22 March 2004

1. Safety of MMR Vaccine
2. Sudden Increase in Spitting Up
3. Feeding Problem
4. Viral Rash
5. Headaches, Bruises
6. Getting Rid of Head Lice
7. Shakes When Excited, Overweight
8. Refuses to Sleep Through the Night!
9. Disclaimer

• Read Questions & Answers in Another Column

Safety of MMR Vaccine

What are the risks associated with this vaccine and what are the dangers of NOT innoculating the child with the MMR vaccine?

Many thanks.

-AC

Dear AC: The following information comes directly form Vaccine Information Statements published by the CDC. This information should be provided by pediatricians (in the USA) to the parents prior to administering vaccines for which VISs are available.

Measles, mumps, and rubella are serious diseases.

Measles

• Measles virus causes rash, cough, runny nose, eye irritation, and fever.
• It can lead to ear infection, pneumonia, seizures (jerking and staring), brain damage, and death.

Mumps

• Mumps virus causes fever, headache, and swollen glands.
• It can lead to deafness, meningitis (infection of the brain and spinal cord covering), painful swelling of the testicles or ovaries, and, rarely, death.

Rubella (German Measles)

• Rubella virus causes rash, mild fever, and arthritis (mostly in women).
• If a woman gets rubella while she is pregnant, she could have a miscarriage or her baby could be born with serious birth defects.

You or your child could catch these diseases by being around someone who has them. They spread from person to person through the air. Measles, mumps, and rubella (MMR) vaccine can prevent these diseases. Most children who get their MMR shots will not get these diseases. Many more children would get them if we stopped vaccinating.

A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. The risk of MMR vaccine causing serious harm, or death, is extremely small. Getting MMR vaccine is much safer than getting any of these three diseases. Most people who get MMR vaccine do not have any problems with it.

Mild Problems

• Fever (up to 1 person out of 6)
• Mild rash (about 1 person out of 20)
• Swelling of glands in the cheeks or neck (rare)

If these problems occur, it is usually within 7-12 days after the shot. They occur less often after the second dose.

Moderate Problems

• Seizure (jerking or staring) caused by fever (about 1 out of 3,000 doses)
• Temporary pain and stiffness in the joints, mostly in teenage or adult women (up to 1 out of 4)
• Temporary low platelet count, which can cause a bleeding disorder (about 1 out of 30,000 doses)

Severe Problems (Very Rare)

• Serious allergic reaction (less than 1 out of a million doses)
• Several other severe problems have been known to occur after a child gets MMR vaccine. But this happens so rarely, experts cannot be sure whether they are caused by the vaccine or not. These include:
  • Deafness
  • Long-term seizures, coma, or lowered consciousness
  • Permanent brain damage

Sincerely,
Dr. Warren

-JCS

Dear JCS: It is possible that an increase in spitting could be a result of overeating, but unless you can say that the increase in spitting corresponds to an increase in eating, that would be a difficult conclusion to draw. It is unusual for an infant to first start having a spitting problem at 10 months. All infants spit up, some more than others, but this generally starts to decrease as infants spend more time upright. Toddlers don't walk around spitting up.

On the other hand, if your child is happy, growing well, and eating well, since all infants spit up, there may be no reason to be concerned. Only you can decide if the amount of spitting is an issue. I can understand your not liking the mess, but that alone wouldn't make it a cause for concern. If you are certain that there has been a significant increase in your son's spitting up, you should discuss it with your pediatrician.

Sincerely,
Dr. Warren

R. was born 3½ weeks early, at 5 lbs. and 17 inches, after a pregnancy that developed problems in the 26th week (I was on intravenous turbutaline(?)) from weeks 26 through 36 of my pregnancy with her, and delivered 3 days after ending medication). My weight gain was only 18 lbs. with this pregnancy and not for lack of eating. (My second child was born 3 years later in a full-term, non-complicated pregnancy at 7 lbs. 11 oz. I gained 30 lbs. in this pregnancy. My son is a robust eater.)

