19 March 2007

1. Nighttime Bathroom Trips
2. Headaches, Hot Flashes, Puberty, Breast Lump
3. Hemangioma
4. Micturition Tremor
5. Hypoxia Seizures
6. Crooked Toes
7. Cold, Sinus Infection, Ear Infection, On and On
8. Immunizations for AIDS Babies
9. Disclaimer

• Read Questions & Answers in Another Column

Nighttime Bathroom Trips

1. Our three year old daughter is quite small - in the 15% in both height and weight. She is very healthy, bright and active. She gave up diapers in April or so and by about June was resisting pullups at night, and was waking up dry. She wears underwear to bed and has had only one nightime accident (when a sitter forget to get her to pee before bed). She goes to bed at 7:15 and can sleep from between 6 and 6:45 Am. My question is more often than not she will wake up (and wake me) to go to the bathroom. If this is before 5:00am she will go back to sleep, after that it is rougher sleding. If I put her on the toilet before I go to bed, there is only a small chance she will wake me and usually she can sleep (and so can I) until her "regular" wakeup time.

Am I creating a bad habit by taking her to the bathroom before I go to bed? We never did this nor needed to with our older daughter, so I am confused.

2. We moved to a new house, one town over, two weeks ago. All of a sudden our 5 year old is waking up every night at 2:00am, and waking me, to take her to the bathroom. Prior to this she might wake up in the middle of the night once or twice a week at most. I am assuming this is related to the new house and checking that we are home, etc. But, during the day she goes to the bathroom without company most of the time. Does my assumption make sense? Should I just ride it out? Last night when she woke me I said, "okay honey, I can hear you, you go by your self" and I stayed in bed - What are your thoughts?

As you can guess, I am particularly exhausted these days. All help would be very appreciated.

You have helped me before under the screen name of xxxxx.

Best regards.
-Beth

Dear Beth: It's always a pleasure to hear from one of my faithful readers.

If your daughter's sleep is not disturbed by the late night trip to the bathroom (she goes right back to sleep) it should not result in any long term consequences. Eventually she will learn to wake up and take herself to the bathroom. To facilitate that, when you are reasonably rested, you should periodically try not putting her on the toilet before you go to bed.

Your 5 year old is feeling strange in her new environment. It is affecting her sleep, and because she does not yet feel comfortable, she seeks your assistance and reassurance when she gets up to go to the bathroom. I think you are handling it just fine. If you are patient and reassuring you can wean her away from needing your intervention. Eventually the new place will feel like home to her.

Sincerely,
Dr. Warren

Thanks again.

-Beth

Dear Beth: I did understand that the issue was getting some sleep and not bed wetting. And I don't consider that selfish. There are times we have to be up with sick kids and we do it willingly, but night after night of sleep deprivation takes its toll. A little rest will make your life better, and in the end will give you more energy to meet your kids' needs. So you see... it's not selfish for you to want sleep. It's in the children's best interest!

Sincerely,
Dr. Warren

-Di

Dear Di: It is possible, and even within the early limits of normal development, for an 8 year old girl to have breast buds, the first sign of puberty. These start as small lumps right under the nipple. They are not always symmetrical so some girls have one breast bud at first until the other side develops. Your description sounds like a breast bud, but since I have not examined your daughter, I cannot state with certainty what it is.

I have never heard that early pubertal changes were associated with headaches or hot flashes. While these may occur with menopause, your daughter's symptoms are not likely to be hormonal. Headaches and temperature instability may accompany any infectious illness. If the symptoms pass within a short time it may just be a virus. But if the symptoms are severe or persist, your daughter needs to be evaluated by her pediatrician.

Sincerely,
Dr. Warren

Thank you very much in advance!

We are looking forward to your answer!

Best regards,
-Victor

Dear Victor: Since you describe the "angioma block" as being red, I suspect you are talking about a hemangioma (strawberry birthmark). Unless a hemangioma is ulcerated, in a location where it is causing a problem, or large enough to cause a bleeding problem, it should be left alone. Hemangiomas may cause problems by their location, for example, a hemangioma of the eyelid may interfere with vision in the affected eye. Most problematic hemangiomas are internal. For example, a hemangioma in the throat can obstruct breathing. Enormous hemangiomas may sometimes consume clotting factors resulting in bleeding problems. The usual hemangiomas which are present at birth and become apparent in early infancy are usually no more than a cosmetic issue. Since most of these (including internal hemangiomas) begin to shrink after two years of age, it is best to leave them alone if they are not causing a problem. Even if laser surgery is done when the child is older the cosmetic result will be better if the hemangioma is allowed to shrink naturally first.

