Ask Dr. Warren ~ The Questions & Their Answers

5 April 2004

  1. Peeling Hands & Feet
  2. What Age Dental Care?
  3. Bronchiolitis vs. Asthma
  4. Weight Loss During Illness
  5. Pectus Excavatum
  6. Getting Baby Out of Parents' Bed
  7. Nursing, Fluoride, and Iron Supplements
  8. Dealing with a Picky Eater
  9. Disclaimer
Disclaimer

Dear Readers:
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.

Sincerely,
Dr. Warren

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Peeling Hands & Feet

Dear Dr. Warren: This afternoon after my 4 year old grandson finished his bath, I noticed him picking at his feet. At that point, I looked and saw that his feet both were badly peeling on the soles and when I checked the palms of his hands, they were in the same condition as the feet. I checked out the hands and feet of his brother and sister and their skin was entirely normal. Last night he repeatedly rubbed his eyes and said they hurt. He also complained of leg pain. I thought perhaps the leg pain was from playing hard that day; however, when he got up this morning he began rubbing his eyes and said again that they hurt. He also complained of leg pain again this morning after a full night of sleep. His cousin was hospitalized for a couple of days and the parents are awaiting blood results (he had blood in his urine and that was his only symptom). The doctors suspect a strep infection in his case and he received several rounds of antibiotic while in the hospital. When I saw the peeling of my grandson's hands and feet, I became quite concerned. His parents, unfortunately do not share that same feeling. Could you let me know what could cause the conditions I have described above? His mother had toxic shock when she was about 17 years of age. Her hands peeled. That fact has contributed to my concern. Also, last week, while on a trek with his grandfather, mother, and baby brother, to a small stream in the woods behind our house, when he came inside, I noticed a spot of blood on the back of his neck just at the bottom right of his hairline. He appeared to have been stuck or something, but no one knew what had happened. Don't know if there is any correlation, just needed to check.

-JG

Dear JG: Peeling hands and feet may be seen with strep infections including scarlet fever, Kawasaki syndrome, toxic shock, eczema, severe sweating, virus infections, allergic reactions, contact dermatitis. I generally do a throat culture on kids I see with peeling hands or feet unless the cause is clearly something else.

A spot of blood on the neck by the hairline in a child with no history of injury who was walking in the woods is most likely a tick bite. If the tick didn't remain attached, it wouldn't have been attached long enough to cause any disease. I doubt there is any relation to the rash.

Sincerely,
Dr. Warren

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What Age Dental Care?

Dr. Warren: I am currently writing an article on a baby's first year and my copy-editor wants me to include dental information from a source other than a dental association. So my question is, at what age should a child go to the dentist for the first time? The ADA recommends by age 1. Is this true?

Thank you so much for your time.

-KJ

Dear KJ: If the American Academy of Pediatrics has ever made a policy statement regarding dental care, I am not aware of it. I would venture to say that most of my patients do not see a dentist in the first year of life and many don't see a dentist until they're three. Many infants don't have any teeth at one year of age. On the other hand, any infant who has teeth and nurses his bottle or sleeps with a bottle is at risk for developing nursing bottle carries (bottle rot). If this is the case, the tooth damage will be well established before two years of age, so it would make sense to start dental care early.

Sincerely,
Dr. Warren

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Bronchiolitis vs. Asthma

Dear Dr. Warren: My son is 7½ months old. He had bronchiolitis in December which was treated with albuterol orally. Recently he had bronchiolitis again. This time he was treated with a nebulizer. He was diagnosed by a nurse practitioner who said it could be bronchiolitis or asthma. We'd have to see. During this second episode we were on vacation and visited the emergency room at one point because I was worried that he was still coughing a lot at night. The doctors there said he was okay and to continue the nebulizer. They did a chest x-ray and said it was normal. When we arrived home, the hospital called twice to remind us to follow up with our pediatrician and also to say that there was a spot on his x-ray and they were just checking up. What could that spot be? It's been 3 weeks now. He's not coughing but still sounds congested at times. The nurse practitioner said his lungs were clear but I'm still worried. When will we know if it is asthma or not? Should I have them send the x-ray or just do a new one? Thanks

-JD

Dear JD: Bronchiolitis is a respiratory infection in infants, usually caused by RSV. Infants who have bronchiolitis wheeze. Most infants don't have several bouts of bronchiolitis in a short time. That is why the doctor mentioned that your son could have asthma. If your son has recurrent episodes of wheezing, then it is likely that he has asthma. Time will tell. For more information about asthma read my article What is Asthma? and other articles about asthma which are all listed at www.mindspring.com/~drwarren/.

I won't try to guess what the spot on your son's lung is. It is most likely related to the infection. The doctor who called you should have provided you with more information. You should have both a copy of the x-ray and the radiologist's reading of the x-ray sent to your pediatrician. Your pediatrician can then determine the need for a follow up x-ray.

Sincerely,
Dr. Warren

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Weight Loss During Illness

Dear Dr. Warren: We are parents of a 22 month old boy and our doctor told us he is failure to thrive. In Jan. we got his wt. up to just below the 25th percentile. A month later he became ill with some kind of virus infection causing him to run high temps, and lasted a week. During that time he lost three lb's. putting his wt. to drop off the curve. Our Question is would that illness cause him to loose that amount of wt. in that amount of time and how long does it take to get him to the point that he is no longer classified as Social Failure to Thrive?

