18 April 2005

1. Components of Physical Exam
2. Colic
3. Pachygyria
4. Konjac Root
5. Swearing 4 Year Old
6. Congential Ocular Motor Apraxia
7. Advanced Bone Age
8. Premature Puberty?
9. Disclaimer

• Read Questions & Answers in Another Column

Components of Physical Exam

Thanks!

-CP

Dear CP: If you're looking for official practice guidelines, you might try the American Academy of Pediatrics Web site at http://www.aap.org. If you're just looking for my opinion I'd say a complete exam ought to include the following:

• Hearing screening
• Vision screening
• Urinalysis (some studies suggest that the yield is so low that it is not justified. On the other hand, I've heard it described as "a liquid biopsy of the urinary tract." It's not an expensive test, and it's certainly non-invasive. With healthy kids, the "yield" of physical exams should also be low)
• Hemoglobin (annually for menstruating girls, otherwise every 2-3 years)
• Blood Pressure
• History:
  • review of systems, complaints, current meds, school progress, social adjustment, use of alcohol, drugs, cigarettes, sexual activity. Some of these subjects can be brought up in such a way as to make sure the teen knows it's okay to talk about these things with no pressure to answer questions, and full assurance of confidentiality.
• Height, Weight, Review of Growth Chart
• Review of Immunizations
• Examination:
  • eyes, ears, nose, throat, heart, lungs, abdomen, pulses, lymph nodes, spine, hernia
  • evaluation of pubertal development - male genital exam should include palpation of testes and examination of penis. Female exam should include evaluation of breast development. Some doctors would start annual breast exams once there is breast development. Pelvic exams are generally not indicated before 18 without a history of sexual activity.
  • examination relevant to any existing conditions or new complaints.
  • rectal exams are not part of a routine physical in children.

Sincerely,
Dr. Warren

Treatment already being given:
Message on stomach, which causes temporary relief.

-Mr. & Mrs. R

Dear Mr. & Mrs. R: Unfortunately there is no proven therapy that relieves colic, perhaps because not all crying babies are crying for the same reason. Fortunately, most colic resolves by 4 months of age. The first thing to do is to see if there is a reason the baby is crying. The baby should have a complete physical to be sure everything is okay. If the baby is nursing, Mom has to review her diet to make sure she isn't eating anything which gives the baby gas. Many nursing mothers are not aware that when they drink milk it may make their baby's colicky. If the baby is formula fed, it's worth trying a hypoallergenic formula like Alimentum or Nutramigen to see if the symptoms will be relieved.

Chamomile tea is a popular treatment for colic. It is harmless, but no study has ever established it as an effective treatment. Mylicon drops may be helpful for gas pains, but again, no study has shown it to be an effective treatment for colic. If the baby is crying most of the night, you might want to consider purchasing a device like Nature's Cradle by Infant Advantage. You can find more information at their Web site. *

Young infants should be swaddled (wrapped in their blankets) for sleeping. For intermittent crying, there's nothing like taking turns walking with the baby or rocking gently in a rocking chair in a dark room with your baby in your arms while you sing sweetly to him. For the occasional really bad night, the motion of a little car ride sometimes puts the baby's to sleep.

Sincerely,
Dr. Warren

Thank you.

-BK

Dear BK: The condition you are referring to is called pachygyria. "Pachy" refers to the fact that the brain surface is similar to elephant's skin, and "gyria" refers to the normal grooves (gyri) on the surface of the brain. I remembered this term from medical school (many years ago) but had a great deal of difficulty finding any information about it. Pachygyria is a rare development disorder resulting from impaired neuronal migration. Usually, it is a sporadic phenomenon, but rare dominant or autosomal recessive syndromes are known. It generally is associated with neurological impairments such as developmental delays and may be associated with seizures. Since it is a structural abnormality of the brain, there is no medical treatment (unless treatment is needed for seizures). Management is done through early intervention programs with speech therapy, PT, OT, and later on, appropriate educational placement.

