7 August 2006

1. Difficulty Getting Pregnant
2. Persistent Diarrhea
3. Bed Wetting and Sexual Abuse
4. Toe Walking
5. Developmental Delay
6. Caffeine
7. Spitting Up
8. Irregular Menses
9. Disclaimer

• Read Questions & Answers in Another Column

Difficulty Getting Pregnant

I only went on the pill for a little less than an year. I've been trying to get pregnant... I haven't had a regular period. It always come earlier and earlier... Is this normal...?

After I do have my period, I find that later I have more discharge... brownish color like blood I guess, sometimes it's egg white with blood strands is this normal?

I know, I should wait one year... then see a doctor about my unfertility.. or whatever "seems to be going wrong for the two of us"...our doctor says to relax.. How can one relax when all I hear from relatives is "aren't u preggie yet?"

I'm overweight...but, does that really matter? I've seen other woman bigger than me..having lots of babies! What's wrong with me?

-KV

Dear KV: Menstrual cycles are often not as regular as most women think. The only part of the cycle which is regular is that menstruation occurs about 2 weeks after ovulation if the egg is not fertilized. If a woman does not ovulate for a cycle or two she may be very irregular. If ovulation occurs early enough after menstruation resulting in a very short cycle, this may contribute to difficulty conceiving. Staining for a day or two after menstruation stops is not unusual. Being overweight should not interfere with conception unless your weight problem is caused by a medical problem. While it may be too soon for a complete infertility evaluation, if you have concerns about your menstrual cycle and it's impact on your efforts to get pregnant, you should consult your gynecologist.

Sincerely,
Dr. Warren

Any direction to look into would be greatly appreciated.

-TL

Dear TL: After 4 weeks of intermittent diarrhea, vomiting, and abdominal pain associated with a 4 pound weight loss your daughter needs a thorough evaluation by a pediatric gastroenterologist. This could include stool analyses, x-ray studies, ultrasound studies, and endoscopy.

Sincerely,
Dr. Warren

Have you seen many cases of bed wetting that also led you to believe because of other symptoms that the child may be a victim of CSA?

Have you seen any cases when bed wetting was definitely related to, or directly caused by CSA because of an admission by child or abuser, or evidence being investigated by outside parties? If and when you have seen this, or by your own knowledge on the subject, is the reason for the bed wetting caused by fear of parent or the close proximity of the sexual organs of a female child to the bladder? Or both? Or something else?

I appreciate any, and all information you can provide for me.

Thank you.

Sincerely,
-CG

Dear CG: I have not seen any cases of bed wetting related to sexual abuse. Bed wetting is a fairly common childhood developmental problem. In the typical situation, the bed wetter has never had any prolonged periods of being dry. If a child who has been previously dry starts wetting, then it is more likely to be due to an external cause. This could include diabetes, urinary tract infection, and any cause of psychological stress including sexual abuse. In situations where the cause is psychological, the bed wetting usually represents a form of regression and has nothing to do with the fact that the urinary organs and sexual organs are related. In regression a patient subconsciously goes back to a younger age when he was dependent and taken care of, and feels safe. In the case of an older child who is sexually abused, regression may also be a subconscious attempt to be more infantile and thus less sexually desirable.

Sincerely,
Dr. Warren

Thank you

-KD

Dear KD: Most children who toe walk do it by habit. Many of them previously spent a great deal of time in infant walkers pointing their toes down to reach the floor. Toe walking could be seen with neuromuscular conditions such as cerebral palsy; however, in the absence of any other neuromuscular abnormalities or developmental delays it would be unlikely. By 2½ years of age your pediatrician should certainly have had some suspicion of a problem if there were more to the picture than toe walking.

Even if everything is okay you child's heel cords could become tight if he always walks on tip toes. If he keeps his toes pointed down even when he is not walking or cannot stand flat on the floor, he should be evaluated for physical therapy to stretch his heel cords.

Your pediatrician should advise you, based on his examination, whether there is any need for an orthopedic or neurological evaluation.

Sincerely,
Dr. Warren

According to my sister, nothing was amiss for the first year and a half or so until they began to wonder why he did not try to walk or talk or respond to voices. They then took him to get his ears checked and tubes were inserted on the Pediatrician's advice. When the parents realized that the child still gave no responses, they went on this now seemingly endless search for answers.The child can not or will not speak, makes guttural sounds, is at times very alert but not for long, then behaves like he is not aware of his surroundings. He does respond to his mother (my sister), father and siblings at times but hardly never to strangers. He is otherwise a healthy, happy and very affectionate child. No one seems to know how to help Michael, other then to suggest and prescribe speech and stimulative therapies. What could this ailment be and what could have caused this child to behave this way?

Any advice will be greatly appreciated.

