5 February 2007

1. Persistent Diarrhea
2. Green Stool
3. Lipomyelomeningocoele
4. Short Bowel
5. Masturbating 2 Year Old
6. Cough and Cyanosis
7. Head Banging, Hitting
8. My Penis Has Not Grown
9. Disclaimer

• Read Questions & Answers in Another Column

Persistent Diarrhea

-Gretta

Dear Gretta: Some newborns have up to 6 loose stools each day, usually after each feeding. Of course I can understand your concern if the baby previously had a much smaller number of stools per day, but the crucial issue is whether or not the baby is in any danger until your pediatrician returns since seeing several different doctors has not helped. 7-10 stools per day is probably excessive, but if they are not frankly watery, the baby is not acting ill, is eating well, and is gaining weight well, you can certainly wait until your pediatrician returns to pursue the matter and determine if any additional evaluation or intervention is warranted.

I am unfamiliar with the term "DF brand" with regard to formula. Certainly formula sensitivity has to be considered as a cause of diarrhea. One to two weeks on a hypoallergenic formula such as Alimentum or Nutramigen should help if that's what's going on.

I recently learned, when I consulted a pediatric gastroenterologist regarding one of my patients who had persistent diarrhea, that urinary tract infections may cause persistent diarrhea in young infants. A less likely possibility to consider is a bacterial or parasitic infection since a 9 week old is unlikely to be exposed to such infections (unless a caretaker or family member is ill).

If the baby is not gaining and growing well, then he will need to be evaluated by a pediatric gastroenterologist to determine the best course of action. In the meanwhile, it is crucial that you are certain the baby is not becoming dehydrated and is not acting ill. If the baby is acting ill then urgent intervention is warranted.

Sincerely,
Dr. Warren

-Dr. F

Dear Dr. F: If the only change you see is that your baby's stools have turned green, there is no cause for concern. Often the stools turn dark, and therefore have a green appearance if the baby is taking an iron supplement. Stools are more likely to be green in an infant who is having diarrhea, but if the stool pattern and eating pattern has not changed, the green color is not significant.

Sincerely,
Dr. Warren

Thank You

-LW

Dear LW: You would probably have more success finding information if you searched for information about spina bifida, myelomeningocele, or meningomyelocele. According to Walsh: Campbell's Urology, 7th ed., Copyright © 1998 W. B. Saunders Company,

Myelodysplasia is the all-inclusive term used to describe the various abnormal conditions of the vertebral column that affect spinal cord function. More specific labels for each abnormality include the following: a meningocele occurs when just the meninges [the membranes covering the brain and spinal cord] extend beyond the confines of the vertebral canal with no neural elements [nerves] contained inside it; a myelomeningocele implies that neural tissue, either nerve roots or portions of the spinal cord, have evaginated with the meningocele; a lipomyelomeningocele denotes that fatty tissue has developed with the cord structures and both are protruding into the sac. Myelomeningocele accounts for over 90% of all open spine conditions.

Usually the meningocele is made up of a flimsy covering of transparent tissue, but it may be open and leak cerebrospinal fluid.

It is for this reason that urgent repair is necessary, with sterile precautions being followed in the interval between birth and closure. In 85% of affected children there is an associated Arnold-Chiari malformation

The neurologic lesion produced by this condition can be variable. It depends on what neural elements, if any, have everted with the meningocele sac. The bony vertebral level often provides little or no clue to the exact neurologic level or lesion produced. There may be differences in function from one side of the body to the other at the same neurologic level.

Complications can include fractures and infections in the legs, urinary tract infections, and of course, some of the social problems associated with having a disability. Just as some children who have "perfect lives" may suffer emotional distress and others may do well, children with disabilities may overcome their disabilities and excel, or be overwhelmed an unhappy with their lot. The medical problems of a child with myelomeningocele can certainly put a strain on a family, but most of the kids I've known with it have done very well. As adults they go on to have careers and even families.

As regards the cons of surgery, all surgery has risks including death. The surgery for myelomeningocele will not eliminate all disability, but it is life saving. It is not possible for a child to continue with an untreated open spine. Eventually the child will develop meningitis.

