19 December 2005
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physican who knows you and cares about you.
Dr. Warren
-Dr. R
Dear Dr. R: Actually, I do not and cannot give prescriptions on-line. I give advice. I can recommend Cetaphil lotion for dry skin and bathing with Dove soap. Dry skin which is not helped by such management needs evaluation by a physician to see if there is an additional problem such as eczema which requires treatment or if a prescription for Lac-Hydrin lotion would be appropriate.
Sincerely,
Dr. Warren
Thank you.
-AS
Dear AS: If your daughter's CBC is fine, then she is not anemic. The pallor of her face represents the fact that she has been ill. She has had several major illnesses in a short period of time. Since her appetite has returned and she has more energy, she just needs additional time to fully recover. Even after an illness is gone the body requires time to heal.
Sincerely,
Dr. Warren
-L
Dear L: Although children may sometimes do things which are difficult to comprehend using adult logic, hunger and thirst are pretty powerful drives. A baby is not likely to refuse sustenance over a long period of time unless he is not feeling well except in the rare instance where a child is under so much pressure to eat that he resists. An infant is not likely to wean from the breast abruptly unless he is getting enough food elsewhere.
If your son is eating jarred food, it has a high liquid content, but eventually, your son will get thirsty and then he will either take a bottle, take liquid off a spoon, or become proficient at drinking from a cup. What you need to do is make all possibilities available to him without pushing him, and he will let you know what he prefers.
Sincerely,
Dr. Warren
Thanks for your time.
-Andrea
Dear Andrea: The black eyes were most likely due to the fall. I cannot think of any reason a pneumonia would cause black eyes, assuming you mean real black eyes (as in blood pigment in the skin) and not just dark under the eyes. X-rays cannot show all injuries. It is likely that your son had sufficient bruising of soft tissues in his face to result in the black eyes.
Sincerely,
Dr. Warren
Thankyou again for all your time and help
-A & R C
Dear Mr. & Mrs. C: I can understand the great stress you are under with your precious baby ill and you being accused of causing her injuries through abuse. The sad fact is that many child abusers hurt a child whom they love or who is the light of their life. In a brief moment of rage and/or stupidity they do something which can never be undone with serious consequences they never imagined. Not all child abusers are monsters looking to hurt a child. With more support from society and more education in child care, many injuries from child abuse could be avoided. As a child advocate, my first concern is the children, but I realize that to help the children, we must help and educate their parents.
You are mistaken in your understanding of shaken baby syndrome. There may be no visible or external signs of head injury and there may be no other injuries at all in an infant with shaken baby syndrome. Violent shaking causes the brain to bounce against the inside of the skull causing brain injury and bleeding inside the head. These infants may present to the emergency room when they unexpectedly stop breathing, have difficulty breathing, have seizures, become lethargic or drowsy, or go into a coma, or die. Subdural and retinal hemorrhages accompanied by the absence of external signs of trauma are the hallmarks of the syndrome. The diagnosis is suspected when the examining physician finds the bleeding inside the eyes (retinal hemorrhages) in a child with no visible signs of trauma. Infants who survive may suffer permanent damage to their vision or even blindness, and permanent neurological damage which may include seizures, motor deficits, and mental retardation.
Shaken baby syndrome does not occur in a child from gentle shaking or even rough play. In order for your play with your daughter to have resulted in her injuries, you would have had to play with her in a intense manner inappropriate for a 10 month old. This would surely have caused her to cry. You would have had to be pretty oblivious to her discomfort to think she was enjoying such rough play, or foolish enough to be even more vigorous in your play thinking her crying would stop.
Unless your daughter has a clotting disorder or an abnormality of blood vessels which would account for easy bleeding, you have to face the fact that somebody shook your baby inappropriately and violently, causing her injuries. As I explained earlier, that person could certainly be someone who loved her and did not intend to harm her. Unfortunately, some babies are shaken by parents who would never hit a child and who do not realize that it can hurt the child. Nonetheless they are responsible for serious injury because they would have to recklessly continue shaking the baby with complete disregard to the infant's distress in order to cause such injuries. Reasonable, responsible, caring adults with any degree of self control don't do that.