-AJ

Dear AJ: You have not provided me with any information regarding what kind of evaluation your nephew has had. Has he seen a neurologist? Did he have an EEG, imaging studies such as a CT scan of the brain or MRI, metabolic studies, or chromosome studies? What did the doctors conclude?

If there were no specific abnormalities found on examination, depending on the results of social and psychological evaluations the doctors should be able to tell you if the child is mentally retarded or has pervasive developmental disorder (sometimes known as autism).

For most forms of developmental delay other than certain metabolic disorders which might benefit from dietary changes or medication, the most important treatment is early intervention services including OT, PT, and speech therapy.

Sincerely,
Dr. Warren

1) What effects does caffeine have on a growing child's body?

2) What are the up sides and down sides to caffeine usage?

3) Are there any negatives to using caffeine in the long term?

4) Have you ever had a case that evolved caffeine as a factor? Is this even possible?

5) What advice would you give to a teenager who used caffeine daily to stay up and do work?

6) How do you use chemistry in your line of work?

7) What exactly does caffeine do to a person's body?

8) Would caffeine have a greater detrimental effect on children than teens or adults?

9) Is there anything besides caffeine that would give the same effect without the negatives that you know of?

10) Is it possible for a person to OD on caffeine and approximately how much would it take? Would it be possible to intake this much without being aware of it?

11) Do you believe that soda makers put caffeine in their product to get kids addicted? Why?

12) Is it the caffeine or the sugar in the soda that makes kids hyper in your opinion?

13) As a child, did you use caffeine, and, if so, what do you think of that usage now?

14) As an adult, do you use caffeine, and, if so, what do you think of it?

15) Did you take any sort of chemistry class in school?

-Leslie

Dear Leslie: 1. Caffeine does not have any specific effects on growing bodies. Caffeine has the same undesirable side effects in children and adults. Caffeine is a stimulant. As with most stimulants, it can increase the heart rate, cause palpitations, nervousness, excitability, irritability, tremors, and insomnia. It does not appear to suppress the appetite to the degree of many other stimulants. While these side effects are the same in children or adults, I'm sure you can appreciate how a child who is excitable, irritable or nervous could act out and be disruptive in a way that most adults with a modicum of self control would not.

2. While caffeine may help many people to get going in the morning and even give them a midday boost which could help productivity, most adults can make an informed decision regarding when they want to have caffeine and when they want to take a nap instead. I can't see any upside to letting children consume caffeine. For the most part, children who consume caffeine do it accidentally along with soft drinks without making any conscious or informed choice to consume it.

3. Caffeine is an addictive drug. Even those who use it regularly can never predict when they may become overstimulated by it. Nor can they predict when their schedule may cause them to miss their morning coffee and cause withdrawal symptoms.

4. Caffeine withdrawal can cause headaches, therefore, caffeine intake becomes an issue in any patient complaining of headaches.

5. Sooner or later the body has to get the sleep it needs. Caffeine can't eliminate the need for sleep. It can only postpone it. Therefore caffeine is at best a stopgap measure which can be used successfully for a specific project. It can't increase productivity longterm. If you're addicted because of regular use, adult, teen, or child, be prepared for withdrawal headaches when you miss your usual dose.

6. An understanding of biochemistry is useful to understand the metabolic pathways which go awry in some disease states. For those doing research in medicine, chemistry is a crucial part of pharmacology and even genetics. But for the most part, those of us who treat patients are several steps removed from the chemistry involved in our treatment and don't really use chemistry in our daily work.

7. Caffeine is a stimulant. (see question 1.) If you're looking for detailed information about how it actually works in the brain you'll have to check a pharmacology book or perhaps an encyclopedia.

8. Caffeine is more likely to effect a child's behavior adversely since children have less self control than teens and adults and less insight into their actions.

9. As stimulants go, caffeine is one of the safer drugs. If you're looking for a safer, healthier alternative, a combination of good nutrition, adequate sleep, and exercise can be quite stimulating. Many people who exercise regularly claim to get quite a rush from it. There's no question that a jog around the block can wake up a person who is falling asleep at his desk. Of course, anyone who has had a sports injury can attest to the fact that even exercise isn't risk free.

10. Caffeine overdose can cause upset stomach, diuresis, visual disturbances, palpitations, headache, confusion, irritability, tremors, convulsions, and hallucinations. My toxicology test does not provide any dose information. Perhaps your local poison control center could give you that information. Since some medications contain caffeine, it is possible for a small child to accidentally ingest an overdose just as children get into other poisons. A child would have to consume a lot of caffeinated beverage to have a serious overdose. I'm sure many adults and children experience mild overdoses by overdoing caffeinated beverages and ignoring the symptoms that suggest it's time to stop. Not too different form getting seriously drunk.

11. Beverage makers know what sells. I don't know if they consciously attempted to create addiction. These days, it is just as important for companies to provide caffeine free alternatives for the health conscious who want to avoid caffeine.

