10 October 2005

1. Infant with Urine Infection
2. Smelly 3 Year Old
3. Inguinal Lymphadenitis
4. Help to Gain Weight
5. Shrieking 6 Month Old
6. Tanner Staging of Puberty
7. Risks of Using DEET
8. B-12 Deficiency, Poor Feeding, and Neurologic Damage
9. Disclaimer

• Read Questions & Answers in Another Column

Infant with Urine Infection

Thank- You.

-Tina

Dear Tina: A 5 month old who has had one bladder infection does not necessarily need to be seen by a specialist. Neither does she necessarily need to be on medication for a year. If the baby had a VCUG done which showed reflux, and if the reflux was mild, it would be appropriate to treat with medication to prevent urine infections for a year and follow to see if the reflux resolved. Then if the reflux persisted, a referral to a urologist would be necessary. It sounds like you need to talk to your doctor to make sure you understand what he has done in the evaluation of your child's bladder infection and why he has recommended his current treatment, including the risks and benefits of the current treatment, the risks of not treating as recommended, and the alternatives with risks and benefits.

Sincerely,
Dr. Warren

Could this be a sign of something serious? What can we do to lessen his odor?

-MF

Dear MF: Your son's odor problem probably doesn't have any medical significance; however, it is unusual for a 3 year old to have a potent body odor. You should make sure there isn't any rash under your son's arms which could account for an odor. Inflamed skin can sometimes smell terrible. You should also note whether or not your son is showing any signs of precocious puberty. Most metabolic disorders that cause an unusual odor become evident before 3 years of age and their odor is not localized to the underarms; however, given your son's diagnosis of autism, if he has never been screened for metabolic disorders, his neurologist can send a urine to test for amino acids and mucopolysaccharides.

Powder is as good a way as any to deal with the odor problem. If the odor is localized to the armpits, you could try a mild underarm deodorant.

Sincerely,
Dr. Warren

I can't find the inguinal lymphadimitas on the internet anywhere and would like your feedback.

-Sheri

Dear Sheri: The term inguinal refers to the location where your son had swollen glands. The inguinal area is the groin - same location for a hernia which is then known as an inguinal hernia. Lymphadenitis means infection in a lymph node. Lymph nodes or glands often swell in response to a localized inflammation. The inguinal nodes would be the ones to swell in response to an infection or inflammation of the foot. The swollen nodes are part of the bodies defense against the spread of infection. Sometimes, in doing battle to protect the rest of the body a lymph node may become infected itself (lymphadenitis). Hot soaks and antibiotics will often clear up such an infection, but sometimes a more serious infection or one that doesn't clear with antibiotics may require surgical drainage and IV antibiotics.

A lymph node that swells suddenly and is tender is usually an inflammatory node and not a cancer, especially if a source of inflammation can be found, such as the bee sting on your son's foot. If the inflammatory node becomes infected as described above, it is lymphadenitis. A blood count may have shown evidence of bacterial infection but may have been normal. In any event, a normal blood count cannot rule out cancer. Under the circumstances, it seems unlikely that the lymph node is cancerous, but should there be a question due to its persistence, the node should be biopsied to clarify the diagnosis. You should be aware that once the swelling of an inflammatory lymph node goes down the node can still usually be felt for months and may swell again in response to virus infections and minor inflammations like athlete's foot.

If you are looking for additional information search using the key word "lymphadenitis" since the word inguinal just refers to the location and is not part of the condition.

Sincerely,
Dr. Warren

-(unsigned)

Dear 16: I'm missing some important information necessary to give you the best advice. Are you tall and thin, or do you weigh only 90 pounds because you are petite? Do you eat a lot and still have trouble gaining weight, or do you have a small appetite? Are you engaged in physical activities which would burn an enormous amount of calories? Have you always had difficulty gaining weight?

If you haven't had a complete physical you should have one since some medical conditions can contribute to difficulty gaining weight. You may need blood work to check for an overactive thyroid, a urinalysis to check for diabetes, and your doctor should review your growth and your diet to determine what would be a reasonable goal for you and if you are eating appropriately.

That having been said, there are a few things a person can do to gain weight.

• Consider weight training to add muscle mass. Very few people who want to gain weight are actually looking to add body fat.
• Even though vegetables are an important part of the diet, don't fill up on salad and vegetables at meal time and then find yourself too full to consume sufficient protein and carbohydrate calories.
• You could take a nutritional supplement like Ensure, but if you have a small appetite, drink it shortly after a meal, or at least, not too close to the beginning of a meal, or you'll end up eating less.
• You can increase the fat content of your diet without adversely affecting your cardiac health by increasing your consumption of dishes that are prepared with vegetable oil (preferably corn, safflower, or olive) such as fried foods like French fries made in vegetable oil, or pastas and salads made with oil.

