4 September 2005

1. Not Tolerating Milk?
2. Hemoglobin = 9
3. OtoLam, Chiropractic - for Middle Ear Fluid
4. Variations in Blood Pressure
5. Masturbation
6. Frequent Fevers, Ear Infections, and Sinus Infections
7. Nasal Congestion, ? Milk Allergy
8. Chicken Pox? Or Something Else?
9. Disclaimer

• Read Questions & Answers in Another Column

Not Tolerating Milk?

-DM

Dear DM: Was your daughter on a milk based formula like Enfamil or Similac? If she was, then you already know that she tolerates milk protein and lactose. Her gas pains may be coincidental or related to adjusting to the decreased carbohydrate content of milk compared to formula. Is she constipated? If so, look to solve that problem before giving up on milk.

Milk protein allergy can cause vomiting, congestion, and even hives. Lactose intolerance can cause diarrhea and gas. If your daughter is really miserable and it's not clear whether the change in diet is the cause, go back to the formula for a while and try again when she seems to be better.

Sincerely,
Dr. Warren

-WM

Dear WM: The most common causes of a low hemoglobin in an 18 month old are iron deficiency, usually caused by inadequate iron intake, and genetic anemias like Thalassemia trait. Very often when patients tell me all other blood work was normal it doesn't help me think about the case since I have no idea what blood work was done. Since a hemoglobin of 9 is not normal, with appropriate blood tests it should be possible to determine the cause of the anemia. A consultation with a pediatric hematologist may help in interpreting the test results.

Sincerely,
Dr. Warren

Thank you for your time.

-DH

Dear DH: The OtoLam is not an alternative to tubes, but rather an alternative to general anesthesia for tube placement. The following abstract describes the procedure and the data:

Office-based insertion of pressure equalization tubes: the role of laser-assisted tympanic membrane fenestration.
Brodsky L - Laryngoscope - 1999 Dec; 109(12): 2009-14
From NIH/NLM MEDLINE, HealthSTAR

Authors:
Brodsky L; Brookhauser P; Chait D; Reilly J; Deutsch E; Cook S; Waner M; Shaha S; Nauenberg E

Abstract:

OBJECTIVE: To describe the role of the hand-held otoscope combined with a flashscanner CO2 laser, OtoLAM (ESC/Sharplan, Yokneam, Israel), for pressure equalization tube (PET) insertion in an office setting.

STUDY DESIGN: Prospective, multisite, clinical cohort trial (Institutional Review Board approved; informed consent) in the setting of pediatric otolaryngology outpatient departments at four tertiary care children's hospitals. METHODS: Selected for the study were 54 patients (96 ears), ages 6 months to 23 years, who met standard indications for PET insertion using cold-knife myringotomy and tube insertion under general anesthesia. PETs were indicated for recurrent otitis media, chronic otitis media with effusion, and eustachian tube dysfunction-all unresponsive to medical therapy. Topical anesthesia was achieved with iontophoresis (n = 1) or topical anesthesia: 8% tetracaine on an Otowick (Xomed Surgical Products, Jacksonville, FL, catalogue No. 400141) against the tympanic membrane for 45 to 180 minutes (n = 53). Laser-assisted tympanic membrane fenestration was performed with the OtoLAM set at single pulse, 2.0- to 2.6-mm spot size, and between 3 and 18 W. Insertion of grommets was accomplished using the otomicroscope and an "alligator" microforceps. Restraints with papoose were used in 79% of children with a mean age of 34.4 months (SD = 60.9 mo). Clinical, parent/patient, and physician satisfaction and comparative cost impact outcomes are described. RESULTS: All ears but three (3%) underwent successful placement of a PET. Pain was described as "absent" in 39%, "present but tolerable" in 30%, and "severe" in 30% of children at the time of procedure; 5 minutes after the procedure pain was described as "absent" in 75%, "present but tolerable" in 22%, and "severe" in 3%. Tube plugging (3 of 74 available ears; 4%) or persistent otorrhea (1 of 74 ears; 1.4%) occurred infrequently at the 1-month follow-up. Before PET insertion, hearing loss was noted in 66% of cases (mild, 38%; moderate, 22%; and severe, 6%). Mild hearing loss was noted in only 8% and moderate hearing loss in 2% of 47 (50%) of the ears at the 3-month follow-up. Ninety-two percent of parents were highly satisfied with the procedure in preference to PETs in the operating room under general anesthesia, and 97% preferred OtoLAM with PET insertion, rather than further courses of antibiotics; only one parent would rather have had the PET insertion under general anesthesia. Cost savings to health care organizations, particularly payers, and to parents are substantial (32%-48%) and warrant attention. Cost to the physician is manageable only if an appropriate approach to the third party payers results in a substantial increase in reimbursements.

