8 January 2007
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
-Mr. & Mrs. B
Dear Mr. & Mrs. B: Although severe hydrocephalus would cause significant developmental delays, a developing hydrocephalus may not. It may cause brisk reflexes, but at 6 months that may not be a reliable sign since those nerve pathways are not fully developed.
If the baby's head has always been large and its growth has remained on the same percentile curve, and especially if there is a family history of large heads, then there is probably no cause for concern. If, on the other hand, the baby's head growth has been crossing percentiles and is now outside the normal range, even if the head started out large, then it is time for further evaluation such as a CT scan or ultrasound of the head.
Sincerely,
Dr. Warren
Thank you for your help!
-JR
Dear JR: In the early stages of Lyme disease the blood test may be negative. This could include the stage where the typical rash arises (which occurs in about 60% of patients) and the stage of flu like symptoms which may include joint aches. By the time there is actually arthritis (joint swelling, redness, and pain) the blood test should be positive.
There are many conditions which can cause joint pain. Rheumatic fever is one of them. Usually the joints in rheumatic fever are swollen and exquisitely tender, the child is running fever, and the child has a pathologic heart murmur. Besides rheumatic fever arthritis can be associated with juvenile rheumatoid arthritis (JRA), inflammatory bowel disease (IBD), lupus, viral infections, and joint infections (which would usually be localized to one joint). Since I don't know what other blood tests your daughter had besides the Lyme titer, I won't discuss other testing except to point out that blood tests cannot totally exclude all diagnoses. If the symptoms persist you would be wise to consult a pediatric rheumatologist.
Sincerely,
Dr. Warren
A sincerely confused college student,
-Jay
Dear Jay: Your confusion results from the fact that your life is good enough and your insight is good enough to recognize that you have no reason to be depressed, but sure enough, you are describing the symptoms of depression and before they become severe enough for you to suffer feelings of low self worth, or even worse suicidal thoughts, you need to get help.
Sure there are young men who are sensitive enough to cry about things that their friends wouldn't shed a tear over, and these days it's so much more acceptable than when I was growing up. But you're describing an unclear feeling of either anxiety or depression that you're struggling with which arises for no apparent reason in any way related to what's going on when it happens.
Too many people have difficulty distinguishing situational depression from major depression which is a psychiatric disorder (also known as a mental disease). Even those who are depressed due to their circumstances may benefit from psychiatric help. For them, counseling may suffice to empower them to get through the bad times until they can change or learn to live with their circumstances.
Major depression is a biochemical disorder which may indeed be inherited genetically. It is not a character flaw and cannot be overcome simply by strength of character. You clearly have the insight to recognize that these feelings you are experiencing don't belong based on your circumstances. You have not let them alter your life or become an excuse for failure. Neither have you sought to blame others. Without even knowing you I have no doubt about the strength of your character, but even the strongest character can succumb if the depression symptoms become severe enough. The erroneous belief that strength of character is enough to overcome depression and that there is a stigma associated with mental disease or psychiatric treatment has prevented far too many people from seeking the help they need and deserve.
You have recognized that there is a problem. Just as you would see a doctor for a persistent belly ache, even if you had been managing to live with it, you should see someone for your problem. Don't let anyone dissuade you by telling you to "snap out of it" or "There's nothing wrong with your life so stop being a cry baby." You know that there's nothing wrong with your life and that's the proof that you need help for the way you feel. For diagnostic evaluation, you should see a psychiatrist, not a psychologist since you may need medication. If the psychiatrist feels that there are significant psychological issues, he can provide counseling or refer you to a psychologist.
At 20 years of age you don't need your parents' permission to seek medical care, and indeed, psychiatric care is medical care. If they are paying the bills, you probably do have to talk to them about it, but that depends on how you have handled your need for medical visits in the past. If you have a good relationship with your parents, you should keep the doors of communication open and tell them what's going on. Keeping them out of the loop may increase their anxiety if they are aware that something is going on in your life and deprive them of the opportunity to be supportive. If you do decide to talk to your parents you should tell them that you are seeking help, not ask them for permission. Then be prepared to offer them reassurances that you have a problem which is not a result of your life or the way they treated you. And no matter how that conversation turns out, even if they forbid you to go for psychiatric help (which is most unlikely), go for the help you need.
Sincerely,
Dr. Warren
I appreciate for your input.
