8 May 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
-(unsigned)
Dear Parents: Stool withholding after a painful bowel movement (or for any other reason) is a common enough problem in a pediatric practice, but is not so common or necessarily obvious that you would have been aware of it in your preschool students. Treating a child who has chronic stool withholding can be difficult, so it may be worth your while to consult a pediatric gastroenterologist who has experience in this matter.
If your child has mastered holding his stool in to the extent that he can go a week or more without even a little stool, the only way to break the cycle is to empty him out completely and then make it virtually impossible to hold it in. This may even require that he have loose stools resulting in frequent accidents. This particular aspect of treatment is the part that many parents need the most support for. Many parents whose children are stool withholders actually consult their doctor about soiling which results from the stool withholding. As a result, most can't accept the increased mess that ultimately results in more success using a toilet. Please read my article, Fecal Soiling. From its title you probably never would have guessed that this article has information about the problem you're having.
Senokot is a mild stimulant laxative. It generally does not cause cramps, but anything that makes the intestines push more will cause your child to have cramps if he succeeds in holding the stool in while the intestines are trying to push it out. In order to work best, the Senokot must be combined with a bulk former (such as the lactulose) to soften the stool, and a lubricant such as mineral oil to make it hard for the patient to hold the stool in. As you can guess, this will result in accidents, but it will also make it possible for your son to experience pain free bowel movements and get over his fear.
Potty training certainly complicates the matter. Although it may be a step backwards, you might want to consider letting your son have his bowel movements in a diaper until you've made some progress getting him to have regular, soft, painless BMs.
Sincerely,
Dr. Warren
-GP
Dear GP: I'm not sure what basis your son's teacher has for concluding he may have a stress or anxiety disorder. I certainly would not ignore her observations, but the symptoms you describe are not that unusual in boys with an immature nervous system. Most children do mature out of bed wetting, but there is also effective treatment for bed wetting (see my article, Bedwetting) which your doctor should discuss with you.
The behavioral symptoms you mentioned sound very much like attention deficit disorder (ADD, ADHD). For a complete evaluation to determine if your son has primarily emotional issues or attention problems interfering with school your son should see a psychologist who does evaluations of school problems. ADHD can benefit from medication as well as specific changes in your son's educational program which address your son's difficulties.
Hearing testing is certainly a reasonable part of the evaluation of any child with school problems. I have never heard of selective hearing testing. The phrase selective hearing generally refers to a person's ignoring something he doesn't want to hear.
Being a deep sleeper does not suggest a sleep disorder as the cause of your son's problems. Disturbed sleep, daytime sleepiness, sleep apnea, and other specific sleep complaints suggest a need for evaluation at a sleep/wake disorders center.
Sincerely,
Dr. Warren
-LP
Dear LP: Many 2 year olds fall a lot because they run a lot and don't pay adequate attention to their surroundings. It is rare for children to suffer significant head injury from the usual childhood falls, but it depends where and how the child falls. A child who lands head first on a hard ceramic tile floor or goes flying head first into an object could suffer a concussion, skull fracture, or even have bleeding inside the head.
How much falling is too much? There's no way for me to give you a number. If the child falls frequently during activities in which other children his age don't fall or seems to be generally more clumsy than other children his age, then he should be evaluated by his pediatrician or a neurologist.
I'm not sure what your concerns are about your nephew's appetite. Children's appetites do vary from day to day. Your question didn't provide any specific details or concerns about your nephew's appetite.
Sincerely,
Dr. Warren
The first was held to term with no complications. The baby's speech developed normally with no intervention.
For the second pregnancy I went into labor at 32 weeks and was held to term with the aid of tributaline/brethine po. The delivery was uncomplicated. The babies speech did not develop normally and he has required speech therapy.
For the third pregnancy I went into labor at 33 weeks initially requiring Magnesium sulfate and subsequently a tributaline pump to maintain the pregnancy to term. The baby was delivered full term uncomplicated. The third baby's speech is not developing normally and she will also need speech therapy. She is 20 months and has not developed a vocabulary as yet.
question: Is there any connection between taking tributaline/brethine during pregnancy and delayed speech development in children.
