7 November 2005

1. Encopresis
2. Recovery from Spinal Tap
3. How Tall Can I Get?
4. Child Doesn't Feel Pain
5. Oral Contraceptives Not Advised While Nursing
6. Prenatal Cocaine Exposure
7. Rieger's Syndrome
8. Nighttime Nose Bleeds
9. Disclaimer

• Read Questions & Answers in Another Column

Encopresis

Even if she goes to the toilet, it still happens in her panties everyday and she really hates it. I feel so sorry for her, we have tried medication, she and her dad stayed in a hospital for a week there they tried to learn her how to go to the toilet, we have praised her and giving her candy in reward for everytime she succeed.

We have workt on this problem since she was about 4 year. And all you said about a child not willing to go, a child how hold in, a child that doesn't feel that it has happend and don´t feel the smell all of it is correkt for us. But now she sometimes get sad and wonder " When will it end?" She really tries and it still don't work. She have gone regularly to the toilet for 3 years. I wonder will it ever end? Is there grown ups with this problems, and how are they dealing with it? Please anser me.

-CS

Dear CS: The oldest child I have seen with encopresis was 12. I'm sure that there are some that are older. I cannot be sure why your daughter still has a problem since I have not examined her. What doctors could not solve in the hospital, I don't propose to solve by e-mail.

If your daughter was a stool withholder, a child who always held in her stool, even if she is using a toilet regularly she may still be full of stool unless she spends the time to fully empty herself out. If her intestines are chronically dilated, she may need to be emptied with an enema periodically until she is completely evacuating her stool regularly. This is not something you should undertake without a doctor overseeing her treatment since neither the laxatives or enemas which may be needed are desirable long-term. Encopresis cannot be cured in a week, even in a hospital. I would suggest that she be under the regular care of a gastroenterologist to manage this problem.

Sincerely,
Dr. Warren

-S

Dear S: I have never seen post spinal tap pain persist longer than a few days. If your mother has been laid up in bed she may need to get moving to get some relief, or may need some physical therapy to relax her back muscles. She should discuss it with her doctor who knows what's going on with her.

Sincerely,
Dr. Warren

Thanks!

-C

Dear C: Even with complete growth data and a physical examination I cannot accurately predict how much a person may grow. If you have only recently started menstruating, you will probably have your growth spurt for the next year or two and then slow down. That could result in anywhere between 3 and 8 inches additional for you, depending on how long your growth spurt lasts, how much you grow during it (which is determined largely by genetics), and how many years you continue to grow before growth ceases altogether. One of the biggest variables is puberty. The earlier you start and the more quickly it progresses, the fewer growth years you have. If you've already been menstruating for a few years, wishing to be 5'8" may be unrealistic.

Sincerely,
Dr. Warren

Thank you

-NL

Dear NL: The only disease I can think of, or find any reference to, which causes insensitivity to pain in children is Familial dysautonomia (Riley-Day syndrome). Is this what your neurologist diagnosed? Is your daughter otherwise completely healthy and developmentally on schedule? If so, that diagnosis may not fit. Behrman: Nelson Textbook of Pediatrics, 15th ed., Copyright © 1996 W. B. Saunders Company says the following:

Familial dysautonomia (Riley-Day syndrome) is an autosomal recessive disorder that is common in Eastern European Jews, among whom the incidence is 1:10,000-20,000 and the carrier state is estimated to be 1%. It is rare in other ethnic groups.

The disease is expressed in infancy by poor sucking and swallowing. Aspiration pneumonia may occur. Feeding difficulties remain a major symptom throughout childhood. Vomiting crises may occur. Excessive sweating and blotchy erythema of the skin are common, especially at mealtime or when the child is excited. Breath-holding spells followed by syncope are common in the first 5 yr. As the child becomes older, insensitivity to pain becomes evident and traumatic injuries are frequent. Corneal ulcerations are common. Newly erupting teeth cause tongue ulcerations. Walking is delayed, clumsy, or appears ataxic because of poor sensory feedback from muscle spindles. The "ataxia" is probably related more to deficient muscle spindle feedback and to vestibular nerve dysfunction than to cerebellar involvement. Tendon stretch reflexes are absent. Scoliosis is a serious complication in the majority of patients and usually is progressive. Overflow tearing with crying does not normally develop until 2-3 mo of age but fails to develop after that time or is severely reduced in children with familial dysautonomia.

