10 July 2006

1. Mom Needs a Full Night's Sleep
2. Tuberculosis
3. Side Effects of Iron
4. What Age Peanuts?
5. Evaluate Chronic Abdominal Pain
6. Enlarged Spleen
7. Daydreaming or Seizure
8. Ringworm
9. Disclaimer

• Read Questions & Answers in Another Column

Mom Needs a Full Night's Sleep

Thank you.

-KC

Dear KC: If you have succeeded in teaching your son to put himself back to sleep most of the time when he awakens, you have done all that can be done to encourage good sleep habits. There is nothing I know of that can teach a child to sleep for longer periods before he awakens.

I agree that it's important for parents to get enough rest in order to be the best parents they can be. If you can't get enough rest with your son's nighttime waking even when he is awake only briefly, then you need to get a break for yourself. Even if you can only get one night away from the kids it's important to do so once in a while.

Sincerely,
Dr. Warren

-G

Dear G: Tuberculosis is an infection caused by a bacterium called Mycobacterium tuberculosis. The primary location for infection is in the lungs, although infants and children can develop meningitis, kidney infections, lymph node infections, and bone infections as well. Very young infants may even develop tuberculosis all over the body.

The infection is spread by inhaling the organism. People with active tuberculosis spew out millions of tuberculosis germs every time they cough. Although it is possible to be exposed accidentally just by walking through a cloud of airborne germs from an infected person who has just coughed, most children are exposed by frequent contact with someone who has active disease, usually a caretaker or relative.

I've talked about "active disease" because it's also possible to have inactive disease. Most healthy people who develop a primary tuberculosis infection successfully wall off the disease in their lungs. They are diagnosed because of a positive skin test. Their chest x-rays are normal and they do not have evidence of disease elsewhere in their bodies. These people are not contagious. Children with primary (inactive) TB are treated for 9 months with INH to prevent future activation.

Active TB causes symptoms based on the part of the body where the infection resides. The most common symptoms are fever, night sweats, weight loss, and productive cough. Treatment requires 6 months or more of a regimen of 3 or 4 antibiotics. Advanced cases cause cavities in the lungs and may require surgical treatment of the affected lobe.

Sincerely,
Dr. Warren

-VL

Dear VL: Most people tolerate iron without too many side effects but iron has been reported to cause constipation in some people and diarrhea in others.

Sincerely,
Dr. Warren

Thank you.

-RK

Dear RK: I generally recommend avoiding nuts until at least 2 years of age because they pose a choking hazard. This can be equally true of peanut butter because it is sticky and can get caught in the roof of he mouth. There is some truth to the idea of delaying the introduction of allergenic foods to avoid allergies. Infant's intestines allow larger molecules to be absorbed than older children. These larger molecules are more likely provoke an allergic response. That is the reason for not introducing eggs into the diet before at least 8 months (I recommend 1 year). I honestly don't know if the matter has been studied with regard to a specific age at which peanuts can be introduced and doubt there would be a substantial difference between the response of a 2 year old and a 3 year old.

Sincerely,
Dr. Warren

Thank you.

-Very Concerned Mother

Dear Very Concerned Mother : Umbilical hernias do not develop because of tension on the umbilical cord. When present, umbilical hernias cause a visible bulge in he navel. Other than the bulge they almost never cause symptoms. So, while there may be reason to further evaluate your son's abdominal pain, it has nothing to do with he events surrounding his delivery.

Migraines can certainly cause nausea, vomiting, and abdominal pain. In some instances, the vomiting is the most bothersome symptom with he headache being a lesser issue. If your son has not had any evaluation for abdominal pain, it would certainly be reasonable to consult a pediatric gastroenterologist and/or do some tests such as abdominal and pelvic ultrasound.

The bed wetting is probably not related to the abdominal pain.

Sincerely,
Dr. Warren

Till now she is doing very well. No signs of illness. But her milt is still very large (estimation ... twice the original size). All the blood tests so far are OK. The doctors are puzzled and although they keep on testing and consulting each other, they ran out of options. It is something very rare.

I realize that it is difficult to answer a question like this from a distance, but have you any suggestions which could put us on the right track again ?

Thanks in advance.

