13 December 2004

1. Should Adenoids Be Removed?
2. Significance of Excess Amniotic Fluid
3. Recurrent Blisters in Throat
4. Very Frequent Urination
5. Hepatitis C
6. Allergies and Nursing
7. Lumps
8. Sore Throat
9. Disclaimer

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Should Adenoids Be Removed?

Thank you.

-Concerned Mother

Dear Concerned Mother: The adenoids are lymphoid tissue similar to tonsils and lymph nodes. They participate in the body's fight against infection. Because of their location, they become inflamed in the fight against upper respiratory infection. Inflammation is part of the mechanism through which the body guards against infection, however, when the inflammatory response produces excessive symptoms or tissue enlargement, as is the case with enlarged adenoids, it becomes more of a liability than a benefit.

Even though the adenoids participate in the fight against upper respiratory infection, there is enough lymphoid tissue in the upper respiratory tract that removal of the adenoids will not leave a child more prone to infection. In fact, if the adenoids are chronically infected, the child will tend to be sicker with the adenoids than without them. The adenoids may shrink down on their own without surgery, but given the frequency with which young children get colds and other respiratory infections they may remain enlarged for the duration of childhood. Because of their location, enlarged adenoids can obstruct the eustachian tubes and the sinuses contributing to chronic or recurrent ear infections and sinusitis. They can also obstruct the nose resulting in mouth breathing. Chronic mouth breathing can adversely affect the development of the palate and jaw.

Whether or not to consider having adenoids removed depends on what type of problems a child is having due to his enlarged adenoids. Recurrent ear infections, recurrent sinus infections, and/or sore throats or disturbed sleep from chronic mouth breathing may all be reasons to consider surgery. If the symptoms are not severe, with time the adenoids may shrink enough for the symptoms to resolve without surgical intervention, but this could take many years.

Sincerely,
Dr. Warren

-Mark

Dear Mark: Excess amniotic fluid is called polyhydramnios: According to Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company , polyhydramnios is associated with certain congenital anomalies including anencephaly, hydrocephaly, tracheoesophageal fistula, duodenal atresia, spina bifida, cleft lip or palate, cystic adenomatoid lung malformation, and diaphragmatic hernia. It may also be seen with the following congenital syndromes: Achondroplasia, Klippel-Feil, 18- and 21-trisomy, TORCH, hydrops fetalis, multiple congenital anomalad. Polyhydramnios may also be seen with diabetes mellitus in the mother, twin-twin transfusion, fetal anemia, fetal heart failure, polyuric renal disease, neuromuscular diseases, nonimmune hydrops, chylothorax, teratoma, and for unknown causes.

Certain congenital anomalies can be diagnosed prenatally by ultrasound. The most common causes of polyhydramnios are maternal diabetes and multiple births which do not have to be associated with any fetal abnormalities. Even in the absence of fetal anomalies polyhydramnios increases the risk to the pregnancy by increasing the risk of premature labor or abruptio placenta (premature separation of the placenta).

Sincerely,
Dr. Warren

Sincerely,
Tina

Dear Tina: If you have white patches in the throat, your doctor should culture for a yeast infection. Treatment with antibiotics may aggravate a yeast infection.

If you have recurrent mouth sores, you might do better consulting your dentist. Recurrent mouth sores with swollen gums may occur with neutropenia (low white blood cell count). Neutropenia can occur in cycles so your blood should be checked when you have the sores. I have never seen a situation where the sores are only in the throat with neutropenia.

Herpes virus can cause recurrent outbreaks of blisters, but herpes generally involves the whole mouth during the initial outbreak with recurrences in the form of fever blisters on the outside of the lips. I have not seen recurrent herpes involving the throat.

Iron deficiency, folate deficiency, and vitamin B-12 deficiency may be associated with mouth sores. If your sores are always premenstrual, an estrogen-dominated oral contraceptive may help.

Removal of your tonsils should not have resulted in any kind of recurrent blisters in your throat; however, if the problem is only in your throat, perhaps you can see an ENT specialist when you have an outbreak.

