30 August 2004

1. "Early Menarche"
2. Patch of Hair Loss
3. Teeth Turning Gray
4. Recurrent Scarlet Fever
5. Childhood Osteoporosis
6. Desperate to be 6 Feet Tall
7. Kawasaki Disease and Immunization
8. Eczema
9. Disclaimer

• Read Questions & Answers in Another Column

"Early Menarche"

We are led to understand that this has to do with adrenal dysfunction.

Do you have any suggestions?

Is there any medical research you can refer us to that will let us study up on this subject ourselves.

Thank you.

-(unsigned)

Dear Family Member: You could be describing adrenogenital syndrome. For more information you could look up adrenogenital syndrome, virilization, and precocious puberty.

The child should be seen by a pediatric endocrinologist as soon as possible for a thorough diagnostic evaluation and to start treatment. Without early, appropriate treatment, the child could have some irreversible changes.

Sincerely,
Dr. Warren

Sincerely,
-MP

Dear : The only way I know for you to find out what the patchy area on your son's scalp and the hair loss is, is to show it to your pediatrician. Since you could be describing ringworm, I'd suggest making an appointment.

Sincerely,
Dr. Warren

-SS

Dear SS: Sometimes the iron in formula can cause a gray stain on the teeth. If the stain is more evident on the back of the teeth and the surfaces are not smooth you could be talking about decay. If your son slept with a bottle in his mouth or nurses his bottle all day long he would be at risk for cavities. If in doubt, consult a dentist.

Sincerely,
Dr. Warren

4 weeks ago my 6 year old son was diagnosed (and treated ) for scarlet fever, even tho the strep test was negative. Upon completion of a 10 day course of Amoxicillin, 3 days later the rash returned ( only in the groin area and armpits ) not a bumpy rash just the entire area being bright red ( like a bad sunburn)... returning to the doctor, and yet another negative strep test the antibiotic was upped to Augmentin... after completing this 10 day course, it is back again!!! just the entire groin area and armpits... bright red, no bumps.... no fever.

Could it be possible for him to have it again? Or perhaps antibiotic resistance? or perhaps not even be strep/scarlet fever? I am just very concerned about the overuse of antibiotics and would like a second opinion especially with both strep test being negative. Would an allergic reaction to something perhaps cause this affect , even tho it is localized to groin and armpit?

Thank you for your time and consideration.

-A very concerned/confused Mom
TC

Dear TC: The rash of scarlet fever is most intense in the groin and at the armpits, but does cover the entire body. It consists of red, fine bumps which come together making the skin feel like sandpaper. Scarlet fever is caused by group a streptococcus. If your son's strep test has been negative on all occasions, that makes the diagnosis questionable; however, if your doctor is running a quick strep test in his office, since their accuracy is only 90%, he can send a specimen for culture to be sure.

I wouldn't be too quick to dismiss the possibility that this could be scarlet fever since each course of antibiotics got your son better and each time he came off the medicine, the rash returned. I have seen strep throat relapse like that. It is not caused by antibiotic resistance since the patients always get better when they are on the antibiotics. Since streptococcus is a free living organism (bacteria like strep can live on surfaces without causing infection unlike viruses which must invade cells), after an infection has been successfully treated, the patient may still be carrying some strep in his throat which can then cause another infection, a relapse. This happens because once the tissue is no longer inflamed antibiotics don't get into the tissue in high concentrations. Since penicillin doesn't get into saliva in high concentrations not much medicine gets to any remaining strep which may be on the surface of the throat. Strep carriers don't always get sick, and eventually the body gets rid of the carrier state.

Even though I've seen relapses of strep, I can't recall ever seeing relapses of scarlet fever the way you described. The rash of scarlet fever doesn't come and go that quickly. If your son has no sore throat or fever, and just the recurrent rash, perhaps you should have him checked by a dermatologist. If it is recurrent strep, there are a variety of treatment regimens including an injection of LA Bicillin, treatment with penicillin plus rifampin for the last 4 days of penicillin therapy, and treatment with Duricef or Augmentin. If your son has chronically inflamed tonsils with recurrent strep, he may need a tonsillectomy.

Sincerely,
Dr. Warren

I also must add, after writing you last night, he developed a low grade fever, sore throat, and today the rash is appearing on other parts of the body... fine red bumps , rough like sandpaper, just very concentrated in the groin and armpits ( hot spots as my husband calls them ).

So now my question is, how long could this go on for? Is it real uncommon for this many relapses? His Doctor did not seemed to concerned over the second one, and I will be taking him in again tomorrow.

Thank you, Thank you , Thank you.

-TC

Dear TC: I have seen children have as many as 3 or 4 relapses before an additional course of action was taken. It's frustrating, but other than trying different antibiotics, the only other options would be tonsillectomy, or penicillin twice daily for several months. We see this problem of recurrent strep every spring. Usually the cycle ends by summer.

