13 September 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
Thank you.
-Stressed in Colorado
Dear Stressed: Sometimes when we want a young child to do something and the child resists, there is no simple solution. At that point, it becomes crucial to put the problem in perspective. Lots of 17 month olds still drink from bottles. If your toddler has no interest in her sippy cup yet, it's not a serious matter; however, the fact that you are so concerned about this matter may actually come across to your baby. She may not understand what she is feeling, but it may make the whole sippy cup matter stressful to her.
The first thing I would do is to simply convince yourself that it won't be a big deal if your baby doesn't use a cup just yet. I assure you she will. Next, make sure she always has her bottle available when you offer her a cup so she won't get the message that using a cup will mean no bottles. If she's attached to her bottle, associating the cup with loss of the bottle is sure to create resistance. Finally, offer her sips of what you have in your cup whenever the opportunity arises. It may not be as neat as a sippy cup, but the association of a cup with sharing with adults is bound to make it more desirable.
Sincerely,
Dr. Warren
I just want to know how to help her. Should I see a specialist? Please help me.
Thank you in advance.
Regards,
-RD
Dear RD: One of the biggest mistakes parent make with a constipated child is stopping all treatment as soon as the child has normal bowel movements. The problem with that is, that if the child tends to constipated, the constipation will very likely recur. The function of the rectum is to store stool and reabsorb water from stool until the stool is evacuated. The longer a stool sits in the rectum, the harder and drier it will become. That means that the longer a person goes without a bowel movement, the harder the stool will become.
If the hard stool causes your daughter to bleed and have pain, at the moment she has the pain she will try to hold the stool in. This makes the stool harder resulting in more pain and more trauma to her anus. It can become a vicious cycle in which the pain causes the child to withhold stool, the stool withholding causes the stool to become hard, and the hardness of the stool causes pain. The best treatment is lubrication with mineral oil. If the mineral oil keeps the stool soft and keeps your daughter regular, there is no rush to get her off it.
Sincerely,
Dr. Warren
She initially was diagnosed by our pediatrician as having a sinus infection. (She has had numerous sinus infections over the last 6 months, all successfully treated by antibiotics.) She was placed on Cefzil for 14 days along with Sudafed. She improved, but not to the point of the cough being eliminated.
After being off the Cefzil for 4 days, she was put on Augmentin for 10 days for the small remnant of sinus infection that still existed, along with Claritin. Although the coughing diminished, after about 7 days it picked up in intensity again.
At this point, our pediatrician determined that there was no infection left, but just a persistent post-nasal drip. He prescribed Nasanex spray once per day along with Sudafed. We have also given her Zyrtec in place of the Sudafed. The cough symptoms have not changed.
My daughter saw an allergist several days ago, who examined her, ran a standard series of allergy tests and gave her a pulmonary capacity test, none of which showed any problem. The allergist's opinion is that since my daughter does not cough when occupied, nor does she cough in her sleep, that the cough is simply a habit that will diminish with time and that no medication is needed.
Our pediatrician feels that the allergist's exam confirms that nothing was missed in his own staff's exam that can be treated via medication. He is advising us to sit tight for a week to 10 days and ignore the coughing behavior.
Although the cough does not seem to bother my daughter in any way except in her ability to get to sleep, it is a disruption within her school classroom and it is certainly of continued to concern to those of us who are not seeing the symptoms abate.
I would appreciate your thoughts on the feasilbility of the cough being simply habit versus a symptom of something that would be suitable for diagnosis by an ENT speciailist. Along with this, if you feel that this cough is probably a habit, any useful tips to help expedite its departure would be appreciated.
-KW
Dear KW: Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company gives the following information and advice about habit coughs:
Habit cough ("psychogenic cough tic") needs to be considered in any child with a cough that has lasted for weeks or months, that has been refractory to treatment, that disappears with sleep, and that typically has a harsh, "barking" quality. This cough may be absent if the physician listens outside the examination room, but will reliably appear immediately upon the physician's entering the room and paying attention to the child and the symptom. It typically begins with an upper respiratory infection, but then lingers. The child misses many days of school because the cough disrupts the classroom. This disorder accounts for many unnecessary medical procedures and courses of medication. It is treatable with assurance that lung pathology is absent and that the body has just gotten into the habit of coughing even when it is no longer necessary. This assurance, together with speech therapy techniques that allow the child to reduce musculoskeletal tension in the neck and chest and that increase the child's awareness of the initial sensations that trigger cough, has been very successful, often within minutes. .... The designation "habit cough" is preferable to "psychogenic cough," because it carries no stigma and since most of these children do not have significant emotional problems. When the cough disappears, it does not re-emerge as another symptom.Habit coughs may initially result from postinfectious hypersensitivity of cough receptors and then persist beyond the point that there is any physiologic reason for them. Although the cough may interfere with falling asleep, habit coughs do NOT disturb sleep. Therefore, if the cough is disturbing your child's sleep, you should consider the need for further evaluation. You could see an ENT to assure yourself that there is nothing in the nose or throat contributing to the cough, but if your daughter's cough meets the criteria for the diagnosis of habit cough, considering the considerable treatment and evaluation she has already had I would heed the admonition above
This disorder accounts for many unnecessary medical procedures and courses of medication.and avoid any invasive or unnecessary procedures.