Sincerely,
Dr. Warren

It started when he began kindergarten and it seemed to go away on it's own in two weeks. Then after Christmas break it started again only it got worse. He was so frustrated with having to go to the bathroom all the time he started to pee on the floor around the house.

I took him to our pediatrician and he tested him for diabetes and infection and that was negative. He put him on some medication for a bladder spasm and later for bedwetters. Neither really helped. He was urinating up to 14-20 times or more a day. After deciding to let it rest for awhile and see what happens (not draw attention to it) it seemed to pass again after a very long time. However, it came back when he started T-ball for the first time. But, then again it subsided on it's own. Now he has it again about 2 months later and there is no connection (no change or stress to connect it to). He has started to pee on the floor between the wall and furniture so I won't find it (but I do eventually) out of frustration again for having to use the bathroom so frequently. I don't know what to do now. Do you think this might be just a behavioral problem? What would be our next step?

P.S. There has been no bed wetting at all and he says it doesn't hurt to pee, but it feels funny and not right.

Please help !!

-Lori

Dear Lori: According to Walsh: Campbell's Urology, 7th ed., Copyright © 1998 W. B. Saunders Company, "Extraordinary urinary frequency is one of these presentations and has been described by Zoubek and colleagues (1990). These patients are predominately male with a mean age of 5 to 6 years who present with frequency averaging every 30 minutes. After ruling out more serious pathology with urinalysis and US [ultrasound] examination, the patients can be treated by reassurance to the parents or with low doses of anticholinergic therapy [medication], although Koff and Byard (1988) did not find this useful. The symptoms are self-limiting, and cystoscopy is contraindicated."

Since your son has had a normal urinalysis and negative urine culture he should probably have a renal and bladder ultrasound (pre and post void) to be sure there is no unusual cause. Since medication didn't help, your next step might be to consult a pediatric urologist. Even though the urology text did not mention it, I have occasionally seen boys who appeared to have these symptoms because of meatal stenosis (a narrow urinary opening) who improved after a meatotomy (surgery to correct the condition). Since meatal stenosis does not usually cause any symptoms and most boys with frequent voiding get better on their own, I can't help wondering whether the urology text didn't mention it because no study has established meatal stenosis as a cause or meatotomy as an effective treatment.

Most of the time your son's symptoms seemed to be provoked by stress. The fact that you don't identify a stress may not mean there isn't one. Sometimes adults can't recognize stressful situations for kids because adults don't find the same things stressful that kids do. Don't forget that not all stressful situations need to be unpleasant. Being excited about something can also be stressful.

You have to give serious consideration to the emotional and behavioral aspects to this problem. My pediatric training really doesn't make me an expert at thinking like a child, but after observing many of the behavioral aspects of childhood issues, I still can't understand why the need to urinate frequently would make a child urinate in inappropriate places. I could understand if he were playing outside finding a bush to pee on instead of coming inside, but when he's indoors, if he's taking the time to pull down his pants and aim where he thinks you won't find it, how much more time could it take for him to get to a bathroom?!?

Sincerely,
Dr. Warren

Dear Readers: There have been a lot of advances in Pediatric Urology since this question was answered. This child should definitely see a Pediatric Urologist for evaluation of his voiding since certain voiding problems can be diagnosed with tests and treated with bio-feedback.

Sincerely,
Dr. Warren

-C

Dear C: The following is a patient handout about Hepatitis C: unfortunately it is geared toward adults, but will give you some idea of what to expect.:

Copyright © Clinical Reference Systems 1998 Adult Health Advisor Women's Health Advisor

Hepatitis C

What is hepatitis C?

Hepatitis means inflammation of the liver. Viruses are a frequent cause of hepatitis. One of the common hepatitis viruses is hepatitis C. When the liver is infected with a virus, it becomes inflamed and usually becomes tender and swollen. The infection may destroy patches of liver tissue.
If you are infected with hepatitis C, you may develop chronic (ongoing) liver disease. Even mild cases tend to get worse over time, often resulting in cirrhosis of the liver. Hepatitis C also increases the risk of liver cancer.

How does it occur?

