10 April 2006
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
Thank you!
-Tina
Dear Tina: Your son's eyes could look light on the bottom (inside the lower lid) from anemia. Assuming your son has anemia from blood loss, you could treat him with iron supplementation. You should also try to minimize his blood loss by using the correct technique to stop his nose bleeds. When he has a nose bleed you should hold the entire fleshy part of the nostril closed against the middle on the side that is bleeding. You should keep pressure on the bleeding point this way for 5 minutes. If the nose is bleeding through both nostrils or bleeds even with the nostril being held as I have described, you son's nosebleeds could be from high up in his nose and require attention of an ENT surgeon.
At 18 months your son still needs routine pediatric care. If he is no longer eligible for care at the clinic, you must find out what services he is eligible for and how you can get them. You may have to pay a small fee for insurance if your state has a "Child Health Plus" program. Even if you are short on cash, in the end it is less expensive to provide regular care and illness visits for your child in a private office than it is to run to the emergency room.
Sincerely,
Dr. Warren
Dear Readers: When I prepare my columns for posting on my website I review my answers and sometimes think about other things I should have included in my answer, as well as changes I'd make in my advice due to new information or treatments. In this case, my advice was correct as far as it goes, but the first thing that struck me as I reread Tina's description is that a pale child with frequent nosebleeds could have leukemia. Tina did not indicate that her child was ill with fevers or swollen glands (other symptoms that would be seen with leukemia), but since she didn't tell me how long the problem had existed, I can't be certain it wasn't something serious. I certainly hope that she took my advice and found a way to get her child medical care.Sincerely,
Dr. Warren
-SF
Dear SF: Breathing treatments are not part of the routine management of pneumonia. Are you sure your son doesn't have asthma? Children who have frequent infectious illnesses such as URIs usually have frequent exposure due to daycare, school, or older siblings. Those children who have asthma or ear infections often develop complications from simple colds which make them seem much sicker than their peers.
Read my article, What is Asthma.
Sincerely,
Dr. Warren
-JC
Dear JC: The risks of adenoidectomy include bleeding, infection, and the risks associated with anesthesia. The benefit of decreased ear infections is not guaranteed. I have even had patients whose ear infections continued after adenoidectomy and tubes. In addition adenoids may grow back. These could be considered reasons to not go ahead with an adenoidectomy. Now these reasons must be put into perspective.
The risks of complications and anesthetic accidents are real, but small. Most children do very well with an adenoidectomy and have the anticipated benefit of fewer ear infections. if a child has had recurrent ear infections, hearing loss from middle ear fluid, and has failed at medical therapy aimed at preventing recurrence of the ear infections, it is reasonable to do an adenoidectomy in an effort to ameliorate the situation.
Sincerely,
Dr. Warren
-Confused and Concerned
Dear Confused and Concerned: Why was the GTT done? Was your son having any symptoms suggesting hypoglycemia? One doesn't treat lab data. And even if one did, with the lowest blood glucose being 66 at 3 hours, I don't understand how that proves hypoglycemia.
Your son's choice of meat may not be the best quality food, but the protein in it is still complete protein. Eggs and foods prepared with eggs are also an excellent source of protein. Soy protein is a popular protein for vegetarians and is readily available in a variety of forms. If your son is allergic to cow's milk protein, he may be able to tolerate cheeses and other products made from goat's milk.
If your son eats a variety of grains and pastas, that should help balance his diet. The protein portion of his diet doesn't have to provide more than 8-10% of his calories for him to have adequate protein nutrition. The traditional American diet is at least 20% protein.
Sincerely,
Dr. Warren
Any advise would be greatly appreciated.
Thank you.
-CS
Dear CS: The list of possibilities for these symptoms is endless. If your daughter has been "ill" for a short time, she could have a virus infection which she will get over. If these symptoms have persisted a while she could have anything from a vitamin deficiency to mononucleosis to a gland disorder, etc. She needs a thorough evaluation by her pediatrician.
Sincerely,
Dr. Warren
-Teri
Dear Teri: There is no simple way to get an avid thumb sucker to stop. You could paint bitter stuff on her thumb, put gloves on her hands, or have an appliance fitted to her mouth that would prevent her from sucking her thumb. This would probably make her miserable.
You could try using chap stick or lip balm on her thumb every time she takes it out of her mouth in an attempt to prevent it from drying out.
