25 July 2005

1. Poor Weight Gain
2. Febrile Illness, UTI
3. Anesthetic Cream for Shots
4. Antibiotic Dosages
5. Nail Pits
6. Arching Back, Crying, Spasticity, Scissoring
7. Delayed Motor Development
8. Rash
9. Disclaimer

• Read Questions & Answers in Another Column

Poor Weight Gain

Sweat chloride negative; CBC showed 1.9mil platelets, most recent count at 604K (Hematologist does not see any connection to weight); has seen nutritionist, and despite being on a "high-calorie", "high-fat" diet for four weeks, has gained only a few ounces if anything; still eating one bottle of formula (with heavy cream added).

Some days appetite is good, some days not so good.

Generally good health, few colds, only two ear infections in lifetime.

Stools vary from "normal" (solid, dark) to pasty-sticky sometimes light colored.

Otherwise child seems to be progressing normally; walking well, fine motor ok, few words, generally cheerful. Sleeps well for naps, but seems to wake up a few times at night- very upset, but not alert... calms again with bottle and sleeps again. Not sure if she is waking from hunger, pain, nightmare?

Pediatrician is testing: blood chemistry, bone age (results; bone age = 18 mos), sweat chloride (results: negative), urine, stool, and then on from there.

Are there any avenues that we should consider? Any diseases, parasites, infections, allergies, metabolic or hormonal imbalances??? More help will be appreciated!

-CR

Dear CR: The most important detail which you didn't mention is what is happening to your daughter's height. If she isn't growing, she may not be gaining because of lack of growth. There are many causes for growth failure including chronic infection such as urinary tract infection, and congenital heart disease, but the main causes are usually glandular and would be evaluated by a pediatric endocrinologist.

If your daughter's weight is more profoundly affected than her height, then she may need a stool analysis to rule out malabsorption. This may be handled by a pediatric gastroenterologist. Parasites are easy to test for, but in the absence of chronic diarrhea are unlikely to be a cause of poor weight gain.

Sincerely,
Dr. Warren

-Rebecca

Dear Rebecca: "Febrile illness" means an illness with fever. Many illnesses cause fever, so it is not a specific diagnosis. Febrile seizures can occur with any illness which causes fever.

Even young infants can have kidney infections; however any young child who has had 5 kidney infections in 3 years deserves a thorough evaluation of the urinary tract including a VCUG (an x-ray study while urinating with dye put into the bladder) and a kidney ultrasound. If the VCUG shows reflux your daughter may need to stay on antibiotics for a while. You should probably consult a pediatric urologist.

Sincerely,
Dr. Warren

Thank you.

-EP

Dear EP: The only patch that comes to mind is EMLA cream. It is used for skin anesthesia. To the best of my knowledge it would not prevent the pain of an injection into the muscle. It is contraindicated in infants under 3 months (That means it shouldn't be used in such young infants). It must be applied and covered with an occlusive dressing 1 to 2 hours before a procedure. It must be used with caution in patients who have kidney or liver impairment or G6PD deficiency. It may cause methemoglobinemia. It could be absorbed to toxic levels through mucus membranes which could occur if an infant sucked on it.

Sincerely,
Dr. Warren

Yours sincerely,
-SI

Dear SI: Antibiotic dosages are based on weight and the type of infection being treated rather than age. Most 1-2 year olds would take 200 mg or erythromycin twice daily, 187.5 mg of cefaclor twice daily, 125 mg of amoxicillin 3 times daily, or 125 mg of Cefzil twice daily. Higher dosages may cause more side effects. There are some regimens that treat uncomplicated urinary tract infections with 1 dose or 3 days of medication. Uncomplicated ear infections and skin infections can be treated for 5 days. Children with a history of ear infections generally require 10 days of treatment. Strep throat must be treated for 10 days to avoid a high rate of relapse. Sinus infections may require 2 to 3 weeks of treatment. The long duration of treatment is aimed at fully eradicating infections and preventing relapse. Children do not take longer to feel better on these dosage regimens. Most infections respond clinically with improvement of symptoms within 48 to 72 hours of starting antibiotics. Many patients start to improve within the first 24 hours. I know of no evidence that higher doses make patients feel better faster. Neither do I know of any evidence that the duration of therapy can be shorter when higher doses are used. Doses are based on the amount required to reach a concentration in the blood stream and affected tissues which will kill the bacteria causing an infection. Once the therapeutic level is reached, higher doses provide no additional advantage. Since the antibiotics will be metabolized and excreted, the higher dosage also will not maintain therapeutic levels significantly longer.

Sincerely,
Dr. Warren

-RF

Dear RF: Pitted nails may be seen with psoriasis. Other nail conditions may be seen with other skin disorders. If there is a concern, have a dermatologist check your son's nails and skin.

Sincerely,
Dr. Warren

All of a sudden he cries constantly. We can console him to some degree by holding him, but this does not always work either. We have shifted to all the hypoallergenic formulas and that does not seem to be having any effect.

Yesterday, we took him to our new Pediatrician. She said she was concerned with the way he arched his back when he cried and that he had not stopped the "fencer's reaction." She suggested that we go to a pediatric neurologist.

The problem is that we cannot get into see the specialist until mid-September.

All the doctor has told us that none of the symptoms on their own are worrisome, but when put together in one infant they raise a red flag.

WHAT IS THEIR CONCERN? WHAT ARE THEY THINKING THIS COULD BE? DEVELOPMENTAL PROBLEMS? NERVE PROBLEMS?