Two common causes of hepatitis C are intravenous (IV) drug abuse and blood transfusions. Before 1990 the hepatitis C virus was the most common cause of hepatitis in people who had blood transfusions. However, now blood donors can be screened for the virus.
Hepatitis C can be spread by people who do not have an active infection. They are called asymptomatic carriers.

What are the symptoms?

The symptoms of hepatitis C are similar to the symptoms of other forms of viral hepatitis. Symptoms may appear 2 weeks to 6 months after you are infected.
The disease usually begins with typical symptoms of infection:

• loss of appetite
• weight loss
• fever
• general achiness
• fatigue.

Other early symptoms may include:

• itching hives
• pain in some of the joints
• in smokers, a loss of taste for cigarettes.

The following symptoms may follow several days after the early symptoms:

• nausea and vomiting
• foul breath and bitter taste in the mouth
• dark urine
• yellowish skin and eyes (jaundice)
• pain just below the ribs on the right side, especially when pressure is applied
• bowel movements that are whitish or light yellow and may be looser than normal.

Some people develop a chronic form of the disease without any obvious symptoms, even though damage to the liver may be occurring. The symptoms of chronic hepatitis may be persistent fatigue, weakness, and loss of appetite, as well as some of the other symptoms listed above.

How is it diagnosed?

Your medical history and symptoms are the important first step in diagnosis. Especially important is your history of hepatitis risk factors such as blood transfusions or IV drug abuse.
When your health care provider examines you, he or she may find that your liver is enlarged and tender.
Your provider may use the following lab tests:

• blood tests
• analysis of a urine specimen
• analysis of a stool specimen.

Hepatitis C can now be diagnosed with a blood test. It may be discovered at a routine exam when liver function tests are abnormal.
To diagnose chronic hepatitis, the health care provider may order a liver biopsy, a procedure in which a small amount of liver tissue is removed for examination. This is done through the skin after you are given a local anesthetic.

How is it treated?

Your health care provider will recommend getting rest, having a nutritious diet, and avoiding alcohol and certain medications for at least 6 months. Hospitalization isn't usually necessary. In more serious cases (for instance, if you become severely dehydrated), you may need to be hospitalized.
Alpha interferon can be used to treat chronic hepatitis C. Adequate nourishment and avoiding overexertion and alcohol are also important in treating chronic hepatitis. To reduce inflammation, your health care provider may prescribe steroids.
Regular exams are very important and may continue at regular intervals for months to years.

How long will the effects last?

Symptoms may last from 1 to 6 weeks and are usually followed by complete recovery. Relapse is common, however, and can be triggered by drinking too much alcohol or exerting yourself before you are fully recovered. It may also be caused by another infection. Relapses are usually milder than the initial infection and respond well to rest.
After having hepatitis C, a third to half of patients develop chronic hepatitis. As many as 35% develop chronic liver disease, including cirrhosis. Your health care provider may check your blood every few months for signs of chronic liver disease.

How can I take care of myself?

• Avoid taking drugs that are metabolized in the liver. Ask your health care provider which drugs these are.
• Rest in bed until your fever is gone, your urine returns to its normal color, and your jaundice disappears. Ask your health care provider how much bed rest is necessary and when you should resume normal activity.
• As your symptoms improve, you may gradually increase your level of activity.
• Avoid strenuous activities for several months.
• Eat small, balanced meals, even when you feel nauseous. Some foods may not appeal to you, especially in the early stages of the disease. Lightly carbonated soft drinks, juices, and hard candy may help reduce nausea.
• Follow your health care provider's instructions for taking medicines to relieve your symptoms.
• See your health care provider if any of the following occurs:
  • Your appetite continues to decrease.
  • You have worsening drowsiness, confusion, or irritability.
  • You have vomiting, diarrhea, or abdominal pain.
  • Your jaundice worsens.
  • You have a rash or your skin itches.

What can be done to help prevent spreading hepatitis C?

• Use good health habits. Take special care to wash your hands thoroughly with soap and warm water after using the bathroom and before eating or preparing food.
• Do not let others come in contact with your blood; for example, when you have a bloody nose or a cut.
• Avoid sharing needles, razorblades, and toothbrushes with others.
• Avoid sexual activity until the disease is no longer contagious.
• Avoid donating blood if you have hepatitis or may be a carrier.

