5 July 2004

1. What is HSP?
2. Is My Child "Odd?"
3. Newborn Rash
4. Childhood Obesity
5. Diagnosing a Wheeze
6. Swollen Lymph Node
7. Caffeine and ADHD
8. Cradle Cap and Eczema
9. Disclaimer

• Read Questions & Answers in Another Column

What is HSP?

Child's symptoms include swollen joints, vomiting, rashes that then become black and blue marks,,pain in stomach, unable to walk. Dr. states there is no cure, nothing can be given to alleviate any symptom other than pain. Our sweetie cries..... Can you at least tell us what is going on or where we may obtain additional information???? Please!!

-J & C

Dear J & C: HSP stands for Henoch Schonlein Purpura. You can find information on the National Organization for Rare Disorders (NORD) site about HSP.

The following summary comes from the NORD database:

Henoch-Schonlein Purpura is a rare inflammatory disease of the small blood vessels (capillaries) and is usually a self-limited disease. It is the most common form of childhood vascular inflammation (vasculitis) and results in inflammatory changes in small blood vessels. The symptoms of Henoch-Schonlein Purpura usually begin suddenly and may include headache, fever, loss of appetite, cramping abdominal pain, and joint pain. Red or purple spots typically appear on the skin (petechial purpura). Inflammatory changes associated with Henoch-Schonlein Purpura can also develop in the joints, kidneys, digestive system, and, in rare cases, the brain and spinal cord (central nervous system).

SIGNS AND SYMPTOMS

• Onset can be acute or gradual
• 50% of patients have malaise and low grade fever
• Skin lesions occur in all identified patients:

  Lesions appear on lower extremities and buttocks but may involve face, trunk and upper extremities, Begin as small wheals or red bumps, Lesions blanch [turn white] on pressure but later become petechial or purpuric [blood spots or bruises], Lesions appear in crops [many at a time], Angioedema [swelling] of scalp, lips, eyelids, ears, backs of hands and feet, back, scrotum and perineum may be seen.

• Two-thirds of patients experience arthritis:

  Large joints (knees and ankles) are most commonly involved

• One-half of patients experience GI symptoms:

  Colicky abdominal pain associated with vomiting is most common, Occult [not visible] or gross blood in stool, Hematemesis [vomiting blood], Intussusception [a condition usually seen only in infants where the intestine telescopes into itself causing an obstruction], obstruction or infarction [tissue death due to loss of blood flow] rarely occurs, Pancreatitis

• Renal [kidney] involvement is less common

  Hematuria [blood in urine], with or without casts or proteinuria

• Other manifestations

  Seizures, neuropathies, Hepatosplenomegaly [enlargement of liver and/or spleen], Lymphadenopathy [swollen glands], Cardiac involvement, Pulmonary hemorrhage, Rheumatoid-like nodules

• Infantile HSP

  Children less than 2 years old, Rare, Edema and diffuse purpura of face and ears, Fewer GI and renal symptoms

CAUSES

Multiple infectious agents, drugs and toxins have been investigated, with no firm link found

POSSIBLE COMPLICATIONS

Hypertension, Renal failure, Intestinal hemorrhage, Bowel obstruction or perforation, Death very rare

EXPECTED COURSE/PROGNOSIS

Disease may last for a few days with transient arthritis; however, in many cases, the average duration is 4-6 weeks. Occasionally recurrent. 25% of patients with initial renal involvement will have persistently abnormal urine sediment [cells, etc. seen by microscope].

the outcome is excellent in the absence of significant renal disease. The course varies. The disease is often mild, lasting for a few days with only transient arthritis and a few purpuric spots. In more seriously affected children, the average duration is 4-6 wk, but subsequent exacerbations and remissions may occur. The illness may occasionally smolder for 1 year or longer.

There is no specific therapy. In the rare instance in which a specific allergen can be proved, the patient should avoid the antigen. When the disease follows a bacterial infection, particularly streptococcal illness, the organism should be eliminated and, if the disease recurs, prophylaxis considered. Symptomatic treatment is indicated for arthritis, rash, edema, fever, and malaise. Nonsteroidal anti-inflammatory drugs usually alleviate these self-limited discomforts.

Intestinal hemorrhage, obstruction, intussusception, or perforation may be life-threatening in the acute phase; these complications may be managed by the early use of corticosteroids [and appropriate surgical interventions]. Corticosteroid therapy is also indicated for the rare patient with central nervous system manifestations or with the nephrotic syndrome.

Sincerely,
Dr. Warren

Thanks again.

-S

Dear S: Since I see no immediate risk to your son from his "odd" behavior, I'm certain you can wait until your regular doctor returns to discuss his behavioral issues. Since your son is 7 years old, I assume he attends school. I think you could get a much better idea how he compares to other normal children his age from talking to his teacher. I'm not questioning the young doctor's credentials, but I don't think a physician's office setting during a 15 minute visit is the best place to observe a child's behavior. In addition, in spite of physicians' training regarding child behavior, I think a teacher who spends hours each day with lots of kids including yours would be much better equipped to tell you if your child stands out from the crowd in any way, good or bad.

Sincerely,
Dr. Warren

My concern is the fact that this is still with him, and doesn't seem to be getting any better--if anything, it's getting worse. His whole face is red and blotchly, with hundreds of little red and fleshy colored bumps. Does this sound familiar? Isn't there any kind of treatment? What is the time frame for this before it starts disappearing?

Thank you. Your help is appreciated.

-Dave

Dear Dave: The term "stork bite" usually refers to flat, vascular, red birth marks that are commonly found at the base of the skull, on the upper eyelids, on the forehead between the eyes, and less commonly around the nose. These are not related to hormone exposure and usually do fade during infancy.