CONCLUSIONS: The data indicate excellent clinical effectiveness, reduced risk, and high parent and physician satisfaction. Strong incentives for physicians to use this technique are in all stakeholders' best interests. These incentives need to evolve as soon as possible for the more widespread acceptance of OtoLAM with PET insertion in an office setting for appropriately selected patients.

Since allergies can cause congestion, eating foods a person is allergic to may contribute to middle ear fluid, but there are no foods specifically shown to be associated with middle ear fluid. Of the many letters I have received on this subject (please check my web site for more on this subject) most expressed a concern or belief that milk caused middle ear fluid. While I'm sure that drinking milk may contribute to middle ear fluid if the child is milk allergic, the many patients I have who drink milk and don't have middle ear fluid, and the equally large number of infants on soy formula who have ear problems would go against milk being THE cause of all middle ear fluid.

Sincerely,
Dr. Warren

I have won first place in my school for my experiment and will be going to the Regional finals. My question was, "What causes variations in blood pressure". I compared male and female, smokers and non-smokers, exercise, stress and age groups from 10-15, 16-20

And 20 and up.

I have a lot of information from the Internet and noticed your name.

Could you answer – what causes variations in blood pressure, and as this is going to different parts of the world to different professionals. Does your region have a high incident of hypertension?

Thank you for your time in this matter.

-KH

Dear KH: Congratulations on the success of your science project.

There are many factors which affect blood pressure:

• Age: children have lower blood pressure than adults, partially because of size. As people age their blood pressures also go up because of hardening of the arteries.
• Weight: obesity increases blood pressure in all age groups.
• Heredity: essential hypertension (high blood pressure for which no specific medical cause is found) often runs in families.
• Stress: people under stress often have elevations of their blood pressures.
• Kidney disease: part of the biofeedback mechanism that regulates blood pressure resides in the kidneys so certain kidney disorders can cause hypertension.
• Exercise: usually has a beneficial effect on blood pressure, although it will be higher immediately after exercise than at rest.

To the best of my knowledge, Long Island, NY does not have any unusual incidence of hypertension, but don't quote me because I haven't read any studies on the matter.

Sincerely,
Dr. Warren

-Isabel

Dear Isabel: After girls go through puberty (the body changes which make them women) they have vaginal secretions which are related to hormonal changes associated with their menstrual cycles. Masturbation increases the amount of secretions since excitement causes secretions which lubricate the vagina for sex.

When girls first start getting their periods they may be very irregular. It is not unusual for a girl to miss several periods when she first starts menstruating. Masturbation will not affect your menstrual cycle.

Masturbation is a natural way to satisfy your sexual urges until you are old enough to have a partner. There is nothing wrong with masturbation, but as with all things, moderation is a good idea. By moderation, I mean, you don't want to spend so much time masturbating that it becomes the most important activity in your life. There are many other important things teens should be devoting their energies to on the way to adulthood. Sexual satisfaction is only one aspect of growing up. There are so many other parts of growing up which can also provide satisfaction and meaning to your life.

Sincerely,
Dr. Warren

-Isabel

Dear Isabel: There is no test which can show if you're masturbating. This is the second e-mail I've gotten from you about masturbation.