At this time there is no immunization for hepatitis C.

the risk of fulminant hepatitis is low with HCV [hepatitis C], but the risk for chronic hepatitis is the highest among the hepatitis viruses. The usual chronic course is mild even when cirrhosis develops; long-term follow-up indicates that the overall mortality of persons with transfusion-acquired HCV is no different from that of noninfected controls. Interferon alpha-2b is available for treatment of chronic hepatitis in persons 18 yr of age or older with compensated liver disease who have a history of blood or blood product exposure or who are HCV antibody positive or both.

Interferon-alpha is the only treatment currently available for chronic HCV infection in adults, but 20% or less of patients have had a sustained response. Interferon therapy is not approved by the Food and Drug Administration for those less than 18 years of age. Limited experience in children with interferon-alpha therapy suggests efficacy similar to that observed in adults. Children with severe disease or histologically advanced pathology (bridging necrosis or active cirrhosis) should be referred to a specialist in the management of chronic HCV infection.

Persons who have chronic HCV infection are at risk for development of serious liver disease, including primary hepatocellular carcinoma (PHC) with advancing age. However, PHC from chronic HCV infection has been only reported, to date, in adults. Children with chronic infection should be screened periodically for chronic hepatitis with serum liver function tests because of their potential long-term risk for chronic liver disease. Definitive recommendations on frequency have not been established. Children with persistently elevated serum transaminases concentrations (exceeding twice the upper limits of normal) should be referred to a gastroenterology specialist for further management.

Sincerely,
Dr. Warren

Dear Readers: A more recent edition of the Red Book (after this question was answered) adds Ribavirin to the treatment regimen.

Sincerely,
Dr. Warren

-MP

Dear MP: I heartily support the idea of nursing for a full year and avoiding early introduction of any solids. From a nutritional stand point I think your child would do fine on just nursing for a year, but I do have some concerns about not introducing spoon feeding for a whole year. Some children may reject spoon feeding if they don't start somewhere in the range of 9 months. I am curious as to how you know your son is allergic to eggs and peanuts. These are foods which he should not have been exposed to by 7 months.

I have one patient with severe egg allergy. When he was due for the MMR we followed the instructions in the package insert for diluting the vaccine to make a test solution to see if he was allergic to the vaccine. He tested positive so we did not give him the vaccine. The chicken pox vaccine is not made in eggs. It should not be given to anyone who has an allergy to gelatin or neomycin.

Sincerely,
Dr. Warren

-T

Dear T: Lumps can be any size when they're first discovered. Your subject line says breast lumps, but you're describing lumps under your arms. Since they are tender, they could be swollen glands, cysts, or boils. If they bother you or frighten you, you should have your doctor check them regardless of how small they are.

Sincerely,
Dr. Warren

-Worried Mother

Dear Worried Mother: Without any details about the treatment your doctor gave I cannot comment, except that if your doctor felt your daughter had a virus infection, no antibiotic is appropriate. As to the antibiotic being too strong, even if the emergency room doc was a pediatrician, I'd be careful about interpreting his remarks to be a criticism of your doctor's treatment. Some antibiotics in appropriate doses (erythromycin for example) can make some patients vomit. Doctors sometimes make the mistake of explaining it to the patient as if it's due to being a strong medicine (as if this somehow excuses the bad reaction) rather than explaining that it is a known side effect of the medication which results in some patients not tolerating the medicine.

In my experience, ER physicians who are not pediatricians often underdose kids when they treat with antibiotics. If your doctor is a board certified pediatrician (which is generally a requirement for HMOs), he should be aware of the correct doses of antibiotics. Most kids who vomit from antibiotics don't vomit because of inappropriate dosing.

Tonsillitis is the correct diagnosis when a child is sick with swollen, pussy tonsils. Tonsillitis may be caused by strep or viruses. A rapid strep test or throat culture is necessary to diagnose strep. Strep should be treated with penicillin unless the patient is allergic to penicillin. Virus infections should not be treated with antibiotics. Please see my article, Sore Throats for a complete discussion.

Sincerely,
Dr. Warren

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