Rash diagnoses by e-mail have a high potential for being wrong since you need to see a rash to know for sure what it is, but it sounds like you're describing seborrhea and infant acne. These are both conditions of the oil glands which are caused by exposure to maternal hormones. The activated oil glands can flare up for several months. Generally, the acne rash is best left alone. The seborrhea, which consists of oily yellow scales on an inflamed red base, can be treated with 1% hydrocortisone cream if it is very inflamed. The cream will not cure the seborrhea. The rash may recur. The hydrocortisone cream keeps the inflammation under control.

Sincerely,
Dr. Warren

Why do you feel that this issue about obesity is important to the nutrition of children?

What is your role in dealing with the issues related to obesity?

Do u attend workshops or on educational courses on obesity with children? Does your employer or another agency require them attend?

How do you obtain current information on obesity with children?

I hope you will have time to answer my questions. I would really apreaciate your time and effort.

-Rozie

Dear Rozie: I have been a pediatrician for 27 years.

Obesity is an important issue for children for a variety of reasons. First, socially and emotionally it's tough to be a fat kid. Second there are health problems associated with obesity, some of which affect kids, but most of which take their toll later in life. Bad eating and exercise habits which are established in childhood, often persist into adulthood. This is further complicated by the body image and emotional relationship with food that the child carries into adulthood. Finally, being overweight does not mean a person is well nourished. People who consume excess calories in junk food and high fat food may not be eating some of the good foods which provide essential nutrients for good health.

My role, as a pediatrician, is to provide nutritional counseling to all my patients, even the thin ones. When a child starts to gain excess weight, I try to counsel the parents before the child becomes obese. If a child is overweight, I provide counseling regarding appropriate diet, weight goals, and exercise. You can find my basic approach to the problem in my article, Childhood Obesity.

I am self employed, so my "employer" does not require me to attend any workshops, etc. I am required by the hospitals I am on staff at and the insurance companies for which I am a physician to have continuing medical education. This is accomplished by reading journals and attending conferences on a wide variety of subjects. Occasionally that includes obesity, but there is no specific requirement for updates on any subject, including obesity.

By the way, since I'm an internet junkie, I subscribe to a variety of services that send me medical news by e-mail with links to appropriate articles, so if something new regarding obesity developed, I'd probably hear about it right away.

Sincerely,
Dr. Warren

He has recently recovered from a cold with a cough, but he has been free from this cold for about a 10 days and he no longer has a cough. We own a cat and I have a history of allergies and asthma in my family. I realize that he could possibly have allergies, especially at this time of year.

My question is : If I take him to the doctor to have it investigated, will he be able to detect a problem even if my son is not actually wheezing at the time? Like I mentioned, he doesn't actually do it that much, so I'm just not sure.

Any advice is greatly appreciated.

-JB

Dear JB: Wheezing is generally associated with coughing. If you son is making wheezy noises when he isn't coughing and it's not affecting his breathing it may not be wheezing. If you go to a doctor when he is completely asymptomatic, the doctor may not hear anything. Even if you don't hear anything at the time you go to the doctor, if your son has been coughing a lot and "wheezing" the doctor will probably hear something with his stethoscope.

Sometimes kids who wheeze may require several doctor visits before anything is found. If you have a significant suspicion, you should check it out.

Sincerely,
Dr. Warren

-SG

Dear SG: Have you discussed it with your family doctor? At 4 months of age your son should have been seen for at least 2 checkups. The best person to answer your question is someone who has examined the lump.

Yes, a persistent swollen lymph node could be seen with leukemia or lymphoma which is serious; however, children with these diseases have lots of swollen lymph nodes. Swollen nodes in the location you describe could be seen with viral upper respiratory infections or inflamed cradle cap.

In all likelihood, you don't need to be alarmed, but you should make sure your doctor checks it.

Sincerely,
Dr. Warren

I would appreciate any information that you can give me.

-RJS

Dear RJS: Caffeine is not used in the treatment of ADHD to the best of my knowledge and is not an alternative to Ritalin. I have enclosed a citation for the only journal article I could find which mentioned caffeine and ADHD.

Behavioral effects of caffeine and other methylxanthines on children., Hughes JR and Hale KL - Experimental and Clinical Psychopharmacology - 1998 Feb; 6(1): 87-95
Author Affiliation: Department of Psychiatry, University of Vermont, Burlington 05401-1419, USA.

Abstract:

Subjective, performance-enhancing, dependence-producing, and adverse effects of methylxanthines are examined, based on computerized searches (i.e., Medline and PsycLIT). High doses (> 3 mg/kg) of caffeine in children who consume little caffeine produce negative subjective effects such as nervousness, jitteriness, stomachaches, and nausea. Whether lower doses produce positive subjective effects has not been adequately tested. Caffeine appears to slightly improve vigilance performance and decrease reaction time in healthy children who habitually consume caffeine but does not consistently improve performance in children with attention deficit-hyperactivity disorder. Early studies suggest caffeine self-administration and withdrawal can occur in some adolescent soda drinkers.

Sincerely,
Dr. Warren

-SG

Dear SG: I have no preference regarding Dreft vs. Ivory Snow. If your son has eczema which doesn't respond to 0.5% hydrocortisone cream, he may need 1% hydrocortisone or a prescription steroid cream, therefore, you should have you doctor look at the eczema. Keep in mind that the creams control but don't cure the eczema. It is likely to be recurrent. Eczema is very dry, so you will need to use a moisturizer after bathing and should cut the bathing down to every other day if you can.

Cradle cap can also be recurrent. The purpose of rubbing in baby oil is to soften the scales so they can be brushed out. This should be done prior to bathing so that the oil can be washed out. If that doesn't help you may need to use a shampoo like Sebulex.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

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