From Day 1, R. has been what I would call a non-consuming child. She would not suck (bottle-feeding) , and, once she began to do so, her consumption was low. She was monitored for weight gain more frequently than a standard basis. We were given goals for increase of her intake, which were difficult to impossible to achieve.

Once on solid food, R. exhibited preferences for very few foods. Her repertoire of foods she will eat has changed very little over the years. She prefers, soft, bland food. Her meals almost exclusively consist of plain pasta dipped in butter, American cheese, macaroni and cheese, bagels with cream cheese, waffles with syrup and Frosted Cheerios. She will eat broccoli, but only the soft parts. She will also eat white niblet corn. R. loves milk.

R. does not like chicken, hamburger, hot dogs, pizza or most of the foods that the majority of children prefer.

When asked to try a new food, I can see that her mind is already made up before the food touches her lips. Her reaction is varying degrees of dislike. My husband and I have fruitlessly tried to suggest to R. that her reaction is that this is an unfamiliar, new taste rather than one that is one of distaste.

At her 6-year check-up, R. weighed in at 32 lbs. (1 lb. weight gain in a year) and measured 39 inches (1½ inch growth). Our pediatrician and I simultaneously brought up the topic of giving R. a nutritional supplement. Since then, over the last 6 months R. has been drinking a 250 calorie can of Ensure daily and will be returning for a weight check in several weeks.

In other areas of development, R. has been right on target. She walked at 12 months, was verbally advanced in her toddler years and is bringing home top report card ratings from school. R.'s personality is warm and loving, although she frustrates quickly if what she is trying to achieve does not come easily and prefers to be a leader rather than a follower.

I have briefly spoken with a nutritionist who specializes in eating disorders and has dealt with modifying children's eating behavior about potentially seeing R.. Although this was not suggested by our pediatrician, he feels it would not be a detrimental step.

What is your view on the future course we should be taking with R.?

-KW

Dear KW: Your experience is not as unusual as you may think. Since your daughter is eating a variety of nutritious foods, I would not dwell on the fact that her repertoire is limited. If she is taking the nutritional supplement willingly without a decrease in her food intake, great. I see no problem in seeing a specialist who deals with children's eating problems, but I'm reluctant to call your daughter's situation an eating disorder which carries the connotations associated with anorexia nervosa and bulimia. If the specialist is able to provide techniques that will help introduce new tastes and textures of food to your daughter, that's wonderful, but in my experience, it's important not to cross the line where encouraging children to eat and providing them opportunities to try new things becomes a battle. Parental anxiety at mealtime gets across to the child and makes mealtime unpleasant. Unpleasant mealtimes associated with pressure to eat can often result in a child eating less. Please read my article, Nutrition Without Tears.

Sincerely,
Dr. Warren

-TK

Dear TK: The rash associated with virus infections is called an exanthem. Certain viruses cause typical exanthems which distinguish them from others. Chicken pox looks like chicken pox. Measles can be diagnosed by the typical rash and other findings in combination. But many viruses have nonspecific exanthems, and although the symptoms, other findings, and rash, may clearly suggest a virus infection, the specific virus cannot be named just by looking at the patient. Most of these illnesses pass within a few days and have no specific treatment, so that viral testing, which takes several weeks, is not indicated.

Hand, Foot, and Mouth disease is caused by coxsackie virus. It has no relationship to the cattle disease Hoof and Mouth disease and is not related to being with horses.

Sincerely,
Dr. Warren

-Mrs. S

Dear Mrs. S: Since your son has had a complete evaluation for headaches and no cause has been found it's time to focus on treatment. Some people are plagued with headaches most of their lives. If there is a family history of migraines, there is a significant possibility that your son has migraines. You should consult a pediatric neurologist since they deal regularly with headaches and have the most experience with the medications currently available.

If your son is developing bruises on his legs and no place else, if these can't be accounted for by injuries (for example related to a sport or activity) a coagulation workup may be useful, but if this is normal, you could be describing Henoch Schonlein Purpura. Henoch Schonlein Purpura is generally a self limited vasculitis (inflammation of blood vessels) sometimes related to virus infections, allergic reactions, or unknown causes. That would make it unlikely to be related to a lifelong history of headaches. Vasculitis associated with lupus or JRA could be associated with long-term symptoms including headaches. Evaluation by a pediatric rheumatologist might help.

