1 September 2003

1. The Facts About Scabies
2. Help Writing a Story
3. Will It Hurt?
4. Blood in Infant's Stool
5. Breast Size
6. Clear Spit-Up
7. Wry Neck
8. Antibiotics for Conjunctivitis?
9. Disclaimer

• Read Questions & Answers in Another Column

The Facts About Scabies

Help!

-MA

Dear MA: The scabetic mite is a human parasite only. It does not live on other animals and is not transmitted to humans by other animals. Scabies spreads by person to person contact only. The mite lays eggs under the infected person's skin. It does not lay eggs outside which could lay dormant. The mite cannot live for any long periods of time off the human body. Its whole life cycle is only 40 days. Clothing, towels, and bed linens in direct contact with an infected person should be disinfected by washing and should be safe to reuse within 48 hours. No additional environmental precautions are useful or necessary.

Sincerely,
Dr. Warren

In the story the child is 2 or 3 years old and lives with his father and sister in a household which, if not filty, is in such a disorder that it becomes unhealthy. The children's paints, for example are left in the sink along with the dishes, ants have invaded the house. The children eat irregularly and do not have regular bedtimes. I am trying to figure out the a ailment that the child might contract. It should be fatal if untreated and have physical symptoms.

Thank you very much.

-E

Dear E: While it would seem that there should be some terrible disease that would automatically derive from the situation you describe, disorganization and lack of cleanliness do not automatically lead to disease. In the scenario you created, you might think of lead poisoning from the paint, but if it was children's paint, it would not have lead in it. In fact, the law would require it to be non-toxic. Ants may be a nuisance, but they don't serve as a source of disease.

Now let's go beyond the basic information you've given me to consider what can arise from neglect and malnutrition. Children fed junk food could develop vitamin deficiency diseases. Scurvy, caused by vitamin C deficiency, is so rare in this country that it may go unrecognized and be misdiagnosed by physicians. Scurvy does take a long time to develop, and without secondary complications and some poetic license, it isn't fatal.

Any variety of infectious diseases could be neglected until such time as they became serious. Ordinary colds can cause coughs, but so can tuberculosis and pneumonia. Asthma may cause coughing and progress to a serious attack if not recognized and treated.

Hungry, unfed, unsupervised children might forage for food and pick up food poisoning, or even eat some poison. This unkempt house could have rats which could bite a child leading to skin infections or rabies (if the rats are rabid). There could be rat poison which a hungry, unsupervised child could eat and then develop bleeding from the poison. (Rat poison is an anticoagulant).

Think about the direction you'd like to go and then ask me more specific questions once you've decided.

Sincerely,
Dr. Warren

1. Will I feel ANYTHING during surgury?
2. How many stiches will it take?
3. How long will it take to heal? Does it hurt a lot? Are the stiches removed later?

-RT

Dear RT: I assume you will have the surgery done with local anesthesia. Once the local is done, you will feel pressure, but you will not feel any sharp sensations or pain. If you are very anxious about the local anesthesia, you can ask the surgeon about numbing the area with EMLA cream prior to injecting the local anesthetic. It takes time for EMLA to work and so could add about an hour to the procedure.

A wound 1 cm in length would require 3 to 5 stitches to close depending on how cosmetic a repair was being done. That does not count subcutaneous stitches used to close the tissue underneath the skin. Healing of the skin usually is superficially complete within a week although complete healing underneath takes weeks. The stitches under the skin would not be removed, but the skin closures would have to be removed. If there is good closure of the wound underneath, the surgeon could close the skin with Dermabond (glue) and you won't have to deal with stitches in the skin.

The perception of pain is a very individual thing and is greatly enhanced by fear while it is decreased by relaxation. The procedure you ask about should cause minimal pain at most.

Sincerely,
Dr. Warren

-AS

Dear AS: Blood in an infants stool could result from a variety of things from formula sensitivity to an anal fissure, to juvenile polyps. The first thing I would generally try in an infant who seemed well would be a hypoallergenic formula such as Alimentum or Nutramigen. If there was no improvement within 1 week, I would have the child see a pediatric gastroenterologist.