-DB
Dear DB: Since all vaccines have a risk of side effects administering any unnecessary vaccine exposes the patient to an unnecessary risk; however, the HIB vaccine is a very safe vaccine. There is no specific risk associated with having an extra dose, i.e., you can't overdose. Unfortunately, this is an error that almost every pediatrician makes at some time in his career which is why it's best if care can be provided in an unhurried manner with time to double check everything. Fortunately, extra doses of vaccines do not carry any risk besides the risk associated with the vaccine when given in the correct manner. You and your friend need not worry.
Sincerely,
Dr. Warren
-KP
Dear KP: Some kids do have nosebleeds much more easily than others. In the grand scheme of things, 4 to 5 nosebleeds a year is not excessive, and as long as the nosebleeds are not difficult to stop, no further evaluation is necessary.
Keeping the air in your house moist is a reasonable suggestion. In spite of that, the membrane may bleed more easily if it is inflamed by allergies or a cold. If there is a scab in the nose, rebleeding can occur much more easily. Stopping a nosebleed correctly by applying pressure to the entire fleshy part of the nostril on the side that is bleeding for 5 minutes can minimize the incidence of rebleeding. Unfortunately, this is not an option for dealing with nosebleeds which occur during sleep.
Why should most of the nosebleeds occur during sleep? Are there toys in bed which your son could be knocking into? Is there something in his room to which he is allergic? Those are possible considerations.
Sincerely,
Dr. Warren
-TK
Dear TK: By 6 weeks of age 90% of babies smile responsively. That means that 10 % don't. On a purely statistical basis there is a higher risk that those infants who fall outside the developmental norm are outside those norms because something is wrong, but it does not mean that all such infants have a developmental problem. If the baby did not appear to look at you, I would be very concerned. Since 8 week olds don't do a lot, it's hard to draw a conclusion from just one developmental landmark. If your pediatrician finds your baby's reactions and muscle tone to be normal then it may just take more time.
Other landmarks to look for. Does the baby pick his head up? If he is looking at you, does he follow you with his eyes or head when you move? Does he respond to noise? Does he make noises (besides crying)?
Sincerely,
Dr. Warren
Her diaper is always dirty and is wet most of the time. I have run out of ideas on how to encourage her to at least wet in the pot. She never wants to go to the bathroom. Can you help?
-Desperate
Dear Desperate: You actually have a good start in your efforts to toilet train since your daughter is willing to sit on the potty and allow some urine to flow into it. Don't be in a rush to put her in a diaper when she gets off the potty. Encourage her to sit again and see if some more can come out. And praise her for any effort she makes.
Since you describe her as always wet and dirty and she was born with an imperforate anus, you should check with her gastroenterologist or surgeon regarding what degree of control she has over bowel function. In addition, she should see a urologist to be sure that her bladder function is normal.
Before you put any great deal of effort into further potty training which could be frustrating for you and your child, check out the medical aspect of her ability to be trained. For additional suggestions about toilet training please read my article, Potty Training.
Sincerely,
Dr. Warren
I would really appreciate your answer and whether there are some other websites that might provide me with additional information regarding this.
Thank you
-SN
Dear SN: I tend to take media reports with a grain of salt, not that there isn't a grain of truth in them; however, the media is a big business which depends on an audience to earn it's living. To get the biggest audience they can they need to entice you or frighten you into watching their reports. If they presented a balanced, unsensational report with all the boring facts, they'd lose some of their audience. Sometimes I think the media think they are doing a public service by getting people to question the "medical establishment," and perhaps they are. But they are also doing a disservice when they present their sensationalized stories as if they are simply the facts in the news. Most people believe that news reports provide them the whole truth.
According to the most recent reports I have read, there is no link between the MMR vaccine and autism. I frankly can't remember ever hearing anything about MMR and Crohn's disease. I think all people who are frightened about vaccines and listen to reports for information need to listen carefully and learn to critically evaluate the data which link reactions to vaccines to worrisome conditions. Too often these reports focus on guilt by association. The MMR is usually given between 12 and 15 months, the age at which most children are developing language, and therefore, the age at which most language problems might start to become evident including autism. Guilt by association is a good enough reason to do research to see if there is any cause and effect link, but it by no means establishes any such link.
For more information about autism and vaccines and MMR in particular check the Center for Disease Control's vaccine information web site at http://www.cdc.gov/nip/vacsafe/concerns/autism/.
Sincerely,
Dr. Warren
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