Any insights you could give me would be appreciated.

-KN

Dear KN: I can understand your anxiety while waiting for your visit with the specialist. The best person to answer your question is the pediatrician who has examined your baby. Since I haven't seen your baby, the only thing I can tell you is that children who have neurological problems may be more irritable than other babies and they may have abnormalities of muscle tone which cause them to arch their backs. If the baby's muscle tone is normal and the only time he arches his back is when he cries, it could be perfectly normal.

By the way, the asymmetric tonic neck reflex (the fencing position) normally disappears between 4 and 9 months.

Sincerely,
Dr. Warren

Again, thank you for your reassurance.

-KN

Dear KN: The last thing I want to do is make you more anxious after providing reassurances; however, I also think it's important for my answers to be accurate in order to provide effective counsel as well as reassurance. Your original e-mail to me never mentioned "spasticity" or "scissoring."

Spasticity, which is often seen in cerebral palsy, generally doesn't show up in early infancy because the nerve pathways involved in spasticity are not fully myelinated. All normal newborns have increased flexor tone. They keep their knees, elbows, and hips flexed. This is generally decreasing by 4 months. Any significant increased muscle tone (which is what is seen with spasticity) would not be normal.

Scissoring is the term health professionals use to describe a situation in which the legs are held constantly crossed. It is seen with spasticity and is not considered normal at any age. I suppose somebody outside the health professions could come up with the term scissoring just from the appearance of it, but your use of the word makes me wonder who you've been talking to and if I'm missing any important information to properly advise you.

Many 4 month olds simply have no interest in bearing weight on their feet. Some pull their feet up to avoid it. On the other hand, a child who is spastic and scissoring would likely bear weight on his legs because of the spasticity.

Sincerely,
Dr. Warren

We are lucky in having another pediatrician in the family and he also looked at our son. When he first saw him, he said he saw the same warning signs as the first doctor. However, at the end of the visit with our son he said, "look at him now, he is not demonstrating any of the signs." He did go on to say that he did think we needed to follow up because of what he had seen in the early part of our visit. To this point, I went back and viewed video of our first child. She crossed her legs as much as our son does now.

All of this makes me think and hope that this may be a case where the doctor here is being cautious and in good faith wants to rule out the worst case. If it wasn't for the sudden onset of crying, I would not be as worried. Is there anything else that a sudden "personality change" could be attributed to at this developmental stage? When our son is picked up or you talk to him, the crying stops...most times. Could it be early teething? Could it be just his own little way of getting attention from Mom and Dad?

I hope I am not wearing out my welcome, but your information just in this letter has made waiting for our next visit a little less worrisome. My poor wife is obviously a wreck and I am trying to be the calming factor with her until our September 2 appointment with the pediatric behavioral specialist and/or a pediatric neurologist.

Thanks again and any additional insight would be appreciated.

-KN

Dear KN: Sudden onset in crying is generally related to some acute process. While babies with neurological injuries may be more irritable, your son's sudden increased irritability is more likely to be related to an illness, gas pains, constipation, or teething. That he responds to being held is a good indication that he's not in terrible pain. At 4 months he could be crying when he wants attention, but would be unlikely to suddenly demand constant attention. An acute neurological process causing irritability would not be likely to pass without consequence.

Scissoring is not simply legs crossing. Infants who scissor have tight hip adductors along with other signs of spasticity. When one attempts to stand these children they usually hold their legs rigidly straight with the toes pointed down as if on tiptoes, and the legs are held tightly together with the lower parts of the legs crossing.

Since the question of spasticity has been raised, you will need to proceed with a neurological evaluation to know if there is a problem, but as I previously stated, spasticity does not generally become evident so young. Infants with neurological damage are more likely to be floppy.

Sincerely,
Dr. Warren

she hadn't started to crawl, walk, or talk, and she keeps her right hand in the fist position most of the time. She does roll over and sit up, but she loses her balance easily.

She is now 19 months old and has been in physical therapy for about 4 months - without any progress. (she is still the same)

The physical therapist suggested taking her back to the pediatrician because she thinks something may be wrong with her pelvic bones causing her to be off balance, and due to the right side seams weaker than her left.

The family keeps saying that she's just lazy. I work in a hospital and have talked to a few people and have read up on neuromuscular conditions. Just in observing her - I think there's something definitely going on.

Is it possible for her to be slow/or is it possible for cerebral palsy (or any related neuromuscular condition) not to show up on these kinds of testing? What other test and/or conditions should be ruled out?

Please e-mail me back with your comments and suggestions. Your time is appreciated.

Thanks.

-SB

Dear SB: The asymmetry of muscle tone and movement you describe sounds like a hemiplegia and could certainly be seen with cerebral palsy. That is a clinical diagnosis. EEG, blood work, and muscle biopsy could be perfectly normal. The MRI might show evidence of cerebral atrophy on the opposite side of the brain from the problem, but a normal MRI dose not rule out a neurological problem. The child should be evaluated by a pediatric neurologist. Whatever her final diagnosis is, it is not laziness.

Sincerely,
Dr. Warren

-SC

Dear SC: There are so many possibilities for rashes, even with a good description it can be hard for me to tell what a patient has without seeing it. I could suggest that you use a heavy layer of diaper cream to protect your son's bottom when you travel, and use a thin layer of petroleum jelly around his mouth to protect the skin from saliva, but if there is anything suggesting an infection or the rash persists, you need to have it checked by his pediatrician.

Sincerely,
Dr. Warren

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

ask Dr. Warren a question?!?