Sincerely,
Dr. Warren

-D

Dear D: Your 6 month old is just experimenting with her voice and becoming accustomed to the range of what she can do with it. I can understand how it can be grating to hear all day, but eventually your daughter will be ready to try new things with her voice. Just try not to teach her to use screaming as a way to get attention by responding to it when you are busy with other things. If she is shrieking when she is with you, good naturedly tell her "shhh!!" and then talk softly to her, not only to set an example, but also, she will have to be quiet if she wants to hear you.

Sincerely,
Dr. Warren

Thank you.

-BL

Dear BL: The Tanner staging system is a means of staging pubertal development with Tanner I being prepubertal and Tanner V being adult (those are Roman numerals 1 to 5). Each stage has certain characteristics but since the development is continuous rather than in spurts, a child's appearance may not exactly match a specific stage. The Tanner stages for boys are as follows:

• Tanner I ----- prepubertal
• Tanner II ---- Enlargement of testicles
• Tanner III --- Continued enlargement of testicles, enlargement of penis, downy pubic hair at base of penis.
• Tanner IV ---- Adult sized genitals, coarse pubic hair around base of penis
• Tanner V ----- Adult. Pubic hair covers entire pubic area.

Even if your 16 year old is at Tanner V, your pediatrician may be predicting continued growth because he hasn't seen the growth rate taper off significantly yet.

Tanner staging for girls follows similar rules with regard to pubic hair development with the other features of Tanner staging relating to breast development.

• Tanner II ---- Breast buds
• Tanner III --- Enlargement of breasts
• Tanner IV ---- Enlargement of areola (nipple area) on breasts
• Tanner V ----- Adult breasts

Sincerely,
Dr. Warren

Thank you.

-IA

Dear IA: According to an the article "Insect repellents: An overview" by Margaret Brown MD and Adelaide A. Hebert MD, published in the Journal of the American Academy of Dermatology, Volume 36 • Number 2 • February 1997, Copyright © 1997 American Academy of Dermatology, Inc.,

Since first marketed in 1956, deet has remained the most effective repellent against mosquitoes, biting fleas, gnats, and chiggers. Permethrin is applied to clothing rather than to skin, and it is a better repellent against ticks than deet. The risk of serious side effects with the use of deet is slight; nevertheless, the lowest effective concentration should be used.

Investigators have reported dermatitis, allergic reactions, and neurologic and cardiovascular toxicities after the use of deet. Children have untoward reactions more frequently than adults. Four young boys (age range, 3 to 7 years) and a 29-year-old man had seizures within 8 to 48 hours after deet exposure. None had a previous neurologic problem, and all had normal results from a neurologic examination after the seizure episodes. Six girls, 17 months to 8 years of age, had ataxia, encephalopathy, seizures, and/or coma after deet was applied to the skin. Three of the girls died. A 61-year-old woman suffered orthostatic hypotension and bradycardia after application of a deet product. Her symptoms disappeared and she had a stable blood pressure several hours after hospital admission.

Sincerely,
Dr. Warren

-Karin

Dear Karin: Loss of developmental milestones and lack of responsiveness are very worrisome. I can't tell if you're describing a baby who is too sick to interact or if you are describing a neurological disorder. Therefore, based on what you've told me, I'd have to suggest a second opinion (complete physical from another pediatrician) and perhaps an evaluation by a pediatric neurologist. Since your son's weight gain has been poor and he vomits, I'd also suggest blood work to be sure that your son's blood chemistries are not out of whack from his vomiting. A GI evaluation may not be a bad idea either. Lots of babies have reflux, but when they gain and grow poorly, further evaluation and treatment is warranted.

Sincerely,
Dr. Warren

Thank you.

-Karin

Dear Karin: Now that your son has started on the road to recovery with B12 injections, unless he also has pernicious anemia, he should be able to continue his recovery by eating foods with vitamin B12. As his health improves I think you will see him resuming his normal developmental landmarks; however, because of his loss of landmarks, each checkup should include a careful developmental assessment. If your son shows significant developmental delays once he has recovered, you should have him evaluated and enrolled in appropriate early intervention programs.

I cannot tell from your e-mail just how well you are handling this. Do not blame yourself. Maternal guilt will not help your relationship with your son, nor will it help you do a better job of raising him. You did your best by offering your milk to your baby and followed the current recommendations in which no additional supplements are offered. When your baby seemed sick, you took him to his pediatrician. Just continue to be a loving, caring mother, and don't doubt yourself.