Sincerely,
Dr. Warren

What are her chances for improval (she hasn't developed fever since the operation and is in a quite stable condition - breathing on her own, but on infusion and intravenous food + medicines). I have been told that such small babies can sometimes recuperate completely, that intestines can grow again, sometimes even 100%, and that when she gets stronger transplantation is possible.

Please give us some advice and comfort. Tell us what we can hope for and what are her odds.

Immensely grateful in advance

-A Worried Mother

Dear Worried Mother: I have not treated any patients with short bowel syndrome and know little about it, so in order to answer your question, I'm providing you with the material I read. Although it is a bit technical, it is fairly understandable. I have added explanations of medical terms in brackets [these things] where I thought necessary. If you have any questions about what you read, please contact me again. This material is from Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000 W. B. Saunders Company

Short bowel syndrome produces malabsorption [inability to absorb nutrients] and malnutrition after congenital or postnatal loss of at least 50% of the small bowel, with or without loss of a portion of the large intestine. Short bowel results in inadequate absorptive surface and compromised bowel function. The condition may not be permanent because the intestine has the capacity for adaptive growth and increase in functional capacity. Adaptation is a gradual process associated with increase in villus [part of the bowel membrane] height and small bowel surface, rather than lengthening of the bowel.

The small intestine may be congenitally short in conditions in which bowel is lost in utero (malrotation, gastroschisis, and, in some cases, atresia). Most cases involve some surgical resection of the small intestine. Most occur in the neonatal period (necrotizing enterocolitis), although Crohn disease or trauma can account for later onset.

CLINICAL MANIFESTATIONS.

The major clinical manifestations are malabsorption and diarrhea. The ability to assimilate nutrients correlates with the length and location as well as the quality of the residual bowel. Carbohydrate malabsorption and steatorrhea [fatty stools] are common features resulting in diarrhea and failure to thrive. Large volumes of fluid and electrolyte are normally secreted into the upper gastrointestinal tract and must be reabsorbed. The capacity to reabsorb fluid and electrolyte is usually inadequate in the short bowel syndrome and results in loss from the gastrointestinal tract with the potential for dehydration, hyponatremia [low blood sodium], hypokalemia [low blood potassium], and acidosis [too much acid in the blood]. The extent of loss is influenced by the presence or absence of the colon in continuity with the small bowel. Trace elements are also poorly absorbed and are lost in excess. D-Lactic acidosis may occur rarely as a result of fermentation of dietary carbohydrate by luminal bacteria in the small bowel caused by bacterial overgrowth. Patients with this manifestation experience confusion, hyperventilation, and acidosis with an anion gap in the absence of elevated serum lactate as measured by standard techniques, which measure L-lactate. Hypersecretion of acid in the stomach occurs as a result of hypergastrinemia for a transient period after small bowel resection. However, this condition does not appear to cause problems in infants and children. These patients often have associated cholestasis [bile stuck in the bile ducts in the liver] resulting from hyperalimentation [high calorie intravenous feeding] and other factors. Cholestasis may contribute to ongoing malabsorption of fat and fat-soluble vitamins.

TREATMENT.

In the late 1960s, about 50% of infants with short bowel survived. Today, more than 90% survive, even though the infants may have shorter bowel. The use of total parenteral nutrition [all nutrients given directly into a deep vein] has dramatically changed the outcome. These infants cannot maintain adequate nutrition by the enteral [intestinal] route alone and initially must have most of their nutrition given intravenously. Very low amounts of enteral nutrients are given at first as a continuous gastric [stomach] infusion (1-5 mL/hr depending on the size of the infant). Usually an elemental diet is used at regular strength (20 kcal/oz). This approach is important because experimental evidence suggests that exposure to enteral nutrients contributes to adaptive growth of the small bowel. As tolerated, the quantity can be slowly advanced, perhaps by 1-2 mL/hr/24 hr, as the amount of parenteral nutrition is simultaneously decreased. A level is reached at which diarrhea and malabsorption increase, and progression of enteral feedings must be delayed. Bloody diarrhea secondary to patchy, mild colitis may develop during the progression of enteral feedings. The pathogenesis [cause] of this "feeding colitis" is unknown, but it is usually benign. Strictures following neonatal necrotizing enterocolitis may also produce bloody stools.