-DK

Dear DK: One of the joys of the internet is the way it can bring people together from all over the world. Unfortunately, even when we all speak the same language, regional and cultural differences may create difficulty with communication. I don't know if the word "milt" is a Dutch word, or a term used by physicians in other parts of the world, but I had no idea what it was. One dictionary I had led me to believe you were referring to the spleen.

According to Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company the main causes of splenic enlargement are:

Infection

Bacterial: Typhoid fever, endocarditis, septicemia, abscess
Viral: Epstein-Barr, cytomegalovirus, and others
Protozoal: Malaria, toxoplasmosis

Hematologic Processes

Hemolytic anemia: Congenital, acquired
Extramedullary hematopoiesis: Thalassemia, osteopetrosis, myelofibrosis

Neoplasms

Malignant: Leukemia, lymphoma, metastatic disease
Benign: Hemangioma, hamartoma

Infiltration and Storage Diseases

Lipidoses: Niemann-Pick, Gaucher diseases
Mucopolysaccharidosis infiltration: Histiocytosis

Congestion

Cirrhosis or hepatic fibrosis
Hepatic portal or splenic vein obstruction
Congestive heart failure

Cysts

Congenital (true cysts)
Acquired (pseudocysts)

Miscellaneous

Lupus erythematosus, sarcoidosis, rheumatoid arthritis

Sincerely,
Dr. Warren

All the blood tests sofar are looking OK. There is no reaon found for the anemia. The blood in the (here I go again with a translated word) marrow of the bone was OK. Her resistance against diseases is OK.

We actually don't know if the spleen has been this big from the start. We have never checked it before. When she was born , her looks was yellow due to a high level of billirubine (??)which didn't went away even after having her a couple of days in the light under a lamp. It was decided to accelerate the process by blood-crossing (I cannot translate all those medical terms). This helped and after that she was a healthy baby / child till the incident last year.

I hope that this is the information you need.

Again I'm very grateful for your help.

Sincerely,
-DK

Dear DK: Any guess I make as to what actually happened to cause your daughter's anemia and splenic enlargement would be more or less just a guess since it sounds like a thorough evaluation did not provide any answers.

Your daughter's spleen could have been enlarged because your daughter was profoundly anemic and the spleen was participating in the body's efforts to make more red blood cells. That happens in congenital anemia's such as Cooley's anemia (Thalassemia). If that is the case, the unanswered question is, "what caused the anemia?"

Your daughter's spleen could have been enlarged if there was a problem with her red blood cells (I'll explain in just a second). One of the functions of the spleen is to remove damaged red blood cells from the circulation. In some forms of hemolytic anemia, the red blood cells are coated with antibodies causing the red blood cells to lyse (break). The spleen removes the broken cells and intact cells which are coated with antibodies. It enlarges when it is overworked with a lot of red cells to remove. Usually hemolytic anemias can be diagnosed with a variety of blood tests. On occasion the hemolysis may be provoked by a virus infection or reaction to a food or toxin. Reactions to foods or toxins causing hemolysis is usually related to G6PD deficiency. I assume your daughter was tested for that.

Patients with sickle cell disease can have something called a sequestration crisis in which the spleen enlarges acutely and fills with blood leaving the patient profoundly anemic. I don't know if such a thing has ever been seen with other blood disorders or in situations in which the spleen is enlarged for some other reason.

So what I'm telling you is that a big, overactive spleen can cause anemia, and anemia can cause the spleen to enlarge, and finally, that some blood disorders can cause the spleen to enlarge and become overactive.

Sorry I can't tell you which came first or why.

Sincerely,
Dr. Warren

- Dawn

Dear Dawn: Your daughter's apparent "daydreaming" may be part of a seizure disorder. You should mention it to the neurologist who is evaluating your daughter for seizures. You should make sure your pediatrician knows what's going on.

Sincerely,
Dr. Warren

-Sherry

Dear Sherry: I am not aware of any home remedies which can prevent ringworm from spreading. Since ringworm is contagious, it makes sense to wash your hands after handling it, don't share towels, and disinfect any surfaces which may have the ringworm on it. You can treat most ringworm on the skin at home with Tinactin, Lotrimin, or Micatin. Lamisil is now available without a prescription as well. Ringworm of the scalp and nails usually can't be eradicated without taking medication by mouth.

Sincerely,
Dr. Warren

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