Sincerely,
Dr. Warren
We have made frequent visits to the ER, where breathing treatments have been administered, and also shots of Decadron. The breathing treatments seem to do little if nothing. We have resorted to hour long walks outside in the middle of the night, as that seems to help the most. We have tried the steam, however it does not seem to work either. It is not associated with a cold. The last 5 episodes with stridor he had been around old wood piles, fall leaves, and carpet freshner during the day, although the allergy tests came up negative to mold and dust.
One doctor suggested that it might be reflux. That seemed to be a stretch since he had never experienced any symptoms earlier as an infant.
Any ideas?? I just wish my little boy could get some sleep.
-MH
Dear MH: Reflux can certainly develop in a person who didn't have it previously. I developed it as an adult. Certainly children who didn't spit as infants can develop reflux. As to whether or not that is the cause of your son's stridor, that I can't say, but an upper GI series with a cinéesophagogram may show the reflux and might also serve to rule out anything constricting the trachea such as a vascular ring (which usually becomes evident in infancy since it is congenital). If GER cannot be confirmed by x-ray studies, a pH probe might show it. How far to go depends on how convinced the treating doctor is that reflux is a possibility.
Spasmodic croup is often provoked by allergy. These kids often arrive at the doctor's office or ER just fine because a trip in the cold air breaks the attack. I'm convinced that people can have allergies which don't show up on allergy tests because the tests only check for the most common allergens. When my daughter was tested for allergies because of her asthma, all the tests came out negative, so, since we get mice every winter, I asked the allergist, "Could she be allergic to mice?" He said possibly yes. But she wasn't tested for it. Since her allergy tests were all negative, we allowed her to get a cat. She subsequently developed an allergy to the cat, demonstrating that she indeed had a tendency to allergies, even though she tested negative for all the common allergens. The point of the story is that if you have seen an association between your son's croup episodes and exposure to certain substances, avoidance would be reasonable.
Finally, I had a patient who had croup episodes when he had sinusitis. As a physician who tries to avoid unnecessary use of antibiotics, I resisted putting him on antibiotics when he started colds and became croupy, but it did work, and so eventually I took the risk of over treating and prescribed antibiotics as soon as he had a little croup.
Note to Readers: Since this letter was written excellent treatment options have become available for GERD. Under the circumstances, a therapeutic trial of one of these medications might be reasonable. That having been said, usually an endoscopic exam by an ENT whould show evidence of reflux. Maybe the redness at the base of the throat meant something.
Sincerely,
Dr. Warren
-EK
Dear EK: You can't convince a 2½ year old to do anything. A 2½ year old may speak English, but he doesn't speak logic, cause and effect, or long term consequences. You can entice a 2½ year old to do something or you can tell him to do something. You can explain your reasons to a 2½ year old, but you don't discuss things with a 2½ year old. He's a baby. He can't handle choosing between what's best long term and what feels right to him at the moment.
If you want your child out of your bed, he has to learn that he will be okay if he sleeps in his own bed, that the next day will still come and you will still take care of him. He can't learn it without experiencing it. An he isn't going to experience it without being upset about it and crying.
I don't advocate being cruel to children. Growing up is tough. Until children learn to handle separation it is traumatic for them, but they don't learn to handle it without experiencing it. Being a parent is tough. As a parent, you have to decide how you want to equip your child to deal with the future. You have to decide when you are ready and when your child is ready to take the next step. There are a fare share of next steps in your child's life that may not be accomplished without tears.
Please rid yourself of the notion that you cannot make your child cry. A child who cannot be allowed to cry rules the house. Children who rule their homes are ill equipped to deal with the real world where what they want is not always what matters. These children don't have the security of a framework of rules and values to which they must adhere. They do not end up happier and less traumatized than kids whose parents make and enforce decisions that they feel best even if it causes their child to be temporarily unhappy. In fact, children who always have to have their way find every instance in which they can't have their way to be a major trauma since they have never learned to deal with it.
Let me get off my soap box. You're not happy with your child in your bed. He's not sleeping well there either. Make sure your pediatrician has determined that there is nothing disturbing your child's sleep and then get to the business of teaching your child to sleep in his own bed. By all means be gentle and caring, but be firm in your resolve to accomplish your goal and accept that it won't be accomplished without tears. Please read my article, Helping Your Child to Sleep Through the Night.
Sincerely,
Dr. Warren
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