Sincerely,
Dr. Warren

Thank You.

-TT

Dear TT: The following articles suggest that Konjac Root is both safe and effective:

Effect of short-term ingestion of konjac glucomannan on serum cholesterol in healthy men. Arvill A - American Journal of Clinical Nutrition - 1995 Mar; 61(3): 585-9

From NIH/NLM MEDLINE, HealthSTAR Author Affiliation: Department of Clinical Physiology and Occupational Medicine, Orebro Medical Centre Hospital, Sweden.

Authors: Arvill A; Bodin L

Abstract: The effects of the soluble fiber konjac glucomannan (GM) on serum cholesterol concentrations were investigated in 63 healthy men in a double-blind crossover, placebo-controlled study. After a 2-wk baseline period, the subjects were given 3.9 g GM or placebo daily for 4 wk. After a washout period of 2 wk, crossover took place, followed by another 4 wk of treatment. The subjects were encouraged not to change their ordinary diets or general lifestyle during the investigation. GM fibers reduced total cholesterol (TC) concentrations by 10% (P < 0.0001), low-density-lipoprotein cholesterol (LDL-C) concentrations by 7.2% (P < 0.007), triglycerides by 23% (P < 0.03), and systolic blood pressure by 2.5% (P < 0.02). High-density-lipoprotein cholesterol (HDL-C) and the ratio of LDL-C to HDL-C did not change significantly. No change in diastolic blood pressure or body weight was observed. No adverse effects were observed. The results of this study show that GM is an effective cholesterol-lowering dietary adjunct.

Effect of glucomannan on obese patients: a clinical study. Walsh DE - International Journal of Obesity - 1984; 8(4): 289-93

From NIH/NLM MEDLINE, HealthSTAR

Authors: Walsh DE; Yaghoubian V; Behforooz A

Abstract: An eight-week double-blind trial was conducted to test purified glucomannan fiber as a food supplement in 20 obese subjects. Glucomannan fiber (from konjac root) or placebo was given in 1-g doses (two 500 mg capsules) with 8 oz water, 1 h prior to each of three meals per d. Subjects were instructed not to change their eating or exercise patterns. Results showed a significant mean weight loss (5.5 lbs) using glucomannan over an eight-week period. Serum cholesterol and low-density lipoprotein cholesterol were significantly reduced (21.7 and 15.0 mg/dl respectively) in the glucomannan treated group. No adverse reactions to glucomannan were reported.

Sincerely,
Dr. Warren

-JD

Dear JD: If your 4 year old swears,

• First find out what can be done to alter the environment where he is exposed to swearing or remove him from that environment.
• Second, if he is swearing in anger, find out why his is angry or unhappy and figure out how to deal with that. If he is swearing to get attention, make sure he is getting adequate attention to meet his needs.
• Third, make sure your reaction to his swearing is not a source of pleasure for him. He may think it's a great game.
• Fourth, set a good example for him and don't swear. This is essential for the next item.
• Fifth, tell him that when people swear, the only thing people notice is the swear words, and not what the person is saying. Tell him that if he wants to talk to you he cannot swear, and that if he does, you will ignore what he is telling you. Then, make sure your only verbal response to swearing is to tell him that if he wants you to listen to him, he has to talk without swearing.
• Sixth, consistently put him in time out when he swears.
• Seventh, offer to reward him with special time with you if he makes a reasonable effort to stop swearing. Don't expect immediate perfection. He's only 4. Reward his efforts to motivate him to try harder.