Penis size does not increase significantly during childhood until puberty. I am not aware of any standard for penis size based on height. Unless your son's penis is unusually small compared to other children's (which would have been a lifelong issue), I see no relationship of his penis size to any other global problems. With the information you have given me, I'm not sure that there is any reason to be concerned about the size of his genitals.

Sincerely,
Dr. Warren

Thank you.

-DJB

Dear DJB: If your kids get lice that don't respond to treatment with Rid or Nix, you will need a prescription for Lindane shampoo; however, there is no such thing as a treatment that will get rid of lice permanently. If the last time your daughter had lice was in November and she was free of lice until March, the treatment worked, but she got reinfested. There is no way to prevent catching lice. The treatments kill the lice but don't create any kind of barrier or produce immunity to prevent future lice. Care not to use other children's hats, brushes, or combs, or anything else that comes in contact with the scalp can help prevent spread, but there are no guarantees.

Sincerely,
Dr. Warren

My granddaughter is also gaining a lot of weight, all in her stomach. It's hard to find clothes to fit her because of her stomach.

Any advice you can give will be greatly appreciated.

Sincerely,
-Dianne

Dear Dianne: Your granddaughter's reaction to excitement is unusual for a 10 year old. I've seen much younger kids react that way. But unless it's presenting a problem for your granddaughter, it doesn't indicate anything wrong and requires no intervention.

Excess weight gain is a difficult problem ant any age. You can read my advice about childhood obesity at http://www.mindspring.com/~drwarren/obesity.htm. Eating and overeating are complex problems that often include psychological components. Unless you are involved in feeding the child or the child's mother is amenable to accepting unsolicited advice, I would be cautious about interfering.

Sincerely,
Dr. Warren

We are still on a timely eating pattern of 3 solid meals a day for our son, and attempt the same nap periods daily. We are unfortunately at a loss of what to do next. Can you help?

Thanks

-T,T, & B

Thanks.

Dear T,T, & B: Your problem is a difficult one because there is no quick, simple, or pleasant solution. Every parent who has ever found it impossible to allow a child to cry has a good reason for intervening. And I assure that babies' cries were designed to be impossible to ignore in order to assure the survival of the species. The problem is that your son doesn't know the difference between what he needs for survival and what he demands because he wants it or is used to getting it as a way to calm himself or put himself to sleep.

No 10 month old needs to nurse every 2 hours. In fact, no 10 month old needs to nurse in the middle of the night. Your son is a trained-night feeder. He has learned to use feeding to put himself to sleep. It is the only way he knows. He will not learn another way until he stops getting fed to put himself to sleep. The 3 meal a day policy does nothing to aid in this problem because it doesn't deal with his use of the breast to comfort himself to sleep. Your son's constant night feedings have nothing to do with eating habits. If you want to continue nursing, you would be better off offering your breast during the day.

I am not an advocate of "let the child cry until he falls asleep," although sometimes that becomes necessary because going in to some children makes them more hysterical. I consider it reasonable to go in at intervals to check your baby and tell him calmly that everything is okay and he has to go to sleep. If minimal intervention calms the child, that's fine, but children should not be taken out of the crib and nursed or rocked to sleep unless you desire to continue doing that. In your son's case, you must stop nursing him to sleep unless you plan to continue it indefinitely. If he stands up, keep putting him down. He has learned to stand up because your response has made it clear that he will get what he wants. Just as he started to calm without intervention before he figured out to stand up and demand attention, he will learn to stop standing up when he sees that he will ALWAYS be put back down to sleep. Persistence is the key. Your son cannot learn a new sleep pattern if your approach is inconsistent.

How long will it take? I don't know. Kids who have been tried with several methods and failed take longer because they have already learned to be persistent in their demands. If you set an arbitrary length of time after which you plan to return to the old ways if you don't meet success, you will teach your son your level of tolerance and he will learn to exceed it to get what he wants. Once you decide to stop nursing during the night, no matter what else you do, do not go back to it.

Sincerely,
Dr. Warren

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