19 April 2004
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
Can you tell me if this is common? Is it possible to outgrow this condition? How long might it take (estimate)? Anything I can do to aid its return.
-SO
Dear SO: According to Gellis and Kagan's textbook, Current Pediatric Therapy, regarding the
diagnosis of neonatal vocal cord paralysis, ... slightly more than half had unilateral [one side, one vocal cord - not both] paralysis; left-sided paralysis predominated .... Overall, 37% of cases were "idiopathic" [cause unknown] with a 75% chance of spontaneous recovery, 26% were associated with neurologic problems ..., 13% were associated with a breech or other difficult delivery, and 5% were associated with congenital heart disease. Paralysis after difficult or prolonged delivery was usually unilateral ... and had a high probability of recovery. Bilateral [both vocal cords] paralysis caused by neurologic disease was associated with a poor prognosis for recovery.I have annotated the material I quoted in brackets in order to aid your understanding. They did not give any incidence figures; however in 20+ years as a pediatrician I've seen only a few cases of laryngomalacia and no cases of congenital vocal cord paralysis, so it is not very common.The initial treatment for infants with vocal cord paralysis consists of airway support as needed and thickened feeds or nasogastric feeds. GER [gastroesophageal reflux] should be managed aggressively. Most patients with unilateral paralysis improve in terms of aspiration [inhaling secretions or feedings] and voice because of compensation by the normal cord even if they fail to regain function of the paralyzed side. A percentage of patients with bilateral paralysis, usually reported as around 50%, require tracheotomy to alleviate chronic upper airway obstruction. Some reports in the literature are advocating aggressively trying to avoid tracheotomy in infants with bilateral paralysis in anticipation of possible return of vocal cord function or airway improvement through growth.
Vocal cord paralysis is the second (after laryngomalacia [soft trachea and larynx]) most common cause of stridor [noisy breathing] in infants. It is usually relatively high pitched and associated with hoarseness, breathiness, and feeding difficulties.
Sincerely,
Dr. Warren
Thank you.
-NM
Dear NM: Eczema is a chronic allergic type rash. It can be relieved by anti-inflammatory creams like hydrocortisone, but it will recur. It is also a very dry rash, so it helps to use a moisturizing soap like Dove, to not bathe excessively, and to use a moisturizing ointment like Eucerin or Aquaphor, especially after bathing. If the eczema flares up and is itchy, you will need to return to using the hydrocortisone ointment. If it is a persistent problem, you should consult a dermatologist about the management.
Dietary changes can sometimes help. Elimination of foods or formulas to which the child is allergic may improve the eczema. It is important not to restrict an infants diet in such as way as to decrease its nutritional content. In extreme cases it may help to consult an allergist to determine what a child is allergic to. Unfortunately, many children with eczema are sensitive to things in their environment which cannot be eliminated.
Sincerely,
Dr. Warren
Thank-you
-Sue
Dear Sue: Here's what the AAP 1997 Red Book: Report of the Committee on Infectious Diseases, 24th ed., Copyright © 1997 American Academy of Pediatrics has to say about Group A Streptococcus (GAS) carriers:
Antimicrobial therapy is not indicated for most GAS pharyngeal carriers. Exceptions, i.e., specific situations in which eradication of carriage is indicated, include the following: (1) during outbreaks of acute rheumatic fever or poststreptococcal glomerulonephritis; (2) during an outbreak of GAS pharyngitis in a closed or semi-closed community; (3) when a family history of rheumatic fever exists; (4) when multiple episodes of documented, symptomatic GAS pharyngitis continue to occur within a family during a period of many weeks despite appropriate therapy; (5) when a family has an excessive anxiety about GAS infections; and (6) when tonsillectomy is considered only because of chronic GAS carriage.I have had fair success with Duricef, a cephalosporin, in treating recurrent strep. I had one child in whom the only thing that worked was to continue penicillin twice daily for several months. If your daughter has chronically infected tonsils, a tonsillectomy may solve the problem. If you have a dog or cat, consult your veterinarian about testing the pet for strep or treating it with an antibiotic since pets can carry strep and spread it to humans.Streptococcal carriage can be difficult to eradicate with conventional penicillin therapy. A number of antimicrobial agents including clindamycin, amoxicillin-clavulanate, narrow-spectrum cephalosporins, dicloxacillin, and a combination of rifampin and penicillin have been demonstrated to be more effective than penicillin in eliminating chronic streptococcal carriage. Of these drugs, oral clindamycin given as 20 mg/kg per day in three doses (maximum, 1.8 g/d) for 10 days has been reported recently to be the most effective. Proven eradication of the carrier state is helpful in the evaluation of subsequent episodes of acute pharyngitis; however, chronic carriage may recur because of reacquisition of GAS.
Sincerely,
Dr. Warren
Thank you for your time and advice.