Please respond via e-mail.
Thank you for your time.
-Dana
Dear Dana: I searched the literature to see if I could find any association between terbutaline used to stop premature labor and speech problems and found nothing; however, since I am familiar with using terbutaline to stop premature labor I was surprised to see that the only listed indications for terbutaline were asthma, chronic bronchitis, and emphysema. Use of terbutaline to manage premature labor was considered an off-label use. In addition, the manufacturer includes the following warning:
Warnings Usage in Labor and Delivery: Terbutaline sulfate is not indicated and should not be used for the management of preterm labor. Serious adverse reactions have been reported following administration of terbutaline sulfate to women in labor. These reports have included transient hypokalemia, pulmonary edema (sometimes after delivery), and hypoglycemia in the mother and/or the neonatal child. Maternal death has been reported with terbutaline sulfate and other drugs of this class.With regard to use in pregnancy the manufacturer states:
Pregnancy, Teratogenic Effects, Pregnancy Category B: Reproduction studies in mice (up to 1.1 mg/kg subcutaneously, corresponding to 4 times the human oral dose) and in rats and rabbits (up to 50 mg/kg orally, corresponding to 167 times the human oral dose) have revealed no evidence of impaired fertility or harm to the fetus due to terbutaline. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.If your children suffered any of the reported risks of use of terbutaline such as hypoglycemia, that could have some bearing on neurological or developmental problems; however, if the premature labor had not been stopped, the children may have suffered significant problems as a result of prematurity. The manufacturer has protected itself against liability by taking its official stance. The question remains as to whether there was a safer or better alternative. Finally, you must consider whether or not there was anything about the two pregnancies which resulted in premature labor which may also have contributed to the children's speech problems.Labor and Delivery: The safe use of terbutaline sulfate for the management of preterm labor or for other uses during labor and delivery has not been established and the drug should not be used. (See WARNINGS. [above])
Sincerely,
Dr. Warren
-JM
Dear JM: You are describing stool withholding. Your nephew doesn't want to have bowel movements on the toilet. As a result, he holds it in until it becomes large and hard. This results in leakage of stool in his pants and large stools which block up the toilet. The fact that his intestines are chronically filled with stool decreases his appetite. This is a complex problem to deal with. Please read my article, Fecal Soiling for more information.
Sincerely,
Dr. Warren
-RE
Dear RE: Part of the color of normal stool comes from bile. A completely white (not just light color) stool implies that there is no bile in the stool. If that persists there may be some obstruction of bile flow. Therefore if the stool remains white, consult your pediatrician.
Sincerely,
Dr. Warren
-ES
Dear ES: Although it is unusual for a young child to have offensive body odor, it is not the first time I've heard such a complaint. As long as her general health is good and she does not begin to show any signs of puberty (breast development is the first sign in girls), it is not a cause for concern. You certainly may use a deodorant for her. A height in the 95th percentile is normal, but if her height increases rapidly beyond the 95th percentile, such a growth spurt could be seen with puberty, however, breast development generally precedes the growth spurt.
Sincerely,
Dr. Warren
-Mrs. V
Dear Mrs. V: Many parents think that when a child has a cough they must give medicine to cure it. It's most important that you are aware that cold medicines relieve symptoms, but are not essential to your child's getting better. This explanation is intended to provide reassurance and put the use of cold medicines into perspective for you. In most instances it may not be desirable for your child to take any cold medicines. Although amiodarone does not have any listed interactions with cold medications, the stimulant properties of decongestants may make them undesirable to give to a child who has rapid heart rate. On the other hand, your cardiologist may consider his treatment protective enough to allow you to use decongestants. You need to review the usual over-the-counter medications such as cold medicines, fever medicines, etc., with your cardiologist and find out which ones you are allowed to use.
If your child's cough is disturbing his sleep and making him miserable, it would probably be okay for him to take a cough suppressant such as Robitussin DM, but since it is not essential to give medications for colds, I would advise speaking to your son's cardiologist before giving anything.
Sincerely,
Dr. Warren
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