you have given (it seems extraordinary really!)
-Katherine
Dear Katherine: You have raised even more questions for me than I have answers for.
Even if the amount of reflux is small, if it results in esophagitis as suggested by the redness seen in the esophagus on endoscopy, then your son is bound to feel better if he is treated for the reflux. So why isn't he on medication which appeared to make him feel better when he was on it?
If the stool is unusual, a stool analysis might help pinpoint why. For example, it could point toward evidence of malabsorption of specific nutrients. A urinalysis might be important to check for diabetes.
Drinking large quantities can be a symptom of diabetes. Abdominal pain can be seen with poorly controlled diabetes mellitus. Diabetes insipidus causes water loss through an inability to concentrate the urine. It does not cause abdominal pain. Given that your son has NF, it is possible that his pituitary gland has been affected causing diabetes insipidus.
If the MRI is only of the head, it cannot tell you anything about whether or not NF is affecting your son's intestines. I do not have the personal experience with NF to tell you if an MRI of the abdomen would be useful. It was not mentioned in any of the articles I referred to in answering your initial question.
Large, foul smelling, floating, fatty stools could result from pancreatic insufficiency, but it would not cause abdominal pain.
Sincerely,
Dr. Warren
-SMS
Dear SMS: I don't know what you mean when you say cirrhosis with "3 inches of outgrowth." When discussing serious medical problems, unless a person is simply seeking general information, I need much more information about the patient and clear, specific questions.
Asthma increases a patient's risk for surgery. If the asthma is unstable, it may not be possible to give the patient general anesthesia. If the asthma can be maintained under good control so that management of the patient's airway and breathing will not be a problem during the surgery, asthma should not prevent a liver transplant.
Management of the patient after transplant may be complicated by the asthma as well. I am not familiar with the drug regimen used to prevent rejection of the liver transplant. You would have to check with the transplant surgeons to see if the patient's asthma treatment would jeopardize a transplant or if the post transplant treatment would aggravate the asthma.
Sincerely,
Dr. Warren
My father is suffering from Post Necrotic Cirrhosis of Liver plus ascetic since January’94. He is also having Bronchial Asthma since 1956. He is also having Prostate Grade II enlargement since 1991. When he went through check up an evidence of an irregular mass of size 8.3 x 7.6 x 5.7 cm. is diagnosed in the segment VII of liver. He is having urine retention problem for last 6-8 years and recently after intake of the medicines he has less control before urine pass initiates. Because of this frequent urination he is having sleepless nights. He has also developed body itching problem in last 2 months.
Doctors here in India have suggested No Liver Transplant because of Asthma as anesthesia cannot be given. Liver Biopsy is also not done because of the objection taken by some doctors in the institute. The malignancy of the irregular mass is not yet proved.
Please suggest any treatment at the earliest as it is very urgent. And also let us know whether any treatment can be done in India/Abroad. Kindly suggest the nutrition + medicines and oblige.
Sir, if possible please send any communication link of the specialist in LIVER CIRRHOSIS, as it is very very URGENT.
Kindly respond on my mailing address given herein.
Thanking you.
Yours faithfully,
-SMS
Dear SMS: If your father has liver cancer, I don't know of any treatment besides surgery. While he may be a candidate for chemotherapy or radiation treatments if he cannot tolerate surgery, you need a diagnosis before such treatment can be initiated and then would have to consult an oncologist. If your father's condition is entirely secondary to cirrhosis if he goes into liver failure, dietary management can help prolong his life, but there are no cures for liver failure other than transplant. Asthma is not a contraindication to essential surgery, but if your father has severe asthma, he may be at high risk for death during or after surgery. Unfortunately, livers are not available for everyone who needs them, so to get a transplant, a person has to be put on a list. The person's position on the list is determined by the severity of his liver disease, and the chances of a successful transplant. If your father is old and in poor health, he may not meet the criteria to have a transplant because doing one will not significantly prolong his life.
I cannot tell you if his treatment would be any different in another country. I am happy to answer questions via e-mail and on the Web, but as a pediatrician in practice in the USA, I have no means of providing my readers with referrals to other physicians. If you have the means to get medical care in another country, I would suggest obtaining a copy of your father's medical record to be reviewed by such physicians before making a trip. It is possible that your father's physicians are correct that he is not a candidate for heroics, in which case, the time has come to deal with your father's fate.
Sincerely,
Dr. Warren
-AP
Dear AP: Your daughter's eyes could be crossed and she could be falling because of a vision problem. She could also have these symptoms from a neurological problem. She needs to see a doctor. If it's still a few weeks until her eye exam, make an appointment with her pediatrician.
Sincerely,
Dr. Warren
-AP
Dear AP: Crossed eyes may occur in a child who is farsighted and therefore has to work so hard to focus on close items that the eyes cross. A muscle imbalance in the eyes may cause eyes to cross. These conditions don't generally cause a child to fall which is why I suggested seeing a neurologist. Eye movement is controlled by the brain. Sometimes crossed eyes can occur with a variety of neurological problems including brain injuries, cerebral palsy, and even brain tumors.