When possible, an infant may be given a small amount of formula by mouth to maintain an interest in oral feeding. As children age beyond the first year, it is sometimes possible to add a small amount of solids by mouth (cereal, pureed chicken). For infants with an extremely short bowel, it may take several years or more until parenteral nutrition can be stopped. An infant with as little as 15 cm of bowel with an ileocecal valve [the connection of the small intestine to the large intestine], or 20 cm without, has the potential to survive and eventually to be weaned from parenteral nutrition.

Certain factors appear to influence the length of time until a child is independent of parenteral nutrition. Infants with less than 40 cm of small bowel take twice as long as infants with 40-80 cm of bowel (average of slightly more than 2 yr vs slightly more than 1 yr). The absence of an ileocecal valve doubles the time to complete adaptation, all other factors being equal. The length of residual ileum [the last part of the small intestine before the large intestine] is inversely correlated with the time until adaptation. Infants with necrotizing enterocolitis and gastroschisis have more difficulty adapting than children with similar bowel resections for other indications. Identification of small bowel bacterial overgrowth has been associated with prolonged dependence on parenteral nutrition.

Bacterial overgrowth is common in infants with a short bowel and may delay progression of enteral feedings. Metronidazole [an antibiotic] is used empirically, as are nonabsorbable antibiotics that cover gram-negative organisms. Occasionally, a drug that slows gastrointestinal motility, such as loperamide, can be helpful. However, these drugs often do not appear to alter the course. When the small bowel is in continuity with the colon, bile acid malabsorption can cause colonic fluid secretion. In this situation, cholestyramine [a medication], 0.25-1 g every 6-8 hr, may be helpful in reducing the watery diarrhea.

LONG-TERM COMPLICATIONS.

Long-term complications include those of parenteral nutrition: central catheter [the intravenous line in the deep vein for the feeding] infection, thrombosis [clotting], hepatotoxicity [liver toxicity], and gallstones. For this reason, a continual effort to advance enteral feedings slowly must be considered. Other long-term complications of short bowel include the potential for late vitamin B12 deficiency. Stores of vitamin B12 acquired in utero are so great that deficiency may not appear until 1 to 2 yr of age. Therefore, it is important periodically to check vitamin B12 levels during and after the 1st years of life. Gallstones were found in 60% of infants receiving chronic parenteral nutrition who had had terminal ileal resection but in none of the children with an intact ileum. Renal [kidney] stones can occur as a result of hyperoxaluria [excess oxalate - a chemical or crystal - in the urine] secondary to steatorrhea with increased oxalate absorption and recurrent dehydration.

FUTURE DIRECTIONS IN MANAGEMENT.

Certain nutrients have been considered potential stimulants of adaptive growth in experimental animals, but their role in humans remains to be determined. These include glutamine, soluble fiber, short-chain fatty acids, and short-chain triglycerides. Another area of interest is the role of peptide growth factors in promoting adaptive growth of the bowel. Bowel-lengthening surgical procedures have been performed with mixed results. Small bowel transplantation is used in children who have no hope of ever progressing from parenteral feedings. Small bowel and liver transplantation can be performed and is a particular consideration for the child with severe total parenteral nutrition hepatotoxicity.

Sincerely,
Dr. Warren

I felt inclined to tell you that my baby is slowly gaining weight (she gained cca. 40 grams in 4 days), she is stable, her condition is improving little by little every day. Moreover, last week her doctor started feeding her with small quantities of my milk - she has accepted it, and now I am going to the hospital every day to give some milk for her. Therefore, we hope that her treatment will not be too long, that she will leave intensive care quite soon and be transferred to gastroenterological department where other methods of feeding will be attempted. Anyway, as I have mentioned before, the most important thing is that she hasn't developed temperature nor a new infection since the operation, and that she is slowly getting stronger and better.