There is nothing wrong with masturbation, but you appear to be preoccupied with it. If all your energy goes to either masturbating or being anxious about it, that's not good. If my responses to you have not helped you put masturbation in perspective and allow you to concentrate on other things you might want to get some counseling.

Sincerely,
Dr. Warren

• Viral menningitus -9 weeks old
• ear infections/sinus infections-12 antibiotics in first year of life
• high fevers without a source in first year
• couldn't swallow solid foods(not even a cheerio or grahm cracker)
• Adenoids removed/ tubes put in by Dr. A.
      14 months old ear infections let up/ general health improved drastically
• began to eat solid foods at 16 months (2 months post surgery)
• sinus infections continued but less frequent
• pneumonia at 18 months
• beginning in January began to get viruses . Couldn't stay well for more than 5 days at a time. Symtoms included extremely green discharge from nose, low grade fevers, loss of appetite.

Diagnosed with viruses during January and February this entire time having green discharge from nose, frequent low-grade fevers. Condition never really improved. On two separate occassions had fever of 105. Without source. A few days following the second 105 fever. (2/29) Fluid and blood gushed from his ear and rushed him to Clinic. Said it was serveve ear infection. Gave him omnicef and Floxin drops. D complained of pain for days. That is when I called Dr. A's office. He was in surgery all day, so I called D's Ped. and nurse said it could be popping that he is experiencing. Meanwhile antibiotic seemed to take effect and pain lessened nose began to dry up. We went out of town and while we were away D spiked a fever of 105. (3/10) took him to ER in Charlotte, NC. Couldn't find anything. Red/white blood count normal. Chest X-ray normal (no pneumonia). Treated fever with motrin and tylenol for 24 hours. When we came home took him to Ped. (3/13). Fever had went away, but green nose and cough worsened . Prescribed a long term (2 weeks) treatment of omnicef. It has been 3 days on antibiotic and nose is clear but extrememly runny. Cough is very noticeable and persistent. Chest is beginning to rattle. D is VERY irritable.

Note: D is on a multivitamin and gets extra vitamin C daily.

Mom's concerns:

1. Frequency of viruses/ infections and David's inability to fight them.
2. High fevers (105) without source.
3. Could he be having trouble making antibiodies?
4. Possible allergies

-S

Dear S: Both allergies and an immune deficit may contribute to chronic upper respiratory problems; however, this is really a complex issue since many factors play a role.

Although the fact that your son had viral meningitis at 9 weeks contributes to your impression of him as an unhealthy child, this may have been nothing more than an unfortunate coincidence. Viral meningitis is most common in the summer months and every year some healthy infants develop fever and are found to have viral meningitis. Unusual infections including the recurrence of meningitis have not been a problem for your child. Basically his problems have centered around sinus and ear infections as well as some unexplained fevers. Your concerns center around frequency and severity of these infections.

The first consideration with regard to virus infections, including upper respiratory infections is exposure. Whether your immune system is normal or not, and whether or not you're prone to complications like sinusitis or ear infections, you can't catch a cold without being exposed to the germ. In any child who has had such a difficult time with infections as your son has, it pays to limit his exposure to other people's germs. That means no daycare with groups of other children, avoiding sick friends and relatives, and paying scrupulous attention to hand washing to avoid spreading germs.

The next issue is dealing with the status of his upper respiratory tract. His frequency of ear infections and sinus infections suggests that he should be under the regular care of an ENT specialist. These complications can make the minor colds that other children get through without a hair out of place turn into major illnesses for your son. Children who have these problems may have normal immune systems and a normal frequency of colds, but they may seem to never be well because of the lingering symptoms from ear or sinus infections. Both may require reevaluation of your son's adenoids to be sure they have not enlarged to the point of requiring surgery again. Given the episode of drainage from your son's ear, he may also need tubes again, or if the tubes are in, he may require regular surveillance and treatment with drops to be sure that they do not become obstructed.