Sincerely,
Dr. Warren
-M & T
Dear M & T: Honey is not poisonous to babies, but it could have botulism spores which could cause infant botulism. Honey should not be given to infants under two years of age.
Sincerely,
Dr. Warren
I was told by my family doctor that if my son's CBC count was within the normal range and his growth was on the charts that he could not be suffering from a malasorptive disorder.
My situation is now that I have a family doctor who is sympathetic but feels I need to return to gastroenterologist (appointment for May).
I have a neurologist who told me that he would do a search to see if there is a connection between gastro problems and NF and came up empty handed. (I probably have 100 pages of abstracts, articles etc.- most of which i don't understand.)
I will see a very good gastroenterologist who is swamped, overloaded and who will have half an hour with us and then we will have to wait 4 more months for another appointment (this is health care in Canada I guess - am very grateful for it but this might also explain why so few tests have been done) In spite of the redness on the biopsy and knowledge of my son's previous problems with reflux, she did not recommend we return to meds (although she had told us that the one-hour reflux test was not an adequate test).
We are going around and around in circles. All I know is that it is not cystic fibrosis and likely not celiac disease. I am spending my nights reading medical books, and I am very angry that more has not been done. I am also very worried.
I'm sorry to have vented - it was not my intention but hopefully this will answer some questions.
If I could ask you only one more question it would be: If you were me, what tests would you insist on and who should requisition them? (ie. diabetes, stools, I don't mean tests specific to NF)
I very much appreciate your help - I really need a game plan.
Sincerely,
-Katherine
Dear Katherine: If your son's growth is normal, it is unlikely that he has any significant type of malabsorption. In addition, malabsorption syndromes don't generally cause abdominal pain. However, if your son has the inability to digest certain sugars, that would result in their not being fully absorbed. The resulting sugar load in the lower intestines could cause diarrhea, and the bacterial fermentation of the sugars in the lower gut would cause gas and cramping. That's how lactose intolerance causes it's symptoms. Other disaccharides (complex sugars) must be digested (broken down to simple sugars) before they can be absorbed. If they're not, you get the same symptoms as lactose intolerance. Excessive sugar loads, as occurs when a child drinks too much juice, overwhelms the child's ability to digest the fructose, and the same thing occurs. I don't see how a CBC would have any bearing on the malabsorption picture. A stool for reducing substances and pH could help to determine if there is carbohydrate malabsorption.
Because of your son's excessive drinking, he must have at least a minimal evaluation for diabetes mellitus and diabetes insipidus. This requires a urinalysis and blood for electrolytes and glucose. To test for diabetes insipidus your doctor must test your son's ability to concentrate his urine after water deprivation. This should be done by measuring urine and plasma osmolality before and after a six hour period of not drinking. The most valuable measurements are the urine/plasma osmolal ratio and plasma vasopressin concentrations. If results support the diagnosis, DDAVP should be given to test renal concentrating ability.
Since I'm not there, and I haven't seen your son or reviewed his record, I'm reluctant to say, "If I were treating him I would....," but I just don't understand why he isn't on medication for reflux.
Sincerely,
Dr. Warren
P.S.: In the USA, we have a myriad of different insurance plans. While many of them require approval of the PCP (primary care provider) for any diagnostic procedures to be covered, when a specialist wants a test, the specialist orders it.
-NO
Dear NO: Your description of your daughter's episodes of "not breathing" sound like classic breath holding spells. They all start with a cry. Typically, the child is so upset that the mouth is held open as if to cry, but no sound comes out. If the breath is held long enough, the child turns blue. If held even longer, there may be a few seizure like jerks and the child will go limp. Once the child becomes unconscious, he can no longer hold his breath and normal respirations resume. The child who holds his breath long enough to pass out will usually be tired afterward and may immediately sleep. The child who catches his breath before passing out will generally proceed to a full-blown fit of screaming. Breath holding spells that proceed to unconsciousness are frightening, but not dangerous.
Your daughter's breath holding spells are provoked by crying. They are not specific to the nature of what causes her to cry. They are not a direct result of head injury. If a helmet will prevent your daughter from striking her head in such a way as to provoke a screaming fit, it may help. But if the fall will result in such a cry as to cause a breath holding spell anyway, wearing a helmet will not make a difference.
Sincerely,
Dr. Warren
At this point, my question is: What else can his parents do? Where else can they turn for answers? Are there specialists they should be seeing?
-CC
Dear CC: A low platelet count is called thrombocytopenia. The bruising which results from thrombocytopenia is called purpura. When the cause can't be found, it is called idiopathic thrombocytopenic purpura (ITP). Often ITP turns out to an autoimmune disorder where the patient has produced antibodies to the platelets. This condition is generally evaluated and treated by a hematologist. When it doesn't respond to medical management, a splenectomy may be necessary.
Sincerely,
Dr. Warren
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