20 November 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
Thanks.
-Tammy
Dear Tammy: The symptoms of lead poisoning are not specific for lead. The diagnosis can only be made by a blood test. Routine blood testing should be done on all children under two years of age who have a risk of environmental lead exposure. This includes any child living in a house which has lead paint, even if the house is in good repair. It especially includes a house undergoing renovations, even if the purpose of the renovation is to remove lead.
Lead poisoning causes constipation, irritability, anemia, and developmental delays. Severe lead poisoning can cause encephalopathy resulting in brain damage and seizures.
Sincerely,
Dr. Warren
Dear Dr. Warren: This is Tammy. I got your e-mail but what I wanted to know is, well my mom got shot in the head about 13 years ago. The hospital didn't give her a tetanus shot (I'm sure they were suppose to?). Well she developed some kind of liver disease. We are just trying to find out how she got this. She has got a pellet in her head you can feel and one on her forearm which have moved through the years. I was just wondering if this could have part in her problems. Thanks for replying.
-Tammy
Dear Tammy: While it may have been advisable for your mother to receive a tetanus shot at the time of her injury, not receiving such a shot would not have affected her liver. I do not believe that embedded gun pellets cause lead poisoning, but as I stated in my previous letter, the best way to check for lead poisoning is to do a lead level (blood test). I am doubtful that the gun pellets have anything to do with your mother's liver problem, but cannot comment further without knowing what is wrong with your mother's liver.
Sincerely,
Dr. Warren
I want to sure about her mental health.
May be she is mentally retarded or not.
How can I confirm it .
My wife is my first cousin also.
Please reply on this E- mail address.
Thanking you.
-A
Dear A: There is little you can tell about a 3 month old's future neurological or mental status. The central nervous system is still developing. A baby with severe neurological damage might be floppy (more so than a normal infant), have a shrill cry, be unusually irritable, and feed poorly. At 3 months if your baby smiles at you, responds to your voice, and is starting to reach for things, she is a normal 3 month old, but unfortunately, that does not guarantee continued normal development.
Sincerely,
Dr. Warren
A friend of mine told me that if the entire fingernail comes off then no nail will ever, ever grow back there again. Please tell me this isn't true...? What can I do for him.... is there something I can apply to soothe it when it does come off....? Is there a danger of infection?
We are expats living abroad (in England) and I'm very uncomfortable with the way everything is done so differently, medically. I also cannot reach anyone to ask here as it is late evening..... I will telephone a Dr. in the morning but I would very much like an American Dr.'s advice please.
Thank you.
-MK
Dear MK: When an injury affects the nail root, it is not unusual for there to be a disruption of the nail growth. Unless the nail root was severely damaged, the nail should grow back. Loss of a nail has no effect on whether or not the nail can grow back. While the nail does protect the nail bed, the absence of the nail does not cause a risk of infection. If the nail does not grow back, the skin of the nail bed will thicken sufficiently for the child to manage just fine without the nail. If the nail is loose and might get pulled, it should be trimmed leaving only the part which is attached.
Sincerely,
Dr. Warren
-GS
Dear GS: It is not unusual for young children to repeat the first word of a sentence multiple times before getting the sentence going, especially if the child's mind is racing with things to say or the child is excited. This is not really stuttering. If the same thing should start to happen mid sentence, especially on a syllable in a word rather than the whole word, associated with clicks and squeaks, facial grimace, muscle tension in the neck, word substitutions (giving up on saying a word and using another instead), and frustration and anxiety about speaking, then the child should be evaluated by a speech pathologist.
It is not unusual for healthy young children to toe walk. It is important to remind her to walk flat and to be sure her heel cords are not to tight for her to stand and walk flat comfortably. Her pediatrician can check the tightness of the heel cords.
Sincerely,
Dr. Warren
This is my problem, they have not been able to cure him. They get rid of one infection two days later he has two more. Finally, they decided to take out his adenoids and his tubes in Aoril. His ears were in such bad shape that they bleed very easily. Right now he has 2 different bugs in his ears and one is resistant (strep pneumococcal, I think). He has had these bugs for a month and they have been unsuccessful in curing them. They are talking about sending us to an infectious disease doctor and an allergy specialist.
I found out yesterday he has so much fluid on the ear his eardrum is not vibrating at all. So they are talking about tubes again, but they have to kill the current infection first which they have not been able to do.
Is this going to cause permanent damage? What can I do? Who do I need to see? Why is this so difficult for the doctors to figure out?
No he is not in daycare.
Please help me.
-P
Dear P: I can understand how frustrating it is for parents when the doctors don't have all the answers, but when a child does not respond to the usual therapies which work most of the time it generally implies a more complicated situation and may require further evaluation to determine why things are not going as expected. The human body is complex with some problems defying simple solutions.
Most children who have recurrent ear infections do well with tubes. I've never read or heard a good explanation for what causes ear infections to continue ins some kids who have tubes. With the advent of germs which are resistant to multiple antibiotics, a consultation with an infectious disease specialist may be necessary to find an effective treatment. If one of the organisms has been determined to be a resistant Streptococcus pneumonia, it might be beneficial for your son to receive the new pneumococcal conjugate vaccine to help his immune system fight the infection. It might also be a good idea for your son to see a pediatric immunologist for an evaluation of his immune system.