I don't know all the facts and am not inclined to judge you. You need to educate your self about shaken baby syndrome to understand what actually happened, and you need to find a lawyer knowledgeable on the subject. Your lawyer should arrange for an independent medical examination to be sure that no other medical diagnosis has been missed and whether or not the findings are consistent with shaken baby syndrome. I cannot provide you with any expert medical information which will exonerate you. To the best of my knowledge there are no innocent causes of shaken baby syndrome. I have found several references to shaken baby syndrome which discuss the differential diagnosis. Since I do not have the actual articles, I do not know if they would provide any information which would help you. Your defense team should consult appropriate medical experts and review the following articles:
Sincerely,
Dr. Warren
We tryied to inform ourselves about shaken baby syndrome through parenting clases and what we read and people tell us. We know that we have never shaken her and will never do so. What we found out is that in some of the inocent play activities we play were found to be hazardous to Hannah's health. I wondering if you ever heard of the Long Ranger or the show Ponderosa. Their both westerns and have wonderful theme songs. So we bounce to the theme song. Hannah never cries and she laughs all the way through the song. I admit we might be bouncing to hard but never thought that it could be hurting her. What we found is that the brain will hit the skull and leave small bruises. Hannah has a 4mm subdural hemotoma. And we found out that when you spin a child around in the air or close to the body her eyes keep on moving very vigoursly and never thought that this is dangerous. Know that alot of parents play these games it never occurred that it was harmful. We found out that Ruth's grandpa has blood clotting disorder, and he has to have medicine to control his blood disorder. So they did tests on Hannah and said she didn't carry this gene. Just letting you know again that we never hit, shaken, or did anything on purpose to hurt Hannah. She is like the perfect child. We love her with all our hearts, making wonderful scrap books and taking millions of pictures of her. Boy she loves getting her picture taken. I also found out that CPR activities can cause retinal hemorrhages through my aunt which is like a lpn I think. I never really thought of that untill looking up retinal hemorrhages. When I bring in groceries I don't want to leave her in the car by herself and in the house by herself so I hold her in one of my arms and the groceries in the other. When I'm carring her i put my arm across her chest so that her arms rest over mine, and I have to apply a little more pressure to hold her there to carry her. Never thinking that it was hurting her. Which again she never cried to. I guess the pressure is somewhat like CPR effect but not a serious and can cause retinal hemorrhages.
Both my wife and myself, we don't get mad because it will never do any good. Just make things worse. Hannah never could get us mad at her and besides anything she can ever do is not her fault in the first place. Both of us are very happy and are greatly happy to have Hannah in our lives. We both try to be very responsible because thats how we are, with her previously premed and know changing career plans to accounting for her CPA because of how doctors could not look at all the evidence an not take everything into consideration before making possible solutions and she just couldn't see herself doing that to a family. The doctors and the police told us that none of these play activities can cause small injuries like these. But we found out differently by doing all this reseach and the doctors and police are just looking to find the fastest, easiest solution to a problem that should require deep thought. And myself a prelaw student trying to say that we both have a leave head on us and that we are trying to be responsible parents. Taking parenting classes and learning all that we can about raising a baby from family and experts. The thing is not one of us has hurt Hannah by shaking her. I admit we are unexperienced parents and don't know everything but we are learning. We have happy lives and everything a family could want. No regrets about anything in life. Life is stess free for us which makes hard for people to believe but everything is great. So I tell you again that neither my wife or I would ever shake or do anything violent to my daughter Hannah. She is a gift from God and we are blessed to have her and honored to be able to have the chance to raise such a special child. Thankyou for your time.
We would like it if you would please respond. Thankyou for all your info you kindly given us it is very appreciated, thanks.
Thankyou again.