About 40% of patients have generalized major motor seizures, some of which are associated with acute hypoxia during breath-holding, some with extreme fevers, but most without an apparent precipitating event. Intellectual function is usually impaired but is unrelated to epilepsy. Puberty is often delayed, especially in girls. Body temperature is poorly controlled, and hypothermia and extreme fevers both occur. Speech is often slurred or nasal.

After 3 yr of age, autonomic crises begin, usually with attacks of cyclic vomiting lasting 24-72 hr or even several days. Retching and vomiting occur every 15-20 min associated with hypertension, profuse sweating, blotching of the skin, apprehension, and irritability. Prominent gastric distention may occur, causing abdominal pain and even respiratory distress. Hematemesis may complicate pernicious vomiting.

Sincerely,
Dr. Warren

Will this effect my infant??

-MM

Dear MM: The PDR lists the following precaution for Loestrin Fe and ALL birth control pills:

Nursing Mothers

Small amounts of oral contraceptive steroids have been identified in the milk of nursing mothers and a few adverse effects on the child have been reported, including jaundice and breast enlargement. In addition, oral contraceptives given in the postpartum period may interfere with lactation by decreasing the quantity and quality of breast milk. If possible, the nursing mother should be advised not to use oral contraceptives but to use other forms of contraception until she has completely weaned her child.

Sincerely,
Dr. Warren

Thanks!!!

-JB

Dear JB: I hope the information from the following resources answers your questions.

Kaplan: Comprehensive Textbook of Psychiatry, 6th ed., Copyright © 1995 Williams & Wilkins

Cocaine use by pregnant women represents a hazard to the fetus. In some urban hospitals 10 to 45 percent of women provided with obstetrical care report cocaine use at some time during the pregnancy. There is some controversy about the frequency and permanence of any damage sustained by the fetus, but there is little question that maternal cocaine use can be associated with some perinatal morbidity and mortality. It is exceedingly difficult to separate cocaine effects from the effects of other substances and of maternal behavior, but it may be that some of the toxicity is due to cocaine-induced hypertension, tachycardia, and vasoconstriction, which lead to impaired placental blood flow and decreased transfer of nutrients and oxygen to the fetus. Some toxicity also results from cocaine's effects on the fetus.

Depending on the severity of the placental and fetal effects and when they occur during gestation, the result may be teratogenic, with destruction of developing tissues or overall retardation of fetal growth. Commonly reported abnormalities in fetuses exposed to cocaine are microcephaly and structural abnormalities in brain and urinary tract development. Ischemic and hemorrhagic lesions in the newborn brain have also been reported. Premature birth, placenta previa, and abruptio placenta are complications of pregnancy that are more common among women who use cocaine than among nonusers; low-birth-weight babies also are common.

Despite the risks, only a minority of infants born to such women exhibit what might be called a neonatal cocaine exposure syndrome, which consists of poor feeding, irritability, tremor, and abnormal sleep patterns. Those abnormalities are most evident on the second day after birth and last for less than a week or two. There are reports that sudden infant death syndrome (SIDS) is more common among infants exposed to cocaine, but controls needed for a clear conclusion are lacking. The long-term neurological, cognitive, and developmental consequences of intrauterine cocaine exposure are still not clear, but after the first few months, most such children appear to be developmentally within normal limits.

ABSTRACT: ...CONCLUSIONS: This pilot study supports that teachers blinded to exposure status of early elementary students did rate the cocaine-exposed group as demonstrating significantly more problem behaviors than control children. Although an important first step, postnatal factors that also may influence behavior were not evaluated; hence, causation is not addressed.