Some children tend to run high fever. The height of the fever does not correlate directly with the severity of the illness or the general health of the child. If your son has a few unexplained fevers a year scattered among his many respiratory infections, it may just be his bad luck with regard to what he catches from others coupled with his tendency to run high fever when he is ill. But if he has frequent undiagnosed fevers, there are many possible causes. I've discussed fever of unknown origin in other e-mails and would ask you to search for those if you'd like more information on that subject as I'm not sure it applies here. One thing I would recommend is that a urine infection can only be ruled in or out by doing a culture. Nothing on the examination or history is sufficient to rule out that diagnosis, therefore, a urine culture must be done on any child who has recurrent fevers without a diagnosis.

Allergies don't cause fever, with the exception of extreme reactions like serum sickness which causes hives, swollen joints, and fevers. Allergy may be a consideration in terms of factors which may contribute to sinus and ear infections. Your ENT should help you decide, based on his examination, whether or not an allergy evaluation is warranted. Unfortunately, most of the medications used in the chronic management of allergy symptoms are not approved for 2 year olds.

Given the high frequency of infectious illness in otherwise healthy children, and especially the frequency of recurrent ear infections in children who are prone to them, one of the most difficult decisions in pediatrics is which children should be evaluated for the rare possibility that they have an immune deficit. When a child has unusual infections or a high frequency of serious infections like pneumonia one usually looks for an underlying cause. It's less obvious where to draw that line for a child who has the kind or story you tell. If your child is otherwise doing well, it is less likely that he has an immune deficit. If he is failing to thrive (poor growth and weight gain) then some additional evaluation is certainly warranted. Your pediatrician can certainly draw blood levels of immune globulins. A high level of IgE would suggest a need for further allergy evaluation. A low level of IgA might be associated with the kind of infections your son is having. Other, more sophisticated tests of immune function would require that you consult an immunologist.

Sincerely,
Dr. Warren

-Liz

Dear Liz: Congestion and cough may be a symptom of milk allergy; however, since lactose intolerance is much more common than true milk allergy, most people who talk about milk allergy are speaking about lactose intolerance. That causes diarrhea and gas rather than congestion. LactoFree does not have any lactose, but it is made from milk. It is reasonable to try a hypoallergenic formula to see if it helps a young infant with chronic congestion; however, if it provides no benefit at all within a few weeks, you will probably want to go back to your previous formula if it is less expensive or if your baby thrived better on it.

Unfortunately daycare exposes infants to a large number of upper respiratory viruses. Each infection causes some brief period of immunity, so unless there is a huge number of kids in her daycare, your daughter's cold is probably not making the rounds and returning to her. Since there are so many viruses which cause colds it is not unusual for many different colds to make their way through a group of children together in daycare or school.

There is little that can be done for colds except to provide some symptomatic relief. For infants, this should be done with the least medication possible since many cold medicines cause significant irritability in young infants. For more details read my article, Upper Respiratory Infections (URIs).

Whether or not to see your doctor each time the baby has symptoms or proceed with further evaluation such as a chest x-ray depends on how sick the baby seems.

Sincerely,
Dr. Warren

-Worried Mum

Dear Worried Mum: It has to be very frustrating when doctors give conflicting answers. If the rash persists can you see a dermatologist?

Unfortunately, without seeing the rash, it's not possible for me to give you more accurate information than the two doctors you've seen. It is possible to get chicken pox twice, but it's rare. Regardless of whether or not it itches, if it's chicken pox, it should follow a typical course starting with a red oval bump which form's a dew drop shaped blister. The blister then collapses with a indentation in the middle. Then the lesion forms a crust and finally a scab. The material inside the blister is cloudy, but not pussy. The rash comes out in crops rather than all at once, so within a few days there should be pox in all stages of development at the same time. Since chicken pox is a viral infection, it would not be unusual to have some fever or signs of illness. In addition, the examining physician would expect to find small swollen glands in the neck, groin, and even under the arms.

If the rash is not chicken pox, then it could be another virus, an allergic reaction, a contact dermatitis, folliculitis, or skin infection. If it's not clearing up, you'll need it checked again, if possible, by a dermatologist.

Sincerely,
Dr. Warren

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