-A & R C
Dear Mr. & Mrs. C: I'm not sure what additional response you are looking for from me. As I told you, it is not my job to judge you or exonerate you. To the best of my knowledge there is no evidence in the medical literature to suggest that normal childhood play activities can cause retinal hemorrhages; however, I did provide you with references to several articles to which I do not have immediate access so that you could do your own research.
You state that your own research has shown that normal play activities can cause retinal hemorrhages; however, you do not quote the sources of your research which suggests to me that you don't have any reliable sources. If you do, you should share them with the doctors and the police. I would also be interested in evaluating any information you have on the subject; however, if your research consists of talking to friends and relatives or drawing conclusions on your own based on your firm belief that nobody did anything wrong which hurt your daughter, that is not research.
While vigorous CPR may cause retinal hemorrhages, there is no way simply holding your child across the chest would do the same thing. You're grasping at straws and do not appear to understand the very crucial point that retinal hemorrhages don't just happen in the normal course of events.
I can understand your feelings about what has happened to you; however, the fact is that plenty of babies are abused by parents who do love them but are unable to control their anger and too immature to appreciate the consequences of their actions before the harm is done. The medical profession has learned to recognize the findings which suggest abuse. Since I am not an expert on the matter, I will not proclaim that the system is foolproof. Nonetheless, the idea that medical doctors are interested in a quick solution rather than the best interests of the baby is absurd. Without a firm belief that a child's parents are harming him there would be no purpose in taking a child away from the parents since the best place for a child is with parents who love him.
Your wife's decision not to pursue a medical career may be the best decision for her at this time; however, if she believes there are deficiencies in the manner in which questions of abuse are handled by doctors, she could also pursue a medical career and work to change the system from within. Again, I understand your distress, but blaming doctors is pointless. Something very significant happened to your daughter. If you don't know what (and it wasn't bouncing her on your knee) then you should concentrate your energies on finding out what happened. Somebody out there knows.
Sincerely,
Dr. Warren
-Jamie
Dear Jamie: Blocked tear ducts in infants often open on their own. Massaging the tear duct along the nose may help. Secondary infection (conjunctivitis) needs to be treated with an antibiotic ointment or drops. Compresses are helpful for decreasing and cleaning the discharge and may avoid conjunctivitis. If the baby has frequent conjunctivitis or persistent symptoms you may need to see a pediatric ophthalmologist to get the tear duct probed.
Sincerely,
Dr. Warren
-Jamie
Dear Jamie: If the doctor had intended for you to use any eye drops she would have had to prescribe them. I suspect she meant that if the eye discharge gets worse you should contact her and she would prescribe drops or see the baby again.
Sincerely,
Dr. Warren
I am hesitant to use our computer headphones without taking proper precautions first! Thanks for your help :-)
-Mikki
Dear Mikki: I thought you might find the following article interesting. I've included it in its entirety since I thought you'd like to know how the author draws his conclusions.
John W. Maunder, MA, PhD, MSc, FRES, FRSH"To a systematist interested in the evolutionary relationships between animals, the parasites causing scabies are barely related to those causing lice. Scabies mites are arachnids, but lice are insects. The only relationship is the fact that both are arthropods. Nevertheless, from a purely practical point of view, there are advantages in considering the two together. In particular, both lice and scabies are subject to a host of myths, often very similar in each case.
Medical Entomology Centre
Cambridge Road
Fulbourn, Cambridge CB1 5EL
United Kingdom
"At the root of most misinformation is a failure to realize how very parasitic these creatures are. The general public doesn't get a chance to see the detail of either scabies mites or lice under the microscope, and if they did, they would not have the training or experience needed to interpret what they were seeing. Health professionals sometimes have the opportunity to see and study these parasites, but unfortunately they usually do not get the chance to examine their nonparasitic relatives. Diagnosis is their principal concern. The medical entomologist is in the fortunate position of being able to make comparisons between parasitic forms and their nearest free-living relatives, and so they are able to assess the degree of parasitic adaptation that has taken place.