At this point, I cannot predict the final effect on your son's hearing. Unfortunately, there is some risk of hearing loss with such a history of ear infections. If additional surgery is being contemplated, perhaps your ENT surgeon could refer you to a pediatric ENT at a university hospital for a second opinion.
Sincerely,
Dr. Warren
Thank you.
-MH
Dear MH: For the sake of discussion, let me divide diarrhea into two categories: (1) Irritable Colon, (2) Other Causes. The reason for this is that Other Causes can include a variety of medical problems, some of which can be serious and require evaluation and treatment, whereas Irritable Colon is more of a nuisance than a serious problem, and sometimes people who recover from any cause of diarrhea may suffer with Irritable Colon for some time after the original cause of diarrhea is resolved.
People with an irritable colon experience an urge to have a bowel movement almost as soon as the stool comes into the rectum. Since they have an overactive gastrocolic reflex, they generally need to have a bowel movement right after each meal. The function of the rectum is to hold stool until a person is ready to have a bowel movement. Stool is liquid as it moves through the intestines. As it moves through the large intestine water is reabsorbed. The final reabsorption of water from stool occurs while it is stored in the rectum. In people with irritable colon, since the stool moves more quickly through the intestine and is not generally held in the rectum, the stool is more watery, but unlike pathologic causes of diarrhea, the patient does not suffer excess water loss (dehydration) or loss of nutrients, so other than the nuisance of frequent bowel movements, there is no risk to the patient. It can continue indefinitely. Since fiber can absorb water, increasing the fiber in the diet binds some of the water in the stool making the stool soft but not watery - the same thing fiber does to help constipation.
One of the first things to consider in an infant with diarrhea is formula intolerance. Usually the problem occurs from an inability to handle the sugar in the formula. Just as excess fruit juice can cause or aggravate diarrhea because of an inability to digest all the fruit sugar, an inability to digest lactose (the sugar in milk) or other complex sugars may cause diarrhea. The best thing to do is to try those infants on a hypoallergenic elemental formula like Nutramigen or Alimentum.
Your doctor can easily test the stool for bacterial infection and parasites. Giardia, a parasite, is an important cause of chronic diarrhea. The stool should also be tested for blood, since inflammatory bowel disease may cause blood to be present in the stool. Recently, I learned from a pediatric gastroenterologist that urinary tract infections may cause chronic diarrhea in infants, so it would be a good idea to do a urine culture.
Further evaluation beyond what I have already discussed should be managed by a pediatric gastroenterologist. Such evaluation could include a stool analysis, barium enema, and colonoscopy.
Sincerely,
Dr. Warren
I guess the main concern I have is this: If I don't treat this, can this do greater damage by just letting it go?
I think my doctor wants me to just sleep in a bed that is raised up on the head end and try that for awhile. I'm not positive, but I don't think that's going to stop this.
Thanks.
-RN
Dear RN: Predicting the prognosis (the course and outcome) for an illness or condition requires a diagnosis. Without knowing your diagnosis, I cannot predict whether or not you can expect complication by not following the treatment regimen. If you do have gastroesophageal reflux, it can cause enough irritation of the lower esophagus to result in an increased risk or esophageal cancer.
I understand that you're not convinced that the medication your doctor has prescribed is helping, but keep in mind that if you do have esophagitis (an inflamed esophagus) from reflux, it will take time for the esophagus to heal and for you to feel better. If you don't take the medication the way it was prescribed without skipping any doses, you're not giving it a chance to succeed. The only way the doctor can know if he needs to look further (do additional diagnostic tests) or change the treatment is if you take a medication the way you're supposed to. If you take the medication as it is prescribed and it doesn't help, then the doctor knows to take the next step.
Sincerely,
Dr. Warren
She keeps her head turned to the right. Her chin seems to rest on her shoulder and she constantly looks up and to the right. I turn her head back to center and she almost immediately turns it back. She doesn't make eye contact with me very much at all. Perhaps only a few seconds after I have turned her to the center and am talking to her. She also doesn't respond well to noises such as when I snap my fingers at either side of her head. She seems normal in every other way. She is so precious. I hope I am just a worry wart, but I have my doubts.
I have imagined all sorts of horrid things that could be wrong. Can you please advise me as to what might be the problem(s), if any. I have spoken to her mom about my concerns and she seems to think I am imagining things. I hope I am.
Thank you for your time and trouble.
-Aunt T
Dear Aunt T: The condition in which an infant keeps it's head turned preferentially toward one side is called torticollis. These infants have a tightness of the muscle on one side of the neck. This is actually aggravated by the infant's always keeping the head turned toward one side. The head may also become flattened on one side, further aggravating the infant's preference for keeping the head turned to one side. I generally advise the mothers of these infants to stretch the neck muscles with each diaper change by gently turning the head to the non-preferred side with each diaper change. In extreme cases, consultation with a physical therapist may be warranted. This is the most common cause of what you have described to me. Since I have not examined your niece, I cannot be sure that this is her diagnosis. If she also has limited eye contact and interaction with people, she could have an underlying neurological problem. But it is also possible that her eye contact is limited due to her head turn if she is being held in such a way that she is not facing you. It is also possible that your concern about the head turn is causing you to overreact to your nieces degree of eye contact.
Sincerely,
Dr. Warren
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