-Susan, a Concerned Parent

Dear Susan: Children who are very ill can sometimes lose a significant amount of weight because of loss of appetite during the illness. It could take a couple of months to regain the weight lost. If your child's weight was previously on the 25th percentile and he is eating well now and otherwise healthy, he will regain the weight. Don't get hung up on his percentile immediately after his illness.

Sincerely,
Dr. Warren

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Pectus Excavatum

Dear Dr. Warren: My daughter has inherited pectoral excavatum from her dad. Her pediatrician tells me that her case is very mild and should not be surgically corrected. Her dad's had to be corrected because of a heart condition. Her chest really seems sunk in to me and I wonder if her heart will be able to grow? She doesn't seem to be bothered by it as much as I am. She also has been squatting for about two weeks and I know that that too is a sign of a heart condition. Of course, this may be something that she has just learned to do. We will be going to her doctor Thursday for a checkup but I wondered what you had to say about the pectoral excavatum. Is this a rare thing and how have other children developed as they have grown? I asked my husband's cardiologist about this condition being inherited and he told me that it was virtually impossible. Well, I guess we have achieved the impossible. I would like to know what you think about the condition.

Thank you for your information.

-SD

Dear SD: Pectus excavatum ( a sunken in shape of the chest) is certainly an inherited trait. It is also fairly common. On the other hand, a severe enough pectus excavatum to compromise cardiac function and require surgical correction is rare. I'm sure your husband's cardiologist was referring to his experience that even though your husband's pectus affected his heart and required correction, this happens so rarely as to not be likely to affect a second family member.

Squatting is seen with a complex congenital cardiac abnormality called Tetralogy of Fallot. It has nothing to do with pectus excavatum.

In my 20+ years as a pediatrician I've seen plenty of pectus excavatum, but I've only seen one patient who required surgical correction. If your pediatrician says your daughter is okay, don't worry about the fact that she has pectus excavatum.

Sincerely,
Dr. Warren

Dear Readers: In answering SD, I have assumed that her pediatrician has correctly assessed the degree of her daughter's pectus excavatum deformity; however, based on past controversy on this web site regarding pectus excavatum, it wouldn't surprise me if I were called to task for this assumption by some of my readers who have had a bad experience with their doctors regarding their pectus excavatum. Please check the following letters for more discussion:
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Getting Baby Out of Parents' Bed

Dear Dr. Warren: I made the mistake of allowing my daughter to sleep in the bed with my husband and me when she came home from the hospital. She is now 6 months old and will not sleep in her crib at all. What do I do?

-AM

Dear AM: Your daughter is used to sleeping in your bed. She won't get used to sleeping in her crib unless she experiences it. She's not going to experience it and get used to it unless you keep her in her crib in spite of her protests. She doesn't know it's okay to sleep there, but you do. So if that's what you want, put her in her crib, do what you can to soothe her, and don't bring her back to your bed or you'll prolong the agony. Don't feel guilty about your choice. Most people prefer not to have their kids in their bed, and I for one, don't recommend having babies sleep in their parents' beds. Please read my article Helping Your Child to Sleep Through the Night.

Sincerely,
Dr. Warren

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Nursing, Fluoride, and Iron Supplements

Dear Dr. Warren: Thank you for taking the time to read my question. My son is 6 months old and I am nursing him as well as giving him cereal, fruit and vegetables. He is thriving on the breastmilk....never been sick and is 19 pounds. Is the iron and flouride supplements really necessary if I'm eating right and giving him iron fortified cereal? And if so, why exactly? Our local levels of flouride are almost zero, so if flouride is necessary, he does need that supplemented. I guess I could always have him blood drawn to check the iron levels, but I'd prefer not to. I'd appreciate any advice you can give me. Thank you.

-Linda

Dear Linda: Recommendations regarding nutritional supplementation for nursing infants have changed over the years. The current recommendations for infants who get the bulk of their nutrition from nursing is that iron supplementation is not recommended because human milk has a substance called lactoferrin which enhances the absorption of iron.

Fluoride is a different story. It is not a nutrient supplement. It is used because it has been shown to prevent cavities. If you live in an area where the water is not fluoridated, fluoride supplementation is recommended from 6 month of age to 14 years.

Sincerely,
Dr. Warren

Dear Readers: Recommendations keep changing. Currently, it is recommended that all nursing infants receive vitamins A, D, And C supplements.
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Dealing with a Picky Eater

Hi Dr. Warren: My child is an extremely picky eater. She is two & a half years old and will only eat 3 or 4 dishes. She absolutely refuses even to taste veggies. Often i will spend an hour with her on the dining table trying everything from reasoning to shouting and she will keep crying for that entire hour but will not taste the food on her dish. i have even tried the tactic of "if you don't eat this you will not get anything else" and she will go to bed hungry but will not even touch the food on her dish. I cannot force her to eat anything as she will instantly throw up. Please help.

-SP

Dear SP: Fighting with kids to get them to eat doesn't usually work and certainly doesn't make mealtime a pleasant experience or foster good eating habits. Take the pressure off mealtime and plan your meals around the nutritious foods you know your daughter eats. Even if her repertoire is small she can be adequately nourished as long as she isn't allowed to fill up on junk food or juice.

Please read my article, Nutrition Without Tears for a complete and reassuring explanation of what is necessary to provide a child a nourishing diet.

Sincerely,
Dr. Warren

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