"Land-living arthropods typically use a respiratory system consisting of internal branching tracheae that carry air directly to all parts of the body. The tracheae open externally at the spiracles, which are paired openings containing mechanisms guarding against excessive water loss, but allow gases to pass. Mites usually have a single pair of spiracles, a few have two.
"Vision is not a dominant sense in mites; nevertheless, most mites possess simple eyes, usually two on each side of what would be a head if they had a neck. They have eight legs that are typically long, strong, and flexible. Mites are typically active creatures.
"Perhaps more remarkably, it can be noticed that the scabies mite has no tracheae. The integument is so thin that the tracheae should be visible as silver air-filled tubes, but nothing of that sort can be seen. Closer examination reveals that no spiracles are present. The mite has discarded the entire respiratory system possessed by typical free-living mites. It now obtains all of its oxygen through the skin, which has to be sufficiently thin and sufficiently moist. In losing its armor, the mite has lost its waterproofing.
"The scabies mites' legs are short and stubby. They only need to reach the wall of the tunnel in which they live. They have also lost their eyes, which are not needed in their living environment.
"The result of these and other adaptations is a creature perfectly adapted to its life-style and quite incapable of free life. Were such a highly specialized mite ever to leave a human being the chances of it ever getting back are virtually nonexistent, and the chance of getting onto another person even lower. A highly specialized mite would rapidly die at anything less than 100% humidity. It is blind, helpless, and cannot jump, and its stubby legs give it a maximum speed on a flat surface of little above zero.
"Anything less well adapted to leave a human being and lie in wait for another can hardly be imagined. No scabies mites ever voluntarily leave a human being, for it would be certain death to do so. Even the few mites that involuntarily leave in the shed skin crusts of immunocompromised patients are nonviable, and indeed, are usually only skeletal remains.
"Often the medical entomologist is asked at what temperature bed sheets should be washed to kill mites. The question is a complete nonsequitur because there are no viable mites in bed clothes, and if almost impossibly there were, they would be dead a few minutes later and could not possibly survive a normal washing procedure.
"Solemn advice is sometimes proffered in textbooks about which acaricides should be used to fumigate schools, hospital wards, school buses, ambulances, police vehicles, and even public toilets. All of this is nonsense, sometimes verging on the ludicrous. The only scabies mite that can be in any way dangerous to people are those already on people.
"Most free-living insects possess the waterproof armored shell typical of land-living arthropods. They have enemies and need defense. Most are at risk of desiccation were they not waterproof. Consider how little water there is in an ant crossing a hot road and how essential its waterproofing must be.
"Most insects can fly; therefore, good vision is a necessity. A bee, for example, has two enormous multifaceted compound eyes and three simple eyes capable of detecting everything from ultraviolet to plain polarized light.
"The blood-sucking lice are regarded by entomologists as being the most parasitic of all insects, because there is no free-living stage in the life-cycle at all. Even the eggs are on the host, and the insects are born, live, and die on the host.
"Human lice feed only on blood drawn fresh from the veins of their host. Therefore, their diet is 100% liquid. The malpighian tubules, which are the equivalent of kidneys in insects, open into the gut. Therefore, any insect that feeds on nothing but liquid must produce feces that are also liquid.
"The louse, of course, does not do this. It produces dry, solid, black, gritty feces (whose presence on pillows forms the basis of one method of checking for head lice.) An individual human louse can take on board several times its own weight of blood when it feeds and does so several times a day. If there is a constant stream of liquid into its mouth and dry feces coming from the other end, what does the louse do with all the excess water? Why is it so necessary to produce dry feces?
"Dry feces fall from the host. Wet feces would soon make the host dirty. The last thing a louse needs is for the host to clean and groom itself, for such activity is in part designed to remove ectoparasites.
"Blood-sucking lice dispose of excess dietary water by transpiring it across their nonwaterproof cuticles. As with the scabies mite, the cuticle of the lice has become soft and permeable to water. Indeed, the louse cuticle is so thin that the gut and its movements can be clearly seen in the living lice when under a microscope. If watched while feeding, the sucking pumps in the head can be clearly seen and the whole length of the esophagus also can be seen, filled with red blood.