Sincerely,
Dr. Warren

-LS

Dear LS: Exercises that build up the pectoral muscles of the chest, such as pushups and bench presses may help your breasts to stand out more. There are no exercises which can affect breast size. Neither are there any foods which can affect breast size, although, since breasts do have a fair amount of fatty tissue in them, weight gain generally affects breast size.

Sincerely,
Dr. Warren

-PB

Dear PB: After milk is digested, it separates into a liquid and solid component. When infants spit up small amounts, generally only the liquid part come out. This will be mixed with digestive juices and mucus which lines the stomach. Since most infants spit up to some degree, it does not sound like you are describing anything abnormal, but if your son has a chronic cough as a result of the spitting, or is gaining weight poorly, or is very irritable, then your son will need further evaluation by his pediatrician.

Sincerely,
Dr. Warren

-DG

Dear DG: How quickly muscle spasms in the neck resolve depends on how severe they are and if there is any underlying cause. I often find that severe neck muscle spasms (known as wry neck or torticollis) respond better to a muscle relaxant like valium than to pain medication. In your son's case, since he is being treated for a throat infection, if he is not significantly better after 24-48 hours on antibiotics, I would be concerned that a secondary infection in the lymph nodes in the neck or an abscess in or behind the throat might be contributing to the severe neck pain. Therefore, I would recommend a thorough reevaluation by his pediatrician if your son is still sick and in pain.

Sincerely,
Dr. Warren

We are concerned that this pediatrian is practicing medicine on our infant child through the nurse via telephone. Do you think this is reasonable?

Thanks.

-Y

Dear Y: I feel like I'm missing some information. If your pediatrician's partner treated your son for conjunctivitis, why did you want to see your pediatrician 4 days later? Without knowing that, I don't know what might have entered into your pediatrician's decision to treat with antibiotics. Conjunctivitis is often associated with ear infections. Your pediatrician may have suspected an ear infection based on the fact that your son had conjunctivitis coupled with whatever reason you had for wanting an appointment to see your pediatrician.

Whether or not that was reasonable depends on what factors went into making that decision. I would need to know why your pediatrician thought an antibiotic was indicated, which, by the way, is information which should have been conveyed to you. I would also need to know why your pediatrician couldn't see your son or felt it was not necessary to see your son. As a matter of policy, I almost never prescribe antibiotics over the phone. This policy is based on two principles.

1. I want to know how sick a child is and what I'm treating before prescribing an antibiotic. That way I can avoid masking or inadequately treating a serious condition, and I can document the child's condition for appropriate follow up.
2. I want to avoid any unnecessary antibiotic prescriptions because they risk unwarranted exposure to potential side effects and they unnecessarily add to the burden of antibiotic resistant organisms in our environment.

Sincerely,
Dr. Warren

The nurse told us to begin using Amoxicylin because the doctor said that he thinks the infection has spread to areas other than his eyes. She advised to continue with the sulfacedimide.

This pediatrician (as well as many pediatricians in the South Orange County area) use nurses to return phone calls even if you specifically ask to speak with the doctor. We wanted to know the reason for prescribing antibiotics. Hopefully, Amoxycillan won't harm the 8-month-old. Some doctors down here use nurse practitioners to do everything and the doctor doesn't even see the patient. When the patient calls to make an appointment, the office clerk says, "The doctor is not available for the next 10 days, but you can see the NP today". This is often done when the patient has an HMO but, in any case, I view an NP practicing medicine as improper.

I hope this answers your questions.

Thanks.

-Y

Dear Y: There is always some risk of adverse reaction to any medication, but amoxicillin is a pretty safe medication with mild side effects. As I said, ear infections may accompany conjunctivitis, but that cannot be diagnosed without an examination, and is not even highly suspected just because the child starts coughing. Overall, the explanation that "the doctor thinks the infection has spread to areas other than his eyes" sounds pretty lame.

It upsets me when I hear that a different standard of care is applied to patients based on their insurance. I have grappled with the limitations that some insurance plans place on the care I can give. Beyond that, even though I realize that a pediatric practice is a business and the physician must earn his living from it in order for the practice to keep running, the basis for all practice policies should still be what constitutes good medical care.

I'm a New Yorker. I've lived in New York all my life and went to school here as well. I don't know any physicians outside my immediate area.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

ask Dr. Warren a question?!?