Sincerely,
Dr. Warren

-(unsigned)

Dear Parent: It is not unusual for infants to shudder (a brief whole body tremor) when they urinate (micturition tremor). You would want further evaluation if your child had episodes of unresponsiveness (even brief), extreme irritability, lethargy, developmental delays, rhythmic twitching of one or more extremities especially with deviation of the eyes toward one side and/or movement of the head to one side, muscular rigidity, limpness and lethargy after the event.

Part of your pediatrician's routine exam includes a developmental and neuromuscular evaluation. I'm sure he took his findings into account in advising you, but if your instinct tells you that there is something wrong with your baby, then you should see a neurologist.

Sincerely,
Dr. Warren

Thank you.

-TP

Dear TP: I have never heard the term "hypoxia induced seizures," which may be why you're having difficulty finding information about it. What you are talking about is known as breath holding spells (breath holding seizures, breath holding). As a result of the breath holding, the brain is deprived of oxygen (hypoxia) and the child passes out. Some children will have brief seizures as a result. The typical breath holding spell starts with a child who opens his mouth to scream, often without the slightest sound coming out. As the child continues to hold his breath he will usually start to turn blue around the mouth and eventually passes out. At that point the child is limp, and because he is unconscious and no longer able to hold his breath, resumes normal breathing. These breath holding episodes may occur under any circumstance that causes the child to cry and most often happens when the child is very upset or angry.

The tendency to have extreme reactions like breath holding spells is an inborn personality trait. Some kids are mellow. Some are not. Children don't hold their breath to manipulate their parents, but unfortunately, they can learn to use it that way. Because breath holding spells can be so frightening, many parents go out of their way to avoid making these children cry. Unfortunately, children who are spoiled cry more easily when they don't get their way, so my advice is, whether or not your child might have a breath holding spell DO NOT change your rules or the way you do things to avoid your child's crying.

Breath holding spells are frightening, but they are not dangerous. Blood work and CT scans are not useful in the evaluation of breath holding spells. If there is any question as to whether or not this represents seizure activity, video EEG monitoring should be able to resolve the issue. As breath holders get older, they tend to do it less and eventually mature out of doing it all together.

Sincerely,
Dr. Warren

Since he was born, his 2nd toe on his right foot does not lay with the others. If you push your big toe and your middle toe together until they touch, this is what it looks like. It just doesn't fit in - just up!!! I know it sounds a little trivial but I need to know - should he be seen by anyone as I am worried it may cause him problems later in life. I do hope you don't think I am a paranoid Mother but I would hate to think later on that there was something I could have done. Thank you very much.

-Tanya

Dear Tanya:

Sincerely,
Dr. Warren

Thank you kindly.

-SS

Dear SS: Colds (URIs) are not serious illnesses, but they may persist for a long time and result in secondary bacterial complications like sinus infections and ear infections. Sinus infections may require up to 3 weeks of treatment. Ear infections may sometimes be recurrent and require multiple courses of treatment. Although this can be quite frustrating, it does not imply any more serious underlying illness. For a greater insight into colds and the problem of recurrent ear infections please read the following articles which I have written:

• Upper Respiratory Infections (URIs)
• Another Ear Infection!?!

Sincerely,
Dr. Warren

Thanks.

-M

Dear M: A 2 month old AIDS patient should receive the standard DTaP, HIB, and IePV. IePV is the inactivated polio vaccine which is currently recommended for all children rather than the live OPV. AIDS patients should not get OPV. If there is a thimerisol free HBV vaccine available, the baby can also receive the HBV at that time. If the baby has been exposed to maternal hepatitis B, the HBV series should have been started in the nursery and should be continued even if a thimerisol free vaccine is not available.

The baby should also start the new Pneumococcal Conjugate vaccine (Prevnar) series.

AIDS babies should follow the same immunization schedule as healthy babies; however, live vaccines such as MMR and varicella, should be given with caution depending on the babies condition. If the baby is severely symptomatic (severely immunocompromised) at the time the vaccine is due, there is a risk that the live vaccine could cause serious disease. On the other hand, keeping in mind that AIDS babies will become much more severely ill with chicken pox or measles than healthy patients, it is advisable for them to receive these vaccines when the status of their immune system allows it. That is a decision which must be made with the advice of the treating physician.

Because of the affect of AIDS on the immune system, it is not safe to assume that an AIDS patient who has been immunized against a certain disease is actually immune to it.

Sincerely,
Dr. Warren

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