24 May 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
-Sandy
Dear Sandy: Nevi (also known as moles) do not become infected unless they are scratched or otherwise injured. Neither do they cluster on the neck or cause lumps in the neck. I do not know what is actually going on with your son, but the fact that your son's "lumps" are now tender is a significant change. If a doctor who has seen your son thinks that you need an urgent consultation with a dermatologist, then I would suggest you take care of it.
Sincerely,
Dr. Warren
Thank you for your time.
-AG
Dear AG: While your pediatrician's statement ("someone has to be below average") may have been lacking in bedside manner and didn't provide enough information to aid your understanding or be reassuring, there is an element of truth to it. The normal range runs from the 5th percentile to the 95th percentile. If your child's growth is normal, he should not be subject to testing or medical intervention. The key question is, "Is your son's growth normal?"
Even if your son's current size is within the normal range, if he has not grown since he is 4 years old, his growth is NOT normal. Your pediatrician can easily see whether or not your son's growth is normal by plotting his height on a growth chart. If he really isn't growing and his height has fallen from the 95th percentile to the 20th percentile over the past three years, your son needs a thorough evaluation to determine why he isn't growing. Your pediatrician can do the initial evaluation which should include a bone age x-ray, thyroid function tests, basic chemistries and urinalysis, and a review of your son's diet, or he can refer your son to an endocrinologist for evaluation. Treatment, if any, depends on what is interfering with your son's growth, if anything.
Sincerely,
Dr. Warren
Thank you
-Meghan
Dear Meghan: While many infants who have asthma improve by the time they're 3 years old, and many children who have asthma improve during adolescence, asthma can persist throughout life. There is simply no guarantee that a child will "outgrow" it. Even those who have significant improvement at certain points in their life may continue to have symptoms when they have colds or if they're exposed to smoke or allergens.
Any child with severe asthma or asthma which is difficult to control should have an allergy evaluation since allergy may play a significant role in asthma. There is no standard age at which to do an allergy evaluation, but allergy tends not to play as much of a role in asthma during infancy as it does in childhood. Unless there was a strong reason to suspect allergy, most allergists would wait until after 2 years of age to do an allergy evaluation.
For more information about asthma please read my articles about asthma which can be found on my list of articles.
Sincerely,
Dr. Warren
Thank you.
-SS
Dear SS: Your baby's fussiness could certainly be a result of cow's milk allergy in which case she may do well on a soy formula. She may also be swallowing air from bottle feeding. Experimenting with different bottles and nipples may help. I generally recommend a bottle with a collapsible bag like the Playtex Nurser.
Don't forget that as long as your baby is nursing, your diet can also affect your baby. Pay attention to whether or not your baby's fussiness occurs after certain foods and avoid spicy foods.
Sincerely,
Dr. Warren
I am attaching a document given by the Doctors of Xxxx for the last child M along with mail. If you need any more details I will provide soon.
Hope you will help them to diagnosis what can be done. Thank you very much.
Yours faithfully
-PN
Dear PN: From the information you provided, it appears that the child who died most recently had a combined type immunodeficiency syndrome. It is likely that the other children had the same. There are a variety of combined type immunodeficiency diseases including Combined immunodeficiency (CID or Nezelof syndrome), Severe combined immunodeficiency syndromes (SCID), MHC class I and/or II deficiencies, Omenn syndrome, Wiskott-Aldrich syndrome, Ataxia telangiectasia, Hyperimmunoglobulinemia E, all of which are genetic. Under the circumstances, it would be wise for your aunt and uncle to consult a genetic counselor, and in the event that they do have additional children, the baby should be evaluated by a pediatric immunologist before the baby becomes sick.
Sincerely,
Dr. Warren
Thank you for any advice you might have, I am sure your time is limited.
-LA
Dear LA: You are describing diarrhea which is the main symptom of gastroenteritis. Most gastroenteritis is caused by a virus infection and will run its course within a few days. There is no medication which cures it. The treatment of gastroenteritis is aimed at preventing dehydration. A three year old who is not vomiting and who is drinking adequate fluids, preferably with electrolytes (Pedialyte, Kaolectrolyte) should not get dehydrated.