Sincerely,
Dr. Warren

-D

Dear D: Osteoporosis would be very unusual in a child. To the extent that it has resulted in multiple fractures over the past 6 years, I would question whether or not she has a mild form of osteogenesis imperfecta (a genetic disorder that results in fragile bones) and suggest a consultation with a pediatric orthopedist or a geneticist. Osteogenesis imperfecta can sometimes be recognized because the sclerae (the whites of the eyes) may have a bluish or grayish color.

Osteoporosis in childhood may be seen with some other genetic conditions or as a result of treatment with steroids, but otherwise would be so uncommon as to require evaluation by a pediatric endocrinologist to determine if there are any abnormalities of calcium or vitamin D metabolism. Since your daughter is a growing child, if she had a significant calcium deficiency, it would be more likely to cause Rickets than osteoporosis.

Sincerely,
Dr. Warren

-D

-(unsigned)

Dear Desperate: I want you to understand that I'm sympathetic to your plight, but I also feel that by 20 years of age, there are certain realities you must face and be able to deal with. Chances are, at 20, you have completed all the body changes of puberty and have an adult body. Once all the changes of puberty are finished and the body is fully mature, growth ceases. Some boys do grow until they are 21, but by that point their growth rate is not sufficient to grow another 6 inches. That is reality and I suggest you deal with it, because if you're desperate enough to change things that can't be changed, I guarantee you'll find people who are willing to take your money and sell you false hopes by offering treatments that don't work.

By the way, I'm 5'6". If I wanted to be a basketball star, that wouldn't be too good, but I've never found it to be a problem. Accept yourself for who you are and plan life goals that you can truly strive for. Those are the challenges that lead people to achieve greatness. Your height is a fate you were given. It is not a measure of you as a person, and you cannot control it or change it.

Sincerely,
Dr. Warren

-A

Dear A: If you are finished growing, which I suspect you are, there is nothing which can make you grow taller. If you are not finished growing, you could consult an endocrinologist to see if growth hormone injections would help, but I suspect that you are not a candidate for growth hormone and I don't think you can expect any significant growth with treatment. I don't want to sound mean, but I thought my last response to you made it clear that it is unrealistic for a 5'6" 20 year old to want to be 6 feet tall. You're not a little kid. It's time to face reality and concentrate your energy on things you can do something about.

Sincerely,
Dr. Warren

*******************************

I was wondering if you could help us out again with some questions on Kawasaki Disease. I have been reading about not giving immunizations until a year after IVGG was given. If our daughter was given her immunizations during the first year. Does she need to be given them again?

Thanks for all your help.

-JB

Dear JB: Immunizations work by causing the immune system to mount a response against the injected (or oral) foreign substance (live virus, inactivated virus, toxin, etc.) resulting in immunity. After receiving IVGG, the passive immunity in IVGG could prevent the immune system from mounting a full response to a vaccine with the result that the immunization might not be effective. IVGG does not have any effect on immunity already acquired from vaccines prior to the time the IVGG was given. Therefore your daughter does NOT have to have immunizations given to her prior to the Kawaski Disease repeated.

Sincerely,
Dr. Warren

Anyway the reason I am e-mailing is that my babies eczema is getting really bad and I am trying everything to get it under control or rather using everything but nothing is helping. Is it possible that it could be his formula? If so what should I try and will it give him any gastrointestinal distress by switching? The only other thing he is getting is rice cereal. I have tried double rinsing clothes in both Dreft and Ivory Snow and only using a fraction of what they tell me to use and I use no fabric softener. What else could it be? Nothing seems to help. If it is not the food or detergent what else can it be and what else can I use to calm it down? Any suggestions are appreciated. Hydrocortisone does not seem to help. Mostly it is concentrated on his chest but he has it also on his arms, legs, and some on his back. He plays a lot on the floor on a blanket. Could it also be carpeting? Should I consult a dermatologist at this point? HELP!!!!!

-SG

Dear SG: Formula sensitivity may sometimes be the cause of eczema. For those infants who are allergic to formulas I recommend a hypoallergenic formula such as Alimentum or Nutramigen. Sometimes eczema can be a result of allergens in the environment which can't be eliminated.

Creams such as hydrocortisone work by reducing the inflammation of the rash, but they don't cure eczema. The rash is chronic and will keep returning. If the hydrocortisone cream controls the rash you should use it when necessary. If it does not control the rash you may need a stronger cream which is available by prescription.

Eczema tends to be very dry, so be sure to use a moisturizer on your child's skin, especially after bathing. Don't bathe more than necessary and use a moisturizing soap like Dove soap.

If these measures and your pediatrician's advice cannot control the rash, then you should consult a dermatologist.

Sincerely,
Dr. Warren

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