-Linda
Dear Linda: It's okay for a child to have bowel movements every 3 days as long as he isn't uncomfortable, has a good appetite, continues to have the BMs regularly, and is able to accomplish the bowel movements without a great deal of distress. If the stools are soft, there is no cause for concern. If the stools are getting hard, you may need to change the cereal or increase the fruit (not bananas which are constipating) to keep the stool soft.
Sincerely,
Dr. Warren
Thank you
-JM
Dear JM: The usual dose of amoxicillin for treating ear infections would come out to 160 mg 3 times daily; however, newer dosage guidelines recommend going to twice that dose for ear infections which don't respond to the usual dose. Some children get diarrhea from antibiotics even when given in small doses. If your son's diarrhea is from the antibiotic, he may benefit from the contents of 1 Bacid capsule 3 times daily to restore the intestinal balance.
Since your son is vomiting and has diarrhea, he may have an intestinal virus rather than a problem with the antibiotic. Some children vomit with ear infections, but ear infections don't generally cause diarrhea. If your son is still vomiting and not tolerating fluids, you need to stop all food and milk and put him on just clear fluids including electrolytes. If he continues to vomit on just clear fluids, he needs to see his doctor. Please read my article, Management of Gastroenteritis.
As long as he is having diarrhea, his diaper area will become very irritated. You need to use a heavy layer of diaper cream with every diaper change. Try a protective an healing ointment like Desitin or Triple Paste.
If your son looks very sick to you, he must see his doctor. Whether or not to do blood work is up to the doctor. Children who are sick look pale from being sick. That does not mean they are anemic.
Sincerely,
Dr. Warren
Please help us. Thank you very much.
-Amanda
Dear Amanda: The condition to which you are referring is called labial adhesions. Unless the labial adhesions are thick or interfering with urine flow, they can be left alone. Just as the Premarin cream helps to open the adhesions, so will the hormones of puberty open the adhesions. Unfortunately, there is no medication beside the Premarin that will open the adhesions, and Premarin can be irritating. Once the adhesions are open you may be able to keep them open by daily application of Vaseline with light pressure to open any adhesions which have formed.
Sincerely,
Dr. Warren
-ML
Dear ML: You haven't mentioned what's happening to your granddaughter's height. Children generally gain weight because they are growing, not because they're getting chubby. If she's eating well but her head hasn't grown and she isn't gaining weight, unless she is getting progressively more skinny, I suspect she isn't growing. If that is the case, she needs an endocrine evaluation to determine why she isn't growing.
If she is growing and appears malnourished in spite of a good caloric intake, then she needs a complete GI workup for malabsorption. An upper GI series will not tell you if she has malabsorption. Treatment of malabsorption depends on what is causing it.
Sincerely,
Dr. Warren
Second question (no nearly so long). My 7 month old is not gaining any weight either. She seems to be a great eater. After I nurse her in the morning she eats about 4oz. of baby cereal mixed with fruit. At lunch (only sometimes after I nurse because of a busy schedule) she will eat 2-3 jars (4oz size) of baby food and then about 1 hr. after she eats I will nurse or give her a 7oz bottle (because she spits up if I do it immediately after she eats). Then for dinner the same schedule as lunch. Then I will normally nurse her right before she goes to bed (between 9-10 and night). Then we start over about 7am the next morning. At 6mos she only weighed 11.4# (she was 7.8# at birth and 11# at four mos.) When I took her back for a weight check 3 days ago she was only at 11.11#. Both her pediatrician and I are worried about this. He said to give her more cereal during the day but when I try this she doesn't eat as much baby food. Now she is eating about every 1 1-2 hrs to 2 hrs during the day. Is there anything else I can do?
And before you think I am starving my children, I have a four yr old who is 40 inches tall and weighs 38-39 pounds.
-CC
Dear CC: Regarding your first child. She has such a variety of problems, it does not necessarily all fit under one diagnosis and your pediatrician must coordinate the care among specialists. It sounds like your daughter has milk allergy, but it is also possible that she has GE reflux contributing to wheezing. Your daughter may also have some degree of a childhood feeding disorder. Is she complaining of stomach pain all the time or just when she is presented with food? If she has pain all the time, either your pediatrician or the gastroenterologist must figure out why. If she only complains at mealtime, it may be a reaction to being pushed to eat. She may have developed the habit of holding food in her mouth in response to reflux or it may be part of the battle of getting her to eat, in which case your gastroenterologist may need to refer you to a feeding specialist. By the way, it's nice that the cardiologist has reassured you, but did he tell you what the murmur is?
If your 7 month old is eating well and not gaining, I'm inclined to ask if she is growing. If she isn't growing, she needs an endocrine workup to evaluate why she isn't growing.
Final comment. What's the big deal about cereal? Sure it has calories, but it's not more calorie dense or more nutritious than other foods. There's just no reason to push cereal on the kids as if that's what makes children grow.
Sincerely,
Dr. Warren
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