21 June 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
The onset of this occured 5 days after his 2 month shots and about the same time I introduced solids--10 weeks. The only episode that has ever happened in the daytime was this inital episode, and I did not witness it (my husband did.) My husband complained that the baby was gasping when I returned from the grocery. My child simply looked mad and like he was throwing a crying fit (sobbing.) I took him and nursed him and he was fine (except this "lurch" in his stomach or diaphragm.) I called my pediatrician and he said that it was just gas going through his system. I promptly decided that my son indeed had simply thrown a fit.
About 1 1/5 weeks later, I put him down for the night (he sleeps with us.) About an hour after he breastfed (he is still breastfeeding) he started this gasping type hiccup in which you could see his chest moving.
I'm going to summarize this so you won't have to read every little detail: It's been 3-4 months now and he still has these episodes. They used to go away in about 3-5 minutes and he continued sleeping. Up until recently they were about a week-week and a half apart and mild. Last night he had one every hour. He typically will be up and down all night when he has these, they are generally an hour after he nurses. If I pick him up as the attack begins, it stops--all he has to be is upright or nursing. If I wait for the episode to go away, it gets worse and more forceful, and is accompanied by the hiccup-like lurch for about a minute after. He has a sharp inhalation with these movements. No other motor activity is present, except now I can tell when he will have an episode because he is always in REM, smiles, frowns, starts to cry in his sleep a little and then proceeds into the gasping, which sounds like a sniff or child's sob. Like I said, if I pick him up immediately I can stop the attack from happening. If I don't, it will continue indefinitely until he wakes up crying. I looks like a nightmare except for the lurch (phrenic nerve, perhaps?)
He had colic for a long time. Either what I am eating or what he is eating does seem to affect the incidence of the episodes. He always passes gas after the episodes and generally sounds a little liquidy after. After the worst attacks, he spits up a lot that morning.
I have been to three pediatricians. The only diagnosis I have had is of reflux--but why the dream-like prelude? I have been referred to a pediatric neurologist, but it's weeks before I can get in--I'm really worried--shoud I be?
After these episodes he wakes up happy, smiling, babbling. He is ahead developmentally. He has been sitting up alone since 5 months and is now learning to crawl. There seems to be no change in him except he seems uncomfortable and clingy later in the day. Most of the time, even after being awake most of the night, he won't take a nap that day at all.
I have dug up these related articles
-JB
Dear JB: GER seems like a real possibility for the problem you describe. Reflux symptoms are likely to be at their worst when a person (infant to adult) is in a reclining position and when his stomach is full. GER can cause respiratory symptoms because of the irritating effect of gastric contents in the back of the throat, the proximity to the airway, and the possibility of aspiration (breathing in material from the reflux). As the reflux starts it may disturb sleep creating your impression that his symptoms are related to his sleep state rather than that his sleep state is related to the symptoms. Your picking your son up may prevent the most bothersome reflux symptoms just because of the change in position. Since reflux is treatable, your son should have a thorough enough GI evaluation to rule in or out this diagnosis.
Other sleep disturbances are possible, but your first experience with theses symptoms was unrelated to sleep, and the association with diet favors GER as a diagnosis.
Certain seizure types are more common in sleep, but I don't believe a seizure state can be aborted by picking up a child. You should certainly go ahead with the neurological evaluation for peace of mind, but it's not first on my list for possibilities.
Hiatus hernia is an interesting possibility which would be uncommon in infants. I must admit I wouldn't have thought of it. A complete GI evaluation should help rule in or out this possibility.
Fructose intolerance ought to cause gas and diarrhea, but unless his only fruit intake is at night, your son's symptoms should not have a predilection for occurring only during sleep.
Sincerely,
Dr. Warren
1. Seems to occur after she's been walking on it for awhile (she's been walking since 11 months old)
2. We notice somethings wrong at the moment because she starts crying/screaming - we expose her legs for our view and can immediately see/feel MAJOR STIFFNESS, SIGNIFICANT SWELLING, THE MOVING OF THE LEFT FOOT OUT, AWAY FROM HER BODY. It's seems like it deforms before our eyes. WE DID NOTICE SOME BRUISING last night for the first time?, THE SIZE OF A DIME, BUT THIS DEVELOPED DURING THE "SPASM"?, AND DISAPPEARED A FEW MINUTES LATER.
3. One can tell by comparing the feet during these occurrences that THE LEFT HEEL IS OBVIOUSLY SWOLLEN, EVEN DURING NON-EPISODES.
She has had x-rays that have shown nothing. We are very worried
-Mr. & Mrs. M
Dear Mr. & Mrs. M: There isn't any deformity that can come and go as quickly as you describe, but muscle spasms can, and a muscle spasm can be firm to the touch and give the muscle a different contour than usual. Since x-rays cannot reveal all causes of pain, if your daughter's symptoms persist, have her examined by an orthopedist.
Sincerely,
Dr. Warren
Thank you.
-DR
Dear DR: It sounds to me like you need some clarification about what's actually going on. Little girls don't develop vaginal yeast infections like adult women because the prepubertal vaginal lining does not support the growth of yeasts. Urinary tract infections are unrelated to yeast infections. Nonspecific vaginitis and yeast infections in the skin may both cause urinary discomfort.
