5 March 2007

1. Motor Delays and Obesity
2. Odor from Ear
3. Possible Blood in Spit Up
4. Esophageal Varices
5. Masturbation Questions
6. Fever
7. Surgery for Labial Adhesions
8. Potty Trained but Won't Use Toilet
9. Disclaimer

• Read Questions & Answers in Another Column

Motor Delays and Obesity

Further, he is a very large baby (born 8 pounds 9 ounces, 21¼ inches long) and now weighs 24 pounds 12 ounces and measures 28½ inches long. I am terribly concerned about obesity although he appears proportionate and eats very little (approximately 28 ounces of formula a day, one serving of cereal and about 2 ounces of vegetable). I am considering switching to whole milk to reduce his caloric intake. I am wondering if reducing his caloric intake will help speed his gross motor skills and help prevent childhood obesity.

Thanks for your consideration of my problem.

-CB

Dear CB: Your son's motor delays are mild since the upper limit of normal for rolling over is 6 months and sitting without support is 7 months. By 9 months most infants will stand holding on, but some refuse to put their feet down and bear weight. Being overweight does not generally cause motor delays; however, if your baby has low muscle tone, the increased weight could make it harder for him to do certain things.

Whole milk has the same calorie content as formula (20 calories/ounce) and provides no advantage in the management of overweight infants. Infants, like adults, gain excess weight by consuming more calories than they burn. Most infants, regardless of their motor development, spend a lot of time in motion. Given your son's motor delays, it might help to get some physical therapy to work on his motor activity. This might also help decrease his weight gain.

Sincerely,
Dr. Warren

My question is pretty basic, I hope. My son's right ear has been emitting a strong unpleasant odor. I have cleaned the outside of his ears thoroughly. Should I be concerned? He has been taking swimming lessons in the last two weeks; however, I have smelled this odor before the lessons; but the smell is more prominent now.
I would appreciate any guidance you can provide us. Thank you for your time and consideration!

Best regards,
-MP

Dear MP: An odor coming from the ear could be the result of inflammation of the ear. A common cause for odors coming out of ears and noses is inflammation caused by an object the child sticks in his nose or ear. If the odor is persistent or strong, even though it is not necessarily a cause for alarm, you should have your son's ears checked.

Sincerely,
Dr. Warren

-AB

Dear AB: It is possible that the brown substance was blood. If it continues, it must be investigated, but if it never happens again, there is nothing more to do about it. Keep in mind that a small amount of blood in mucus in a baby's spit up is not serious. The blood could be swallowed blood from the baby's mouth or nose, and in the case of a nursing baby, the blood could come from the mother's breast.

Sincerely,
Dr. Warren

Now my question:

• Her spleen is still enlarged and to my opinion even larger. If she isn't loosing any blood anymore (her Hb level is between 7 and 8) could I expect the spleen to get smaller ?
• What are the consequences of a large spleen ?
• Are there ways to get it smaller ? Medicine ?

I hope the whole story makes sense. I appreciate your answer very much but please keep in mind that I am a layman in the medical field (I am a mechanical engineer). Thanks and I'm looking forward to see your answer.

-DK

Dear DK: The gullet is known medically as the esophagus. Esophageal varices (varicose veins in the esophagus) usually develop in response to portal hypertension (high blood pressure in the veins of the liver). Esophageal varices can result in catastrophic bleeding. The fact that your daughter has esophageal varices suggest that she still has portal hypertension and that this was not just a momentary problem resulting from the exchange transfusion. Since the liver and spleen are both attached to the portal circulation, it is possible that your daughter's persistent splenic enlargement is due to the current status of her liver.

My advice to you at this point would be to consult a liver specialist for thorough evaluation so that you can know the true extent of the liver damage, the prognosis, the expected course, and the treatments necessary along the way. There are both medical and surgical treatment options available. Without ongoing evaluation and treatment, there is a risk that your daughter could experience a life threatening bleed.

According to Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, Sixth Edition, Copyright © 1998 W. B. Saunders Company

The formation of thrombus [clot] in the portal vein results in a predictable sequence of events. Pressure rises in the portal vein remnant and is transmitted into the splenic vein. The spleen enlarges in response to the pressure. Alternatively, collateral channels begin to open to carry portal blood to the systemic circulation. Increased flow in these small potential veins dilates them to become esophageal, gastric, duodenal, and jejunal varices. Varices proliferate in the porta hepatis and may include venous channels in the gallbladder bed. Meanwhile, normal evolution of the clot occurs. Fibroblasts transform the clot into a firm, collagenous plug in which tortuous venous channels develop. This 'cavernous transformation' occurs over 5 weeks to 12 months. The bowels, meanwhile, are engorged with venous blood. The stomach takes on the endoscopic appearance of 'portal hypertensive gastropathy.' The liver, deprived of portal flow, scavenges what blood it can from perihepatic varices and, sustained by hepatic arterial flow, usually manages to maintain its synthetic and excretory functions. An equilibrium is reached. Ascites [fluid in the abdomen], which may have formed during the initial stages of portal hypertension, recedes. In outward appearance, the child or adult in whom the portal vein has clotted seems unaffected. A careful examiner will note the enlarged spleen. Years later comes the hemorrhage. A varix opens, and large amounts of blood are vomited or passed per rectum. The person with portal vein thrombosis now becomes a patient and, with supportive care, survives the hemorrhage.