Sincerely,
Dr. Warren
-Jackie
Dear Jackie: You've actually chosen quite a complex subject for your mock ethics committee meeting. Hypoplastic left heart is a complex abnormality. According to Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company
Patients [with hypoplastic left heart] most often succumb during the first months of life, usually during the 1st week or two. Occasionally patients may live for months or rarely years. One third of infants with hypoplastic left heart syndrome have evidence of either a major or minor CNS [central nervous system] abnormality. Other dysmorphic features [visible abnormalities of body or face] may be found in up to 40%. Thus, careful preoperative evaluation (genetic, neurologic, and ophthalmologic) should be performed in those patients being considered for either standard surgical or transplant therapy.Sabiston: Textbook of Surgery, 15th ed., Copyright © 1997 W. B. Saunders Company explains your dilemma as a pediatrician very well as follows:
The development of the Norwood procedure [a 3 stage repair for hypoplastic left heart, meaning 3 separate surgeries during the first 2 -3 years of life] and the introduction of neonatal heart transplantation have clearly introduced hope for children born with hypoplastic left heart syndrome. Unfortunately, they have also introduced a dilemma for the parents and physicians. Staged reconstruction and neonatal heart transplantation are themselves in their infancy. The long-term outcomes of children treated with either approach remain unknown. This uncertainty must be conveyed to the parents along with the relative advantages and disadvantages of the two procedures. Because long-term success cannot be reliably predicted, at most institutions compassionate care (no treatment) remains an option for these infants. In the current state of experience, a consensus regarding the best treatment approach has not been reached. Some centers recommend compassionate care, some are committed to transplantation, others are committed to staged reconstruction, and yet others try to provide both approaches. If well-informed physicians who deal with hypoplastic left heart syndrome on a regular basis cannot reach a consensus, how can a parent who has just learned about the defect be expected to know what to do? Thus, while hope has been extended to these families, much uncertainty and many unanswered questions remain. Parents must be given time to understand the diagnosis and prognosis, as well as the treatment options. A compassionate physician must honestly explain the options and expected results without imposing personal bias.As the pediatrician for this child and not a cardiac surgeon or expert on the management of this rare anomaly (the last one I saw was in medical school 25 or more years ago), you will do as I did, and turn to the books and the experts for advice. Assuming you have a relationship with the parents, you can be an excellent source of support for them. If you have not yet established a relationship, you can still help by being an interpreter of all the medicalese the parents will be hearing as they try to decide the fate of their child.
If the parents ask about surgical treatment without transplant you can tell them that "the risk of completing all three stages is considerable, and the long-term results of the Norwood procedure remain to be demonstrated." Transplantation can be done in the immediate newborn period or after a first stage palliative surgery. "After transplantation, patients will usually have normal cardiac function and no symptoms of heart failure; however, these patients have the chronic risks of organ rejection and life-long immunosuppressive therapy [medications which decrease the function of the immune system to help prevent organ rejection]."
According to Sabiston: Textbook of Surgery, 15th ed., Copyright © 1997 W. B. Saunders Company
Which treatment approach is best for patients with hypoplastic left heart syndrome remains controversial. Each technique has its own set of advantages and disadvantages. Transplantation permits establishment of normal circulatory physiology without the need for subsequent surgical procedures. Unfortunately, the wait for an appropriate donor heart imposes its own morbidity and mortality. Furthermore, the length of graft survival that can be achieved is unknown. In addition to the risks of rejection and infection, the specter of posttransplant coronary artery disease looms for all heart transplant patients, including neonates.
The registry of the International Society of Heart Transplantation reported an incidence of hypertension [high blood pressure] of 39%, renal dysfunction [abnormal kidney function] of 17%, graft atherosclerosis of 8%, and malignancy of 3% in a group of 362 children undergoing heart transplantation for a variety of reasons, including hypoplastic left heart syndrome.
