3 May 2004

1. Nursing Infant Vomits Blood
2. Hallucination from Mirapex
3. Immunization for TB
4. Career with Kids Outside Hospital
5. Shock
6. Night Leg Cramps
7. Recurrent Pneumonia
8. Pica
9. Disclaimer

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Nursing Infant Vomits Blood

She continues to vomit often (mostly breast milk at this time), has runny, very bright yellow and unusually smelly B M's (15 x/day) and also has chronic, severe diaper rash. She often needs to be held and is often just not feeling well.

She does have lots of gas and also burps a lot.

Do you have any idea what could be wrong or where I might find some help?

Thank you.

-Barbara

Dear Barbara: I would love to be able to solve the medical riddles that other doctors can't. Unfortunately, when I haven't seen a patient and have no knowledge of what tests have been done and the results of the evaluations, it's hard for me to be brilliant. Certainly, when a nursing baby vomits blood, an often overlooked and important possibility to consider is that the baby could be swallowing blood from mother's cracked nipples. If the baby has chronic pain and diarrhea, the baby could have a variety of gastrointestinal ailments and requires thorough evaluation by a pediatric gastroenterologist. This evaluation may require endoscopy (looking into the stomach and intestines with a special scope).

Sincerely,
Dr. Warren

-LC

Dear LC: Mirapex can indeed cause hallucinations. The incidence of hallucinations is higher in the elderly. The drug should be fully excreted from the body within 1 to 2 days but could take longer with impaired kidney function. By now, the drug should be completely out of your father's system. Unfortunately, the information provided by the manufacturer does not indicate how long hallucinations may persist or if flashbacks occur later as with certain hallucinogenics. You should discuss this with your father's neurologist, who I presume has some experience with this drug, and if necessary, consult with a psychiatrist if your father continues to have difficulty dealing with hallucinations.

Sincerely,
Dr. Warren

I have a three month baby. I live in Dominican Republic. My little baby pediatric told me that is not necesary the tuberculosis vaccine. It's true?

I really need to know it.

Thanks for your help!!

-RR

Dear RR: BCG is used to immunize children against tuberculosis in many countries, but not all. It is not used in the USA because at the current rate of infection in the USA, TB screening and surveillance of at risk populations is preferred. I was unable to locate any specific immunization recommendations for the Dominican Republic. I would suggest you check with your local health department to see what the recommendations are for your area.

Sincerely,
Dr. Warren

• I know I love kids
• I know that I'm excellent and love to give people advice (friends, family, kids, etc..)
• I'm not in love with the profession of medicine

I love motivating people, helping people but as I experience hospital life, I feel that it's just not me. I don't think I want to work with kids with pathological Psychiatric problems but rather everyday life problems that everyone faces.

Any advice?

Thanks again.

-Jeff

Dear Jeff: A medical degree without a residency will not lead you directly into any field working with children (or anything else for that matter); however you education level and specific knowledge would certainly allow you to explore many other fields. I have no experience in job counseling and don't know what's out there for people who change their minds midstream. Your degree alone may qualify you for some positions in industry. If you want to go into social work or some form of counseling, you probably have enough education but would probably have to take some specific courses and do some form of internship (not medical). You could teach health, but may require a teaching degree and student teaching to be licensed. Some private schools do not require certification to teach.

Since you don't like hospitals, keep in mind that even though residency programs operate through hospitals, pediatrics is largely outpatient. If you would enjoy a pediatric outpatient practice, you might want to consider the three year investment in residency as just an unpleasant stepping stone toward a goal.

Since medical schools generally expect their graduates to go on to residency, they probably do not have information about opportunities for those who choose not to; therefore, you might want to go to some job fairs to see what's out there. Check the want ads as well. And talk to professionals who work with children in other capacities to find out about their jobs and any allied fields.

Sincerely,
Dr. Warren

I am doing a school project and we are looking at the kinds of problems that occur when , well lets say a bus tipped over and the medics aren't their yet . We are learning what to do about it temporarily and what not to do that may make the situation worse. For school we are going to make a "homemade first- aid book" We have already looked at the triage- the order they go in to treat which case first i.e., ( severe bleeding, no breathing, shock......) We each get to pick a subject to make a page or two in a first aid book. I chose to do shock since while hurting myself minorly earily in my life, I have had about half the symptoms . And while briefly learning about the other problems and learn many injuries can lead too shock. I think it would be a valuable thing to learn. Well I was browsing the net and it happens I haven't found one thing on shock as in the nausea, cool clammy skin, restlessness, thirst.... shock, I have only seen a shock related to allergies and Toxic Shock Syndrome. I was wondering if you have any information you could get to me before Sunday April 25, that I could possibly use to help me make a page for our "first aid book". It would be great if you could do that for me.

Thank you.

-Anna

Dear Anna: The definition of shock is "Inadequate perfusion (oxygen supply) of tissues which results in organ dysfunction, cellular and organ damage and, if not corrected quickly, death of the patient." In English, that basically means there isn't enough blood flowing to the organs and if that isn't corrected quickly, organ cells will die from lack of oxygen. If the brain or heart are severely damaged by inadequate blood flow, the patient will die.

The cool, clammy skin results from decreased blood flow to the skin, nausea from decreased blood flow to the intestines and brain, restlessness which will progress to unconsciousness from decreased blood flow to the brain.