Abstract:
Most studies of prenatal cocaine exposure have found gestational age or intrauterine growth deficits but few, if any, cognitive effects. In a large, well-controlled study we detected cognitive deficits in relation to heavy cocaine exposure. These findings demonstrate that prenatal exposure to cocaine at sufficiently high doses early in pregnancy has the potential to produce cognitive changes in infants and that more focused, narrow-band tests may be necessary to detect these subtle neurobehavioral effects. A total of 464 inner-city, black infants whose mothers were recruited prenatally on the basis of pregnancy alcohol and cocaine use were tested at 6.5, 12, and 13 months of age. Standard analyses, based on presence or absence of cocaine use during pregnancy, confirmed effects on gestational age but failed to detect cognitive effects. A new approach to identifying heavy users found that heavy exposure early in pregnancy was related to faster responsiveness on an infant visual expectancy test but to poorer recognition memory and information processing, deficits consistent with prior human and animal findings. These persistent neurobehavioral effects of heavy prenatal cocaine exposure appear to be direct effects of exposure and independent of effects on gestational age.

Abstract:
OBJECTIVE: This article was designed to investigate effects of prenatal cocaine exposure on motor development of young children from a predominately underprivileged, urban population. METHODOLOGY: A total of 260 infants and young children were initially recruited from either the newborn nursery or the at-risk pediatric clinic of an urban teaching hospital. Prenatal history and birth outcomes were collected from medical records. Demographic characteristics and additional drug histories were obtained from the mothers. The 199 subjects (98 cocaine-exposed and 101 unexposed) who returned at age 2 years were assessed by examiners blinded to drug exposure status using the Peabody Developmental Motor Scales. RESULTS: Compared with control subjects, the cocaine-exposed group performed significantly less well on both the fine and the gross motor development indices. Mean scores for both groups were within the average range on the gross motor index, but greater than 1 standard deviation below average on the fine motor index. Differences were significant on the balance and the receipt and propulsion subscales of the gross motor scale, and on the hand use and the eye-hand coordination subscales of the fine motor scale. Cocaine status independently predicted poorer hand use and eye-hand coordination scores. There also was an effect of alcohol exposure on the receipt and propulsion subscale. CONCLUSIONS: Findings indicate that deficiencies in motor development remain detectable at 2 years of age in children exposed to drugs prenatally. Although other environmental variables may influence motor development, children exposed to cocaine and to alcohol in utero may encounter developmental challenges that impede later achievement.

Sincerely,
Dr. Warren

Thank you.

-Karen

Dear Karen: The closest thing I could find to what you asked about was Rieger’s syndrome. Smith's "Recognizable Patterns of Human Malformation" says the following:

Rieger described this association of anomalies in 1935.

ABNORMALITIES

Eye. Dysplasia of iris including hypoplasia, mesenchymal tissue filling in the angle of the anterior chamber, and aberrant synechiae of iris.
Teeth. Hypodontia, partial anodontia, or both.
Neurologic. Variable myotonic dystrophy.

OCCASIONAL ABNORMALITIES. Eye: glaucoma, microcornea, corneal opacity, ectopia lentis, aniridia, optic atrophy. Mental deficiency.

ETIOLOGY. Autosomal dominant with rather wide variance in expression. It is difficult to know whether all cases described as Rieger’s syndrome are the same etiologic entity.

Sincerely,
Dr. Warren

-RV

Dear RV: Bloody noses during sleep are not a normal matter of course for all children. Some children get bloody noses much more easily than others for a variety of reasons. Bloody noses with a frequency of 1 per month is not a major cause for concern. Nighttime bloody noses tend to look worse because there may be a lot of bleeding if the child doesn't awaken to get it stopped, and because many children swallow the blood and then vomit it onto their bed sheets.

If your child is not pale, weak, or anemic, and any daytime nose bleeds he has can be stopped relatively easily, then you need not be concerned. You should keep a humidifier in his room during the winter when the heat is on because dry air will make his nose bleed more easily.

Sincerely,
Dr. Warren

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

ask Dr. Warren a question?!?