An external yeast infection is relatively easy to spot because it causes a very red, bumpy rash. Nonspecific vaginitis causes the vaginal area to be red and may cause some discharge. It responds to sitz baths and bland ointment like A&D. Some little girls may have recurrent vaginitis in spite of proper bathing/wiping/hygiene techniques. It can be frustrating, but is not serious. Since you didn't mention it, just in case, let me add to your pediatrician's advice that your daughter should be wearing cotton underpants, not synthetics.
If your daughter is having chronic or recurrent urinary tract infections, in spite of the normal studies you should consult a pediatric urologist. She may need to be on suppressive antibiotics. If she is having recurrent yeast infections, she may need an evaluation of her immune system and to be checked for diabetes (although diabetes generally causes significant other symptoms in kids). Also, make sure any yeast is fully clear before discontinuing treatment and don't feed the yeast by using cornstarch powder.
Sincerely,
Dr. Warren
-LH
Dear LHThe diagnosis of "Growing Pains" refers to a variety of benign leg pains of childhood which tend to occur at rest in active children. Growing rapidly is not painful, at least not physically. Playing hard could certainly result in an injury which could cause a child to refuse to walk, but any pain that persists, causes a limp, or interferes with activity requires further evaluation. Going on the little information I have I'd suggest you see an orthopedist.
Sincerely,
Dr. Warren
Sincerely,
-Jennifer
Dear Jennifer: People with Herpes virus infections are not contagious between outbreaks; however, the affected person would have to pay attention to early and mild symptoms in order to be aware when he is contagious. Herpes only spreads by direct contact, otherwise lots of people would be picking it up in public places. If the affected person observes proper hygiene which includes washing his hands prior to handling the children, and does not permit contact of the affected part of his body (his face) with the children, the risk of spread to the children should be minimal. There is no way to guarantee that the children won't catch anything, but everyone working with children, regardless of what their health is, should observe proper hand washing precautions to protect themselves as well as to avoid spreading infectious illnesses from one child to another.
Most infants and children who get a herpes infection will develop gingivostomatitis, which will cause fever for 1 to 2 weeks and mouth sores. In extreme cases, hospitalization for IV fluids may be necessary to prevent dehydration because the mouth sores interfere with drinking. When the affected child recovers from the gingivostomatitis, he will be prone to develop recurrent fever blisters.
Although it can be a miserable illness, except for newborns and immunocompromised individuals, Herpes is not a serious illness. Of course, the prospect or recurrent outbreaks for the rest of one's life is an issue. Newborns an immunocompromised individuals are at risk for developing life threatening Herpes infections including Herpes encephalitis. These are treatable with antiviral medications if diagnosed early.
Sincerely,
Dr. Warren
We took him for his 9 month check up and our pediatrician felt that he has lower muscle tone. We are concerned about it and would like to know the following :
-P & V
Dear P & V: Low muscle tone is diagnosed simply by the way the muscles feel to an experienced pediatrician. With low tone the muscles feel softer and flabbier than normal. In an infant, one can draw the arm across the chest. If the elbow moves easily past the midline, it is consistent with low muscle tone. If the infant feels like a rag doll and his head lags when you pull him to sit, that is consistent with low muscle tone. Basically, these babies feel floppy.
Children with low muscle tone do make progress, but may take longer to achieve their developmental landmarks. Low tone may be seen in children who are otherwise normal or associated with other neurological symptoms. Your son should be evaluated by a pediatric neurologist to determine the cause of his decreased muscle tone. Once that is done, he should be evaluated for early intervention services like physical therapy and occupational therapy to help him achieve his maximum potential.
Sincerely,
Dr. Warren
Thanks.
Sincerely,
-Dan
Dear Dan: A weight of 20 pounds at 10 months is in the 25th percentile whereas a weight of 25 pounds at 34 months is below the 3rd percentile. This represents a significant decrease in the rate of weight gain. You have told me he is short, but I don't know if he has always been short, or if he has had a decrease in his growth rate. If your son is not growing, that would explain why he isn't gaining weight even though he eats well. You need to review your son's growth (height, not weight) with your pediatrician. There are many reasons why a child may not grow. If your child's growth rate is below the normal range he needs to be evaluated.
You should be aware that steroids can interfere with growth. For that reason, all inhaled steroids including Flovent, carry the warning that they may interfere with growth. In practice, most of us have only seen steroids taken by mouth interfere with growth, but the possible role of the Flovent in your son's decreased growth cannot be dismissed without investigating the cause of his growth failure and perhaps altering his asthma management.
Sincerely,
Dr. Warren
-V
Dear V: I can understand your frustration with your children's recurrent colds and ear infections. Unfortunately, warm clothing and hats have nothing to do with catching or preventing colds. And, assuming your children are adequately nourished, there is no evidence that vitamin supplements alter the attack rate (frequency) or the course (severity and duration) of colds. Colds are caused by viruses. You catch them by being exposed to the germs from other people with colds. About the only thing that you or your children can do to decrease their exposure is to avoid people who have colds (when possible) and to wash your hands before touching your face and especially after shaking hands in a crowd or handling items handled by lots of people such as door knobs, etc. For a greater understanding of colds, I urge you to read my article, Upper Respiratory Infections (URIs).
While medications like Dimetapp and Sudafed can relieve cold symptoms, unfortunately they are not successful at preventing or treating ear infections. If your children have 3 or 4 ear infections a year, that is frustrating, but not serious. If they have persistent middle ear fluid, hearing loss, or go from one ear infection to another, they may be candidates for prophylactic antibiotics, or ventilation tubes. For more complete information on the management of ear infections, please read my article, Another Ear infection !?!.
Sincerely,
Dr. Warren
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