Emetrol is somewhat useful in the management of vomiting but has no role in treating the symptoms you described. For additional information about gastroenteritis, read my article, Management of Gastroenteritis.
I cannot tell what the bumps around your daughter's mouth are without seeing them. You may be describing fever blisters which have come out just because she is ill. Fever blisters are caused by Herpes virus and often recur in those who get them.
Sometimes children seem to get a lot of illness when they are adjusting to a new environment. The stress of change and exposure to new germs plays a role. Usually increased exposure to illness due to increased exposure to other children is the main reason children start to get more frequent illness.
Sincerely,
Dr. Warren
Thanks for your advice.
-M & J
Dear M & J: According to the AAP 1997 Red Book: Report of the Committee on Infectious Diseases, 24th ed., Copyright © 1997 American Academy of Pediatrics, recurrence (ie, second episodes) occur rarely.
The primary concern regarding Kawasaki syndrome is the long-term cardiac complications. Continuation of the monitoring of your daughter's coronary arteries is recommended at this early point. According to the Redbook "an echocardiogram should be obtained early in the acute phase of the illness, approximately 3 weeks and 8 weeks after onset. The care of patients with carditis should involve a cardiologist experienced in the management of patients with Kawasaki disease and in echocardiographic studies of coronary arteries in children. Long-term management of patients with Kawasaki disease should be based on the degree of coronary artery involvement. Children must be examined repeatedly during the first 2 months to detect arrhythmias, congestive heart failure, valvular insufficiency, and myocarditis."
If you have physicians who are experienced in the management of Kawasaki syndrome who are monitoring your daughter for cardiac complications and your daughter has been treated with IVIG [intravenous gamma globulin] and aspirin, then, since it is still early in the course of your daughter's recovery, you simply need to continue with your physicians' close monitoring. If they feel that the rash does not represent a recurrence of Kawasaki syndrome, since it is rare, as long as your daughter is being watched for complications, there is nothing more you need to do.
According to Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company, "acute and chronic inflammatory states may be accompanied by elevated platelet counts." This includes Kawasaki syndrome, but also includes other causes of inflammation. The platelet count may remain elevated for 6 to 8 weeks after Kawasaki syndrome. The exact count does not indicate anything about the progress of the illness. The key is continued monitoring and low dose aspirin if medically indicated.
Sincerely,
Dr. Warren
A little history: Since the week before she turned six months old she has been on 3 different antibiotics for ear infections. Once they finally cleared up she came down with the stomach flu twice in one week. That was two weeks ago. In that time she cut two teeth. Last week she finally got the hang of pulling herself up and does it constantly. She has been crawling backward but learned to crawl forward yesterday. She appears to be very driven with figuring out these new challenges. Among all these changes I have added finger foods which she likes as well as eliminating one breast feeding a day. I now am nursing only 4 times a day w/ 3 solid meals alongside.
Symptoms: Since the stomach flu she has just stopped taking her two naps a day and started waking in the night again crying. If she does fall asleep (only after pulling herself up and my husband or I laying her back down up to 6 times) she only sleeps for 40 min. She screams bloody murder when we lay her down for up to an hour. She also is suffering from separation anxiety. I can't leave her with anyone but my husband and even that sometimes doesn't work. When she wakes in the night or from a nap she only wants me. She has also fallen a lot since learning to pull up and cut the inside of her mouth twice with her teeth and has bruises on her forehead.
Question: My daughter has always been an excellent sleeper and never much of a cryer. Now she cries all the time and never sleeps. Is all of this part of some normal stage for an infant her age or could something be really wrong?
-T
Dear T: Separation anxiety (normal to start at this age), teething, and motor development (standing in the crib, which is incompatible with going to sleep) can all explain your daughter's sleeping difficulty and increased crying. It is not unusual for an illness to interfere with sleep and usher in some new sleep habits as happened with your daughter's flu. Of course illness could contribute to irritability and sleeplessness as well, so if you have any doubt, have your daughter checked by her pediatrician. But it sounds like these personality/sleep/separation changes are age appropriate.
Sincerely,
Dr. Warren
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