Staged reconstruction can be applied to most infants with hypoplastic left heart syndrome waiting only for hemodynamic [referring to blood flow] stability and organ recovery. Two additional surgical procedures, however, must be performed, each with its own risk. Recent improvements in operative risks for all phases of the staged approach have renewed interest in this method, especially when early actuarial survival at some centers begins to match or even exceed what has been reported for transplantation. The long-term results of Fontan correction [the third and most complex stage of the correction], however, predict a late phase of mortality for even the strongest candidates. Thus, the best approach to hypoplastic left heart syndrome remains to be determined.Assuming the child survives all the stages of palliative repair, he will still not have a normal heart, and as stated above, the long term outcome is still not known.
Staged repair, transplant, or compassionate care ending in death: if there are no other abnormalities, especially significant CNS abnormalities, choosing to let your newborn die when there is a glimmer of hope, even a glimmer associated with significant risk, pain, expense, and uncertainty. These are the difficult choices.
The family's life changes forever the minute the child is born. Life either focuses on medical care and medical choices, or the loss of the infant. Dreams change. These stresses unfortunately can tear families apart. In many traditional families the father will be continuing to focus on career advancement along with medical bills while the infant's medical condition will exaggerate the mother's role as caregiver. If the mother becomes consumed by the child's needs and the father does not become involved, it may drive a wedge between the parents. If there are other children, the sick child's needs and the parents' reactions may exaggerate the normal sibling rivalry and guilt feelings which can be associated with it. This can result in behavior problems in the other children creating a whole new family dynamic.
I hope this provides you with enough of an answer to a medical situation to which there are no definitive answers. I have quoted liberally from texts since I am not an expert on the subject. Few pediatricians are. I have included annotations in brackets to clarify medical terms in the quoted text.
Sincerely,
Dr. Warren
Dear Readers:This was originally answered in 1999 using texts written in 1996 and 1997 as a reference. This should not be taken as a statement of the state of care for Hypoplastic Left Heart in 2004; however, I think it is still an excellent example of medical ethical dilemmas.Sincerely,
Dr. Warren
Thank you!
-JT
Dear JT: Even though normal reflux occurs in younger babies more than older babies, it's disappearance is not related to neurological development, but rather to the rotation of the stomach, which changes with growth. The only association with motor development is that when babies spend more time upright the rotation of the stomach begins to change with growth. You almost never see toddlers spitting up as they walk along.
Whether or not your baby is just a big spitter or has significant reflux depends on whether she is gaining and growing well, has any signs of GI distress, chronic cough, or wheeze. If you have reason to believe your baby has significant reflux, the specialist to consult would be a gastroenterologist.
Sincerely,
Dr. Warren
-K
Dear K: Deciding whether or not a 4 month old is unhappy in daycare could be tough. The best advice I can give you is "know your baby." That's not easy considering how much 4 month olds change from day to day, but most young infants smile and coo at their parents, and for that matter, most people. If your baby's social behavior changes and there isn't any illness causing withdrawal or irritability, you should be concerned. Appetite changes may also be a clue. Also, just look at how well your baby is cared for. If your baby is well cared for it's likely that she's also getting attention. Watch how the staff handles the babies when they're dropped off. After 20 years as a pediatrician I still can't resist playing with babies. You can tell if caretakers have a genuine interest in their charges. It's not something people can turn on and off. If the place is adequately staffed by people who like babies, there's no reason a young infant should be unhappy in daycare.
Sincerely,
Dr. Warren
-GL
Dear GL: If your daughter is doing well on Carnation Soy Follow-Up and you have any reason to be concerned about giving her milk (or even if you don't), you can keep her on the Carnation Soy Follow-Up formula indefinitely. On the other hand, keeping milk out of a child's diet can be quite a burden. Even if you felt that your baby's colic was due to milk sensitivity, if she did well on Lacto-Free, she is not likely to be allergic to milk protein. Lacto-Free has no lactose in it, but it does have milk protein in it.
If you're interested, I have several letters about otitis media and dairy. Unfortunately, I don't have a search engine on "Ask Dr. Warren," but if you load the 1997, 1998, or 1999 lists of columns and use your Web browser's find function looking for the word "otitis," "ear," "milk," and "dairy" you should be able to find the letters.
Sincerely,
Dr. Warren
Note to Readers: Ask Dr. Warren does have a Search Engine now even though it didn't when this response was written.
-A
Dear A: If your knees are dark because of scaly skin, you might see some improvement by using a moisturizer and a dandruff shampoo to remove the scale. If you believe the skin is not normal, you should consult a dermatologist. The skin is naturally darker on the thicker skin that covers some peoples knees and elbows. If all else fails, consider makeup.
Sincerely,
Dr. Warren
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