Sincerely,
Dr. Warren

My son, Christopher, displayed all the symptoms I described to you in my email, but it was 5 years ago. I took him to our GP, who could see that Christopher was unwell, he had documented that Chris had been unwell for at least 5 weeks and that he was not picking up, and so he referred us to our pediatrician. At the consultation, I told the pediatrician all of my concerns, just like I did in my email to you. My pediatrician said he didn't want to do any tests, as any testing on a baby hurts the baby and he didn't want to do that, so he said we should just wait and see what happened. He said we could go to a speech therapist to teach Chris to feed. He then insisted I wait 6 weeks before returning, as this was a time thing.

At that time there was no internet, and I didn't know of any other pediatricians in our home town, so I did wait. And Christopher got worse. He became so ill that I was frightened for his life, so I went to another GP, hoping he might have some different ideas. This GP examined Chris and said he thought he was intellectually retarded and that we should have him assessed some time.

As you can imagine, this was all very distressing. I had a baby who was getting sicker each day, and now I was being told he was intellectually retarded. In panic I went back to the pediatrician and demanded tests. ( I'm not usually like that but I was scared). He said he would do tests only because I wanted them done. It was my choice. He did a blood test and an MRI. I thought the MRI was going to be on Christopher's stomach to investigate the vomitting. The Dr didn't tell me he was investigating a brain problem. To cut a long story short, the doctor didn't follow up on the blood test results, so although they picked up the B12 problem, he didn't know. He got a preliminary report on the MRI that said Chris had abnormal brain development, and told us we would have to wait 8 week until the pediatric neurologist visited town. He didn't even bother to make a follow up consultation to kkep a check on Christopher.

Well, we knew Chris didn't have 8 weeks, so we went back to our GP. He was shocked by the deterioration in Chris (3 weeks had gone by since he had last seen Chris). H examined Chris, who was now virtually in a coma, he wasn't waking (he sort of fed in his sleep). Our Gp strongly advised us to seek help in another city, and he warned us not to wait. He helped us arrange a consultation with the pediatric neurologist in the other city. When we arrived at the hospital, we were given little hope of a known cause or a cure. Blood was taken for specialised tests, but an error wa made and they were put in the wrong cannisters. And so they repeated the test done back at home, not because they intended to, but because there was nothing else they could do with this blood. It was here that the B12 deficiency was picked up. So it was a mistake that saved my son's life. By now he was crtitical. The hematologist told me of the urgency to begin the B12 injections with in the hour. And we had lost 3 precious weeks waiting for this diagnosis.

Well, 5 years have passed now, and Christopher has not improved as we had hoped, despite all the love and attention we have given him. He is a beautiful, affectionate child and it has been easy for me to assist him in every way I can. But now the time has come for him to go out into the big wide world, as he must begin to attend normal school. Over here, children with disabilities are only catered for until kindergarten (with early intervention) then they must attend a normal school. Chris may be granted 2 hours of special aid time a week (if he is lucky). And so we are seeking compensation for what has happened to him, from the pediatrician who failed to diagnose his problem and so caused the delay in treatment.

For five years now I have wondered if I was wrong in believing the pediatrician should have helped us when I begged him to. And so I have hired this computer, and used the net to ask online pediatricians like your self what you would do if you were presented with a child in Chrisotpher's condition. Of the 10 pediatricians I have contacted, seven replied and all seven aid that this child needes tests and a work up. I am sorry that I deceived you into believing that this was happening now. Because you have taken the time to follow up with my son, I feel I owe you an apology and an explanation. If only I had your advice five years ago, I would not have waited and Chris would not have suffered so. I hope you are not angry with me.

I'm certain the service you offer has saved many babies, if it had been here 5 years ago, it would have saved mine. Thank you for your time, and most importantly your concern. As I stated earlier, my pediatrician didn't even bother to enquire how Christopher was after we returned home. You haven't even met Christopher, and still you cared.

-Karin

Dear Karin: I am so sorry for your loss, because even though your son lived, you did indeed suffer a loss. No matter how much joy your son gives you, I'm sure you grieve for what might have been.

It is fortunate that physicians in Western Cultures have so little experience with vitamin deficiency states. It is a testament to society's success at nourishing its children (and adults). But an unfortunate consequence is that most of us don't think of vitamin deficiencies as part of our differential diagnosis or recognize these deficiencies in their early stages.