Blood flow to the body (including heart, lungs, brain, skin, and other organs) is dependent on the heart pumping with adequate pressure and there being an adequate blood volume to pump. The body has a variety of ways of regulating blood flow such as increasing the heart rate, increasing the force of the heart beat, and regulating the tone of the small blood vessels. To understand the last part, think of a faucet controlling the flow of water. When you open the faucet wider, more water flows. The body regulates blood flow in order to make sure the heart, lungs, and brain are always getting enough blood. This can be accomplished by tightening the blood vessels to decrease the blood flow to other organs when necessary in order to increase blood flow to the heart, lungs, and brain. A person's blood pressure is a result of the combination of the force of the heart's pumping, the elasticity of the arteries, and the tone (tightness) of the small blood vessels into which the blood is being pumped. If all the blood vessels opened wide at once, blood would be flowing into all the open vessels and the blood pressure would drop because there wouldn't be enough blood to flow everywhere at once.

Now back to shock. When a person goes into shock, his blood pressure drops causing a decrease of blood flow to all the organs. Since the skin is the most visible organ with a large amount of blood flow, the effects of shock may first be most visible in the skin. In addition, in order to keep blood flowing to the brain, heart, and lungs, the body will tighten the blood vessels to the skin, further decreasing blood flow to the skin. This makes the skin cool, pale, mottled, and sometimes blue.

The kind of shock which occurs with an accident is usually HYPOVOLEMIC SHOCK, which means shock that results from not having enough blood volume. This occurs as a result of blood loss. Treatment requires stopping the blood loss and replacing the blood that is lost, but even more crucial than replacing all the blood is quickly getting enough circulating volume to increase blood pressure and blood flow to the organs; therefore treatment also includes IV fluids including blood volume expanders like albumin (protein). Treatment also includes medications to increase blood pressure by increasing vascular tone (blood vessel tightness) and heart pumping. A medication like adrenaline (epinephrine) is often used as a first line drug for treating many of the forms of shock because it stimulates the heart and tightens blood vessels. Severe dehydration can also cause hypovolemic shock.

OBSTRUCTIVE SHOCK could also occur as the result of an accident. If the lower part of the body is injured in such a way as to prevent blood from returning to the heart through the major veins in the lower part of the body, the obstruction of blood flow results in less blood volume for the heart to pump with a result similar to hypovolemic shock.

CARDIOGENIC SHOCK occurs when the heart cannot pump adequately which may happen when a patient has a heart attack, other kinds of heart disease, abnormal heart rhythm, or an injury to the heart (which could occur in an accident). Treatment is similar to hypovolemic shock, but may also include medications specific for the heart problem including medications to control heart rhythm. If there is cardiac tamponade (bleeding into the membrane surrounding the heart which then compresses the heart), the blood surrounding the heart must be drained.

HIGH OUTPUT or VASODILATING SHOCK occurs when all the blood vessels open up at once. Remember the explanation about opening water faucets. Toxic Shock Syndrome, Sepsis (overwhelming infection), and anaphylaxis (severe allergy) cause this kind of shock. Fluids are important for the management of this kind of shock, but it is equally important to use medications to increase the vascular tone in order to increase the blood pressure. Other medications may be required to treat allergy or infection.

Other conditions referred to as shock which share some of the characteristics of shock above include INSULIN SHOCK or HYPOGLYCEMIA (low blood sugar), LUNG SHOCK or ADULT RESPIRATORY DISTRESS SYNDROME (ARDS), and EMOTIONAL SHOCK which is a blunted emotional response to a devastating event (what most people mean when they say something like, "He's in shock.")

Sincerely,
Dr. Warren

Thank You for your time.

-RC

Dear RC: Nighttime foot and leg cramps are fairly common in children. They occur as a result of spasm in muscles that have been used a lot during the day. The best thing to do is massage the cramp. If your daughter has daytime pains, pains that interfere with activity, or a limp then she needs further evaluation.

Make sure the covers are not tight over the foot of the bed as that makes it necessary for the child to stretch his foot out and may contribute to the development of cramps.

Sincerely,
Dr. Warren

Thankful for your response.

-JT

Dear JT: Your son's recurrent pneumonia is more likely related to his asthma than his past history of pertussis. Even with asthma, his high frequency of pneumonia leads me to question whether or not he has been evaluated to rule out cystic fibrosis and gastroesophageal reflux. I would certainly recommend a consultation with a pediatric pulmonologist.

Sincerely,
Dr. Warren

I am wondering if my niece might be putting herself in serious danger by this practice or is this something that should be monitored but not to the point of rehab clinic for tide eaters.

Someone suggested that she might have a vitamin deficiency, but she has balanced meals 3x a day and takes vitamins. Please provide me with some advice.

Thanks

-AB

Dear AB: Pica may sometimes be seen associated with iron deficiency anemia and may then resolve if the iron deficiency is treated. Other than that, pica persisting in a 10 year old is generally related to some psychological problem. Since you, the child's aunt, have recently discovered the problem, I'm curious and concerned about the child's mother's knowledge and involvement in the problem.

As a general rule, detergents and bleach are not highly toxic, but most studies deal with acute ingestion rather than chronic ingestion. Since I have no further information on the toxicity of chronically ingested Tide, I would suggest you contact your local poison control center. I would also suggest that if your niece can't be prevailed upon to stop eating Tide that she get counseling.

Sincerely,
Dr. Warren

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