Sincerely,
Dr. Warren

-G

Dear G: Masturbation does not have any adverse medical effects. It will not harm your prostate. If you have pain when your underpants are under your testicles it is probably a result of pressure constricting blood flow or just pressing in a sensitive area. I cannot imagine it being harmful to you unless the elastic in your underwear is super strong and super tight, but why not pull the underpants down further and avoid the pain all together?!

Sincerely,
Dr. Warren

I have given her 2 tbs of tylenol with only slight result of fever reducing. I have given 2 tbs of Children Advil with a slightly better result of fever reducing, tylenol every 4 hrs and advil every 6 hrs.

At night her fever doesn't allow her to get a full night sleep because she is too hot. I have tried rubbing alcohol to the bottom of her feet to cool her body down with no result. I was told by other parents that it might be viral infection and she needs to let her body take its course. No medication for it is available because is not an infection that requires medication.

Is this true and if so, what else can I give her to make her more comfortable. During the day she feels very bad and has no energy and barely eats anything. I am forcing her to drink lots of water. She does not want juice because it gives her the feeling she is going to vomit.

Please respond to my e-mail address.

Thank you and I await your response.

-Lea

Dear Lea: High fever may indeed be caused by virus infections, and, it is unfortunately true that there is no specific treatment for virus infections. In most instances the body fights off the virus and heals itself; however, if a child is particularly ill, he should be seen by a physician. First, you don't know that your daughter's fever is caused by a virus. She could have something more serious which requires treatment. Second, if a child suffers complications of virus infections such as dehydration, medical intervention and supportive care becomes necessary. It sounds like your daughter is pretty sick and you are concerned. It's time to bring her to her doctor.

For further information about fever management check my article, Fever, but please call your doctor as well. Fever management is not a substitute for the necessary medical evaluation of a sick child.

Sincerely,
Dr. Warren

Thank you very much for your time. Please respond as soon as possable.I do not have much time untill her operation.

-Lisa

Dear Lisa: The condition you are talking about is labial fusion which is a result of labial adhesions. According to Walsh: Campbell's Urology, 7th ed., Copyright © 1998 W. B. Saunders Company,

Labial adhesions are a common problem. Those that are asymptomatic are self-limited in nature and should be left alone. Initial treatment of symptomatic patients should be the manual spreading of the labia and application of vitamin A and D ointment by the mother. For adhesions that persist, the use of estrogen creams is helpful, but application should not be continued for more than 2 to 3 weeks. For those who are unresponsive to estrogen cream management and are symptomatic, I recommend lysis of the adhesions under general anesthesia with resection of a thin strip of skin on each side of the labia minora and re-approximation with fine chromic catgut. Postoperatively, the patient is treated daily with antibiotic ointment for 1 week and then vitamin A and D ointment for 1 month. Surgery has been required in less than 5% of patients with labial adhesions but has been successful in resolving the problem in the majority of cases.

Labial adhesions are commonly seen in patients younger than 6 years, and the condition is often asymptomatic. The lesions usually are associated with local inflammation in association with the hypoestrogenic state of preadolescents.... Once the vaginal pH becomes more acidic, as occurs with adolescence, the recurrent labial adhesions almost always disappear.

Sincerely,
Dr. Warren

-JK

Dear JK: Your 4 year old is apparently frightened by the toilet and comfortable with her potty. It may help to make her comfortable with the toilet by exploring and working on the aspects which might be frightening her. Does the flush frighten her? Is she afraid she could go down the drain? Have her flush the toilet when she is not sitting on it and talk to her about the flush. Does she feel like she will fall in because of the size of the opening? Get her a child sized seat that supports her entire bottom so she won't feel like her tush is hanging in the bowl. Does she feel insecure because her feet are not on the ground and she can't get on and off quickly? Get her a step stool to keep by the toilet.

If none of these measures provide an answer let her sit on the toilet, lid down pants up to become comfortable with it. Eventually open the lid. Eventually get the pants down. But at all times keep her potty available and never let her sense that she will be forced to give up the potty with which she is comfortable in order to use the toilet. When she has mastered the toilet, then it is time to talk about retiring the potty.

If all else fails, remember that eventually she will outgrow her need for her potty. At least she has mastered the skills to stay clean and dry. Believe it or not, there are lots of mothers who would be glad to trade places with you.

Sincerely,
Dr. Warren

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