I had one patient who had Rickets (vitamin D deficiency). She had some vague complaints and was bowlegged (but many infants are), but I never thought of Rickets. I probably wouldn't have made the diagnosis except that I did a bone x-ray to evaluate her poor growth and the diagnosis was evident on the x-ray. The baby was nursed, and we are all taught these days, that it is unnecessary to supplement the nursing baby with vitamins. Fortunately, my patient is doing well.

Since I have read your letter, I will think of vitamin B-12 if I ever have an infant who starts to feed poorly and regress socially and physically. I congratulate the doctor who made the diagnosis. It's unfortunate that your baby did not enjoy a complete recovery.

Sincerely,
Dr. Warren

Dear Dr. Warren: Thank you for your kind words regarding my son who was diagnosed with B12 deficiency. From the way you write I can tell you are a very compassionate person. Yes you are correct, we do grieve for what might have been. It would have been much easier (if it is ever easy) to accept Christopher's disability if he had been born with it. But to know he was born perfectly healthy, and that he developed normally for the first seven months of life is truly heartbreaking. Although I am aware of the cause of Christopher's vitamin deficiency, ie my breastmilk, I know that it is futile to blame myself. My intention was to give Christopher the best start in life. I even had a test prior to my pregnancy to ensure I didn't have anemia, as that condition had been picked up in my other 3 pregnancies and treated during the pregnancies. I decide to treat it before I commenced my fourth pregnancy. A close look at my blood test results at this time shows I was B12 deficient then, but no one noticed it as it is so rare in women my age with no history of Pernicious anemia.

What really hurt was that no one would believe me when I said my baby was ill. I was treated as a mother who just couldn't cope with her fourth baby. My baby became progressively worse everyday, and all I wanted was for a doctor to say, your baby is sick, let me help you. Instead I was just sent home and told to wait, he'll grow out of it. And then when I finally did find someone who would believe me and did do tests,(I took Christopher to another hospital in another city) I wanted some answers. What is going to happen now? What does the future hold for Christopher? But no one had any answers. Again it was just take him home and see what happens.

I waited for the first doctor, the one I had seen on a number of occasions, to contact me and simply say thank god that Christopher's problem has been diagnosed, I'm sorry I didn't believe you when you told me he was sick, how can I help you and Christopher? But that call never came.

I waited seven months, and the only contact this doctor made was to send me his bill. I decided to ring him and ask him why he didn't care about what had happened to Christopher. He agreed to meet with me. At that meeting I said to him that surely we should use this experience to educate others about this condition but he said that there was no need to do that because this is such a rare condition he will never see it again. It disturbed me greatly to think that a doctor who held my child's life in his hands could have such an attitude. Especially when I learned later that he had seen another baby with B12 deficiency 7 years prior to seeing Christopher (He had missed that diagnosis too, that child was also transferred to another hospital where the diagnosis was made). Perhaps if he held the attitude you have he would have remembered the symptoms. I never would have expected him to test for B12 deficiency, but I know now that a simple blood test would have detected the problem in Christopher.

On the learning side of this, logic tells me that if more women are breastfeeding, and women are leaving having children until later, surely this condition is going to become more "common". In Australia, babies are not routinely bloodtested in their first year of life, like they are in the US. In fact, I begged my pediatrician to do a blood test on my child who was obviously ill, and he still wouldn't.

Of all the people I have written to and spoken to about Christopher, you are the only one who has considered how I feel about what has happened to Christopher.You must be a wonderful pediatrician if you can relate so well to not only the child you are presented with but the parents who are also suffering. Watching your baby as he lays dying, and knowing that no one is helping is the most traumatic experience I have ever had.

Although we grieve for what is lost, I must say that Christopher is the most lovable, affectionate child. Everything is a delight to him. For five years now we have delighted in the fact that he is here, and that we did not lose him, and that there is hope that one day he will be able to lead a "normal life".I have a friend who also has a baby who suffered from B12 deficiency and her child has almost caught up to his peers. In fact I know of five other children who suffered like Christopher (I wrote some articles in some of our national magazines, and their parents contacted me) and all five are functioning well. So I know there is hope. That with love and support there is a chance that Christopher will be able to overcome this huge hurdle that has been set before him. Meanwhile, I have embarked on a personal program to ensure I alert as many pediatricians to this condition as I can. If I can save just one baby from suffering like Chris, I would be very happy. I have written to the President of the AMA in Australia and suggested that pediatricians and gynecologists should be educated about this condition, but he feels it is too rare to worry about. And so I will continue to work on this the slow way, one by one.

I hope you never do see a vitamin B12 deficient baby, but I am confident that if you do, you will help the child, and his or her parents.Although you could not help Christopher, your compassion has helped me.

Thank you for caring.

Yours sincerely,
-Karin (& Christopher)

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