12. Studies of the effect of sugar on children, including hyperactive children, do not support the myth that sugar causes hyperactivity. Since caffeine is a known stimulant, it wins by default as the cause for hyperactivity in children who drink caffeinated soft drinks.

13. I didn't drink much soda as a child. When I was a child in the 1950s and 60s, I don't think we paid attention to the caffeine content of drinks any more than we paid attention to the fat content of food. I started drinking coffee with my mother when I was a teenager. I have no problem with highschool kids consciously drinking coffee or caffeinated beverages to help get their morning started, but I'd have to recommend moderation. I can't see any reason for young children to consume caffeine.

14. I like my morning coffee. I usually drink one cup in the morning and sometimes one in the afternoon. I don't think of coffee on my days off, and as a result, even though my caffeine intake is small, I often have withdrawal headaches if I go more than a day without coffee.

15. I took chemistry in high school. As a biology major at RPI I was required to take a number of chemistry courses including general chemistry, organic chemistry, biochemistry, and labs. In medical school I took biochemistry.

Sincerely,
Dr. Warren

Thank you for your help.

-LW

Dear LW: Most infants who spit up but are gaining weight well and are happy are just spitting up as infants do. Some spit a lot more than others. The rotation of the stomach begins to change as the baby spends more time upright. I have never had a complaint of spitting up in a toddler, but I have certainly seen it continue in 7 month olds.

Babies who have significant gastroesophageal reflux (GER) may be irritable and have a chronic cough. Aspiration from GER could cause pneumonia, but in the absence of chronic cough it is unlikely that reflux had anything to do with it.

Sincerely,
Dr. Warren

Thank you for your help.

-LW

Dear LW: 9 ml (just short of 2 teaspoons) sounds like a lot of Maalox for an infant. It's also a rather odd number. Are you sure you haven't misunderstood the instructions. Excess Maalox could cause constipation or upset stomach.

The purpose of giving antacids to patients who have reflux is to decrease the acidity of the reflux. This goes a long way toward decreasing the irritation in the esophagus and throat which can contribute to discomfort; however, the antacid does not do anything to decrease the amount of reflux and so will not affect the amount of spitting. Thickening the formula or using a prethickened formula may help decrease reflux. Medications which speed up stomach emptying can also decrease reflux.

Sincerely,
Dr. Warren

To tell you the truth, I have never gone to see a gyno yet...I'm a chicken I guess. I'm new to this country...and I know my local doctor from Canada told me to do this after two years of having sex...which would be sometime in July for me.

Right now for this month, I got my period on the Feb 15, and it's the 20th now..but, it hasn't been a normal period. Normal for me is...I get it...I know, because that brown stuff comes ..and the next day it will be like pink stuff-blood., then the third day it's "heavy" for the next two days..and then it starts to go away..this time...it never really took off... as to speak. And, I knew I was getting my period as my breasts were tender before...and normally once I get it..it goes away..but still after five days later..I swear my "breasts or so sore, they ache...especially if you apply pressure to the front nipple...area.

Is this normal? and I haven't bled properly..its as if it came but, then stopped...I still have to wear a panty liner as it's just brown stuff...as if its going away..but, tricks me..by sometimes being a bit of blood. I will go to the gyno...just answer this one last question for me ..and I promise I will

My husband seems to think that maybe, I'm pregnant...thus the sore breasts...and maybe something wrong? what do u think..

I don't know...this whole thing is very new to me.. as I was never very observant before about the whole woman business till up seven months ago while I've been charting when I will be ovulating....and when I might get my next period.

The past 3 months its been like this.
Dec I got my period starting on the 21
Jan I got it on the 18
Feb 15
so it seems to come every month three days earlier than the month before. That's all I can tell you for now.. or all that I know..

Thanks...for all this I'm really quite impressed with this email thing... I'm only 25, and my husband 37

-KV

Dear KV: If your cycle is less than 4 weeks you are either ovulating before 14 days after your last period, or you may be having some anovulatory cycles (cycles in which you don't ovulate). Anovulatory cycles are often longer than normal, but may be very irregular. Every woman has one once in a while. Normally, Your uterine lining builds up under the influence of estrogen (one of the female hormones). After ovulation, progesterone (another female hormone) maintains the uterine lining preparing it for implantation of a fertilized egg. If there isn't a pregnancy, once the follicle which produced the egg stops making progesterone, the uterine lining is shed (menstruation). When a woman has an anovulatory cycle, there is no progesterone (since there is no follicle producing an egg or progesterone). In the absence of progesterone, the uterine lining continues to build up under the influence of estrogen and can be shed irregularly resulting in irregular menses. There may be some engorgement of the breasts from the influence of estrogen as well. So, you may be having an anovulatory cycle now to explain your unusual period.... but do make an appointment to see your gynecologist.

Sincerely,
Dr. Warren

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