Sincerely,
Dr. Warren

Thank you in advance for your consideration

Best Regards,
-TM

Dear TM: Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright _ 1996 W. B. Saunders Company says the following:

CONGENITAL OCULAR MOTOR APRAXIA

This congenital disorder of conjugate gaze is characterized by a defect in voluntary horizontal gaze, compensatory jerking movement of the head, and retention of slow pursuit and reflexive eye movements. Additional features are absence of the fast (refixation) phase of optokinetic nystagmus and obligate contraversive deviation of the eyes on rotation of the body. Typically, the affected child is unable to look quickly to either side voluntarily in response to command or in response to an eccentrically presented object but may, however, be able to follow a slowly moving target to either side. To compensate for the defect in purposive lateral eye movements, the child jerks the head to bring the eyes into the desired position and may also blink repetitively in an attempt to change fixation. The signs tend to become less conspicuous with age.

The pathogenesis of congenital ocular motor apraxia is unknown. It may be a result of delayed myelination of the ocular motor pathways. Structural abnormalities of the central nervous system have been found in a few patients, including agenesis of the corpus callosum and cerebellar vermis, porencephaly, hamartoma of the foramen of Monro, and macrocephaly. Many children with congenital ocular motor apraxia show delayed motor and cognitive development.

A disorder of eye movement resembling congenital ocular motor apraxia may occur in patients with certain metabolic neurodegenerative diseases (particularly Gaucher disease) or with ataxia-telangiectasia, or as a sign of brain tumor.

Sensory integration dysfunction is more of an educational or occupational therapy diagnosis. I did not find any reference to it in recent medical literature. The word indicate that your son has difficulty putting different sensory stimuli together into a meaningful whole. A pediatric neurology evaluation may help you determine if his ocular motor apraxia is associated with any other neurological conditions and somehow impacting on his sensory integration dysfunction.

Sincerely,
Dr. Warren

Your response would greatly be appreciated.

-SS

Dear SS: I might be able to give you a more reasonable interpretation of the significance of an advanced bone age if I knew why it was done in the first place. If, for example, your daughter were showing signs of breast development, the advanced bone age would serve as confirmation that this could be precocious puberty. A bone age advanced by one year at age 6 may simply coincide with more advanced development, or it could be associated with glandular abnormalities affecting growth.

Sincerely,
Dr. Warren

My doctor expressed concern about premature puberty. I know there are several problems that go along with this including increased rates of breast cancer, pituitary problems, bone growth problems and the list goes on. Is my daughter at risk for these problems? My doctor has asked us to come back in October for a follow-up, which we will do. However, my doctor has suggested that if there are any other signs of puberty she may want to do a pelvic exam to check my daughter's ovaries. Is she not too young for this? This is an examination through the vagina is it not? I do not want my daughter to have to go through such an examination at a young age; lets face it, even for an adult they are not pleasant. I began menstruating at 13, my daughter's paternal grandmother and aunt were both over 14 when the started menstruating. Why is my daughter so much earlier?

I would appreciate any help or knowledge you can give me on this.

-AL

Dear AL: Breast development at 9 years of age is not abnormal and does not require medical evaluation in the absence of any other signs of a problem. Menstruation generally follows the first signs of breast development by 2 years. Sometimes breast development may start in the absence of further pubertal development (premature thelarche) in which case further signs of puberty and the onset of menstruation may not occur within two years of early breast development. Prior to the onset of menstruation your daughter should experience further breast development and pubic hair growth. While menstruation by 11 years of age is not a picnic, it is fairly common.

If your doctor feels an evaluation of your daughter's ovaries is warranted for any reason, an ultrasound exam is non-invasive and should provide adequate information to determine if further evaluation or intervention is needed. Precocious puberty is an endocrine problem, not a gynecological problem. Just on the basis of breast development at 9 years of age, I don't feel your daughter qualifies, but should you want an expert opinion, you should consult a pediatric endocrinologist.

The timing of menstruation is influenced by genetics, but is also influenced by other factors. Good nutrition in the USA has contributed to a generally earlier age of first menstruation than in previous generations. The genetic aspect is complex enough that you may also have to take into account the paternal grandfather's genetics, and since he didn't menstruate, you'd have to know about other women in his family.

Sincerely,
Dr. Warren

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