Once again, thank you very much for your answer. It meant a lot to us, and some of the information from your letter we weren't able to find anywhere else.

Thanks again. I hope one day soon you will receive a letter from me with the words " Xxxx is coming home tomorrow". If you do happen to hear or read anything else that might be of use to us, please write back again.

Thank you very much.

Grateful Parents,
-J & Z

Dear J & Z: My prayers are with you for your precious baby. I would be pleased to hear how Xxxx is doing as she gets better.

Sincerely,
Dr. Warren

Thanks.

-Danielle

Dear Danielle: It is, of course, possible that a child who has been abused may engage in sexual behavior as a result, but most of the time those behaviors involve other people rather than just masturbation. Masturbation is a natural outlet which causes problems only because of social taboos. Some children have a stronger urge to masturbate than others just as some children engage in other forms of self stimulatory behavior such as rocking or head banging.

Unfortunately, there is no simple way to teach a two year old self control. Even changing undesirable behaviors which are not the result of strong bodily urges requires consistent, recurrent, and persistent intervention. That will require you to gently stop your daughter's masturbation any time you see her engaged in public masturbation and to distract her by substituting another activity or remove her to her bedroom to satisfy her urge. Eventually the message will sink in. The only way I can see to control the behavior right now is to provide her with more activities to keep her busy and to have more of her time supervised, meaning very little time without direct adult supervision.

Sincerely,
Dr. Warren

Thanks.

-FM

Dear FM: Even if a cough is infrequent, if the spasms cause cyanosis (turning blue), have persisted several weeks in spite of antibiotic treatment, and the chest x-ray is normal, whooping cough must be considered as a possible diagnosis. If the baby does have whooping cough, there is no medical treatment which will dramatically alter its course, but if it is leading to cyanotic spells, the baby should be hospitalized until her condition improves.

If whooping cough is not the diagnosis, I would have to recommend evaluation by a pediatric pulmonologist to determine the cause of the cough and the course of treatment. The recurrent cyanotic episodes you describe are potentially dangerous and require urgent evaluation and intervention.

Sincerely,
Dr. Warren

-EC

Dear EC: Children do not need to learn all their behaviors. It is, in fact, because they are young children, that they often engage in unacceptable behaviors that satisfy some internal need in a way no adult would ever consider. Head banging and hitting oneself is a form of self stimulatory behavior. It is satisfying some internal need. Perfectly healthy, normal children do engage in these kinds of behavior. If the child has developmental delays, one must consider the possibility of an underlying neurological condition.

Unfortunately, there is no simple way to teach a 15 month old self control. Even changing undesirable behaviors which are not the result of internal urges requires consistent, recurrent, and persistent intervention. The best approach is distraction and substitution, i.e., distract the child by catching his interest with something, and then get him involved in another activity during which he will, hopefully, not have a need to bang his head.

Sincerely,
Dr. Warren

-S

Dear S: Even though it is a popular myth among men that all penises are about the same size, there is a considerable range of normal. The issue regarding whether or not the size of your penis is normal really depends on whether it is within the normal range of size for a post pubertal male. In addition, if your body changes are not yet complete (the most likely reason that you have no hair under your arms) your penis may still grow more. Considering that there is a range of normal, there is no clinical significance to having a smaller than average penis, as long as it is within the normal range. After all, every man can't have the biggest penis. Keep in mind that your impression that your penis is "fairly small" may be more perception than reality. If you are overweight, a significant part of the shaft of your penis could be buried. Even if you are not overweight, your view of your penis (looking down) is different from the angle at which you may have seen any of your classmates or friends.

Puberty starts at different ages in different people. If you first started developing around 15 or 16, your development is likely still in process. Hair under your arms is still going to develop. But even with regard to hair there are individual differences. Some families have much more body hair than others.

At 17 years of age you should still be having regular checkups which should include a genital exam. Your pediatrician or family doctor should be able to tell you, on the basis of his exam, whether or not there is any need for concern or evaluation. Without examining you, I cannot tell, but I suspect you are a normal young man who is still developing.

Sincerely,
Dr. Warren

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