16 April 2007

1. Increased Appetite After Illness
2. Newborn Rash
3. Spider Veins
4. Abdominal Pain or Stool Withholding?
5. Breast Swelling in a 17 Month Old
6. Strange Posture in 10 Week Old
7. Shrinking Penis
8. School Rules Restrict Toilet Access
9. Disclaimer

• Read Questions & Answers in Another Column

Increased Appetite After Illness

-AD

Dear AD: After recovery from an illness which has decreased a child's appetite, there may be a period of increased appetite during which the child makes up for caloric loss during the illness. This may cause the child's stomach to appear slightly bloated because of the increased food volume traveling through the intestines. It is rare for a child with a good appetite to have anything wrong with her gastrointestinal tract so I wouldn't be concerned about the apparent bloating as long as your child's appetite remains good, her bowel habits remain normal, she appears to be free of abdominal pain, and she is happy.

Sincerely,
Dr. Warren

-SI

Dear SI: Rashes are fairly common in the newborn period. Common rashes include infant acne (usually on the cheeks), seborrhea (cradle cap on the body, yellow scales), heat rash (fine red or white bumps), and eczema (scaly red patches). It is possible that a body wash or detergent you are using could cause a rash. Avoid enzyme detergents and fabric softeners which have a higher risk of causing rashes than other detergents. Consider using Ivory Snow for the baby's wash. For bathing the baby use dye free, perfume free Dove soap.

As long as the baby is acting well and feeding well, you need not be alarmed about a rash, but in the end, the only way to know the diagnosis and have peace of mind is to have the rash checked by the baby's doctor.

Sincerely,
Dr. Warren

-MF

Dear MF: With out seeing what you're talking about I'm GUESSING that you're describing spider veins which are known in medicalese as telangiectases. They can be treated with laser, but since infants have thin skin, I wouldn't rush to do anything as they may become less prominent. It can always be taken care of later if there is a cosmetic concern.

Sincerely,
Dr. Warren

-KR

Dear KR: I cannot tell if your daughter's condition is being properly diagnosed or treated since I have not examined her. Constipation can certainly cause abdominal pain. Severe abdominal pain usually makes a baby cry. The fact that she isn't crying suggests that she is not so much in severe pain, but rather, that she is making an effort to hold in her bowel movements until the urge passes. The cramps come from the intestines pushing to get the stool out. If your daughter is withholding stool (which is what the story suggests), her behavior is primarily a result of resisting the urge to have a bowel movement. She accepts the pain because she has learned that the cramps will pass if she just holds on. She does not understand that she would feel better if she had a bowel movement and probably began withholding stool due to a painful bowel movement.

If you have not seen any progress with the treatment of several different doctors you should consult a pediatric gastroenterologist for diagnostic evaluation as well as treatment.

Sincerely,
Dr. Warren

-LO

Dear LO: You may be seeing some breast tissue development (premature thelarche). Premature thelarche is normal and not a cause for alarm. According to Behrman: Nelson Textbook of Pediatrics, Sixteenth Edition, Copyright © 2000, W. B. Saunders Company,

The term 'premature thelarche' applies to a transient condition of isolated breast development that most often appears in the first 2 years of life; in some girls breast development is present at birth and persists. Breast development may be unilateral [just one side] or asymmetric [not the same size on both sides] and often fluctuates in degree. Growth and osseous [bone] maturation are normal or slightly advanced. The genitals show no evidence of estrogenic stimulation [no other signs to suggest puberty]. The condition is usually sporadic and is rarely familial. Breast development may regress after 2 years, often persists for 3-5 years, and is rarely progressive. Menarche [the onset of menstruation] occurs at the expected age, and reproduction is normal.... Ultrasonographic examination of the ovaries reveals normal size, but a few small cysts are not uncommon.

Premature thelarche is a benign condition but may be the first sign of true or pseudoprecocious puberty, or it may be caused by exogenous exposure to estrogens [for example, if the child ate birth control pills]. In addition to a detailed history, a bone age [calculated from a wrist x-ray] should be obtained.... Pelvic ultrasonographic examination is rarely indicated. Continued observation is important because the condition cannot be readily distinguished from true precocious puberty.... Occurrence of thelarche in children older than 3 years of age most often is caused by a condition other than benign precocious thelarche.

Sincerely,
Dr. Warren

I have seen several doctors and pediatricians, so far all I've had are "we've never seen anything like it".

My son has had x-rays, spine tests, cranial massage and so on, so far no change, the next step the doctor says is a cat scan-I am skeptical as this would involve anaesthetic.

I am trying to see you or if any of colleagues have heard of such a condition.

Please note he was about 7 pounds at birth, I was induced twice and had a 1hr 50 min labour.
2 weeks over due

I hope you can help.

Thanks

-SW

Dear : It sounds like you're describing opisthotonic posturing which can be seen with neurological damage. You should proceed with the CT scan or even an MRI of the brain and the baby should have a thorough evaluation by a pediatric neurologist.