"Therefore, the louse has the opposite problem of that faced by most insects. Instead of needing to conserve water, its problem is to get rid of it. It can only afford to have a thin unarmored skin because as a parasite it has no enemies. The penalty it pays is that it is now a very obligate parasite that can never leave the host, even to lay its eggs, which now have to stay on the host with the parents.
"A louse that is foolish enough to leave the host could never hope to regain its former life. Without being waterproof they quickly dry up, though not as quickly as a scabies mite. Lice cannot walk well because their legs are meant for climbing. On a flat smooth surface they are helpless, however, on a rough surface they can progress slowly. They cannot jump or fly. They are almost blind because their eyes are reduced to a single facet on each side, just enough to tell if it is light or dark and from which direction any light is coming.
"It is so unlikely that a louse off of the host could ever establish itself on another that they never voluntarily leave a host except for another of the same species in still contact with their own host. Consequently, there are no viable lice in the general environment. Of course, sick, dying, and injured lice can fall from human hosts; however, if they were too weak to stay on their own host then certainly they would be insufficiently viable to invade another successfully.
"Occasionally viable eggs do fall off, attached to hairs. These would have to remain warmer than 25øC (the minimum hatching temperature) for probably many days (up to 16, at the maximum hatching period at 25øC). The young louse then has to gain a host, and the whole series of events would need to be repeated with an egg of opposite sex within a short period.
"The louse itself only relies on host-to-host transmission while the hosts are in contact. The human head louse, for example, has learned through tens of thousands of years' experience that if it steps onto anything that is not another human head then the almost inevitable result is death. Head lice do not leave human heads except for other human heads, and no amount of experimentation has ever shown that any other method of transmission has any practical significance.
"In practice, although there are no viable lice in the environment, still the myths abound and are propagated even in respectable literature. Head lice are supposed to be transmitted by hats and caps, combs, chair backs, bedding, school buses, coats touching in cloakrooms, anorak hoods, video earphones, telephones, Father Christmas' beards, swimming pools, and pets. How wonderfully versatile this blind, helpless little insect is supposed to be! The fact remains that the only lice dangerous to people are already on other people. To that extent, the scabies mite and the human louse have something in common despite being such distant relatives."
Most texts agree. Head lice can't live for more than 24 hours off the human body. A louse is certainly not going to crawl onto headphones in search of a new host. On that matter Dr. Maunder is certainly correct. The louse instinctively looks for body heat and human blood. The only way headphones could transmit lice would be if fallen hairs which had living nits attached were accidentally transferred to the next user and the louse hatched before the hair fell free. The idea that fallen hairs with nits attached could contribute to the spread of lice results in the following advice. Items that can't be washed can be sealed in plastic bags for 2 weeks (the longest that nits can survive). It would seem then that careful inspection and cleansing of headphones with a damp sponge should be sufficient to deal with the unlikely possibility that there are any hairs with nits accidentally attached to headphones. Blasting the headphones with air should also suffice to remove any hairs. A disposable cover could also work if it completely enclosed the headphones, but that seems like overkill. Such a cover would have to be porous over the ear piece in order to transmit the sound.
Sincerely,
Dr. Warren
-BD
Dear BD: Blood pressure is age, size, and body build dependent. An infant may have a blood pressure of 70/40. A child may run 80/50 to 90/60 with larger and more mature children approaching adult values. The significance of a reading will depend on the circumstances. A person who normally runs 90/60 may be light headed at 70/40. A patient who goes into shock has a precipitous drop in blood pressure and will be pale, cool and lapsing into unconsciousness. Shock is an acute rather than chronic ongoing condition which generally occurs as part of a medical crisis or serious allergic reaction. Chronic low blood pressure would most likely be due to heart disease. The implications would be most related to the underlying disease rather than the blood pressure reading.
Sincerely,
Dr. Warren
If your questions haven't been answered here, perhaps you would like
to
question?!?