Sincerely,
Dr. Warren

What I was wondering is whether you had or know where I could obtain further info on this condition, perhaps on the internet or any literature.? Is it a condition that affects only the posture or does it have any other implications? Is there treatment?

Sorry to be a nuisance.

Thanks for your time.

Yours Gratefully.

-SW

Dear SW: You are probably having difficulty finding information about opisthotonus (opisthotonos, opisthotonic posturing) because it is not a condition in itself but simply a symptom or finding in certain neurological conditions. Opisthotonus is seen in tetanus and as a result of severe spasticity.

I have assumed that your baby does not have tetanus since it is an acute onset illness which is serious and progressive, and you did not complain about the jaw spasms seen in tetanus which would make eating and drinking impossible. Neonatal tetanus is uncommon in developed countries but is still seen in undeveloped countries where they engage in practices such as putting mud on wounds or the umbilical cord.

Spasticity is a result of brain damage. Because of the way the nervous system develops, even a child who will be severely spastic rarely exhibits such symptoms in early infancy. Spasticity is treated with muscle relaxant medications, physical therapy, surgery, and electrical stimulation.

Since I have not examined your child, I cannot say that you are seeing opisthotonus, but because your description sounds like opisthotonus, I do recommend a thorough neurological exam including brain imaging studies (CT, MRI).

Sincerely,
Dr. Warren

Jack's penis is somehow shrinking in the way that it is retracting back into his body. He is circumsised but when his penis is retracted it looks like he has a foreskin. It makes it difficult when toileting and cleaning him. When he was younger his penis looked normal, in that it was a good length and was often erect in some situations. But now I hardly ever see him erect and it now sits somewhat in his body instead of hanging out. I suppose he is in the midst of puberty, even though he has had little if no penile growth since I first began caring, but I was wondering if the constant seating position might affect the 'condition' of the penis, or its growth. I ask because boys are running around and standing, so their penis is either hanging down or flopping around whilst running etc. And also the fact that most boys are experimenting with masturbation by Jack's age so the penis often handled and erect, and pressured with ejaculation.

In Jack's case his penis is stagnant and because of his condition he is unable to masturbate. Do you think this unhandled stagnant state could be affecting the retraction and low number of erections he has?

If you can offer any advice, or have any suggestions in where or what I may be able to do, anything would be greatly appreciated.

Wishing you all the very best.

-LJ

Dear LJ: Penises don't shrink during childhood. It is likely that your 15 year old charge has more body fat in the pubic area which results in the penis being buried in the pubic fat. If this makes it difficult to clean Jack or to get his penis into a urinal you can press down on the pubic fat pad with two fingers around the base of the penis causing it to "pop out."

The size of a boys penis is not related to his erections or his ability to handle his penis. Since Jack would have difficulty urinating through an erect penis there is no advantage to him to have an erection.

At 15 it is likely that Jack would have started puberty, but some boys don't start until 16. The first sign of puberty is testicular enlargement. The penis grows in the next stage as pubic hair develops. Prior to that there is virtually no growth of the penis from infancy; however, there is significant growth of the child. That along with increased deposition of fat in early adolescence may account for your impression that the boy's penis is shrinking.

Sincerely,
Dr. Warren

Any information and advice I can get would be greatly appreciated.

-LW

Dear LW: Infrequent urination increases the risk of urinary tract infection. As a general rule physicians recommend voiding every two hours. The reality is that most people don't and for those who do not have urinary tract infections, less frequent voiding does not pose a problem. Rules limiting children's access to rest rooms are both cruel and counterproductive. While most children can adapt to a schedule limiting rest room privileges, all of us experience days or times when our bladder fills more quickly or our bowels are irregular. A child who is expected to sit through a lesson in discomfort is not likely to get the full benefit of the lesson. Why should we expect from a child what nobody would expect or dare to demand from an adult.

The problem teachers face is that some children abuse bathroom privileges and that can be disruptive to the class. But it should not be that hard to figure out who those children are and deal with them appropriately with the help of parents.

If the rules are set by the teacher, you should talk to the teacher about it. If you cannot reach a compromise or the rules are set by the school, take it to the principal and if necessary, to the superintendent or school board. In addition, talk to other parents. If other parents are upset about this issue your words will carry more weight as a group. If necessary, enlist your pediatrician's help to write a note to the school indicating that your daughter's health requires her to be permitted to use the rest room more than twice daily.

You should also help your daughter understand what happened. She needs to know that she didn't do anything wrong, but sometimes rules which are made for a good reason can end up being unfair to an individual or under certain circumstances. Even when that happens it's important for kids to respect the concept of following rules for the good of the community. It's good for kids to know that we will fight for their rights when something is unfair, but we don't want them to develop a negative attitude about cooperating with community rules.

Sincerely,
Dr. Warren

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