28 May 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
The nipple itself is not only protruding, but halfan inch behind the nipple where it is normal skin colour protrudes, as though it is a tiny breast. Is this what is called Gynecomastia? How can this be helped?
Is plastic surgery the only option? Or is there anything I can do when it comes to hormones, as I have read a little about how males have more or less male hormones than other and how it can affect their appearance. I heard that ging seng contains male hormones - is that correct and would that help? Would working with weights to increase the size of my pectoral muscles help or just push them out further?
Warren, I am desperate for help and any response that you can give me would be appreciated.
Your faithfully,
-Mark
Dear Mark: You are describing gynecomastia. To the best of my knowledge, hormones are not useful for treating gynecomastia; however, if you have not had a thorough physical exam to be sure that you don't have a glandular condition contributing to the cause, you should. This should include a genital exam to be sure that you have no testicular masses. Since you have had this problem since the onset of puberty, it is likely that it is persistence of gynecomastia from puberty rather than anything else, but when it comes to matters of health, one should not make any assumptions.
Before considering surgery, if you are not happy with that option, you could consult an endocrinologist about hormonal therapy, but as I said, to the best of my knowledge, that is not the treatment. Given the profound effect the gynecomastia has had on your life, you should consult a plastic surgeon. You'll most likely be glad you did.
Sincerely,
Dr. Warren
-Lisa
Dear Lisa: You are most likely describing a pilonidal dimple or pilonidal sinus. These rarely cause any difficulty in childhood. The main problem associated with a pilonidal sinus is that a pilonidal cyst can develop from it. An infected pilonidal cyst is acutely painful and requires surgical treatment.
Spina bifida occulta, a spina bifida with no outward signs, is generally discovered as an incidental finding on x-ray and is not associated with any neurological deficit. If your two year old has had normal neuromuscular development you should not worry that there will be some unexpected or delayed consequences of finding a spina bifida.
Of course you should proceed with the examination by a pediatrician since I cannot be sure of the diagnosis without examining your child. He will advise you regarding the need for imaging studies.
Sincerely,
Dr. Warren
-Joe
Dear Joe: There are many possibilities for rashes, most of which are not a major cause for concern. In the excitement of sexual passion you might not have noticed if your girlfriend's teeth were irritating your penis. You could have some sensitivity to her lipstick. You may have developed a rash from moisture if you had to put yourself away in haste without drying your penis. The only worrisome possibility that comes to mind is that if your girlfriend gets fever blisters, fever blisters are caused by herpes virus. Even if she never had any prior sexual experience, oral sex with someone who has an active outbreak of fever blisters can cause genital herpes. Herpes is not only sexually transmitted. The sores of herpes are groups of blisters.
If the rash looks like groups of blisters or does not go away, you should see your doctor. You do not have to tell your parents that you had a sexual encounter to get an appointment. Just tell them you have a rash. A 16 year old boy should be entitled to have his genitals examined by the doctor without a parent in the room. Of course you need to tell the doctor about your sexual encounter, but he has the right and even the obligation to keep that information private. He does not have to tell your parents any private information.
Sincerely,
Dr. Warren
-MM
Dear MM: Bad knees are not generally the result of physical activity. They are mostly the result of injuries sustained during physical activity. There is no question that a child who is more active is more at risk for injuries, but since injuries are accidental, the child who plays only one sport could just as easily suffer a serious injury. Good coaching which emphasizes strategy and learning skills rather than winning at all cost will certainly decrease the risk of injury. In addition, it's important for young athletes and their coaches to understand that pain is a signal that something is wrong. Playing through the pain is not the manly thing to do unless manliness is equivalent to foolishness. Athletes need to understand that in the end they could lose a whole season of play or even be out of the game permanently by not taking proper care of their injuries.
Sincerely,
Dr. Warren
-Rachel
Frustrated Mom
Dear Frustrated Rachel: The fact that your son vomits all formulas but not solids suggests that he is having gastroesophageal reflux (GER) rather than formula sensitivity. Of course, if your baby seems to have abdominal pain or is very irritable, you could still be dealing with a formula problem; however, your son's good weight gain suggests that you are dealing with excessive spitting as a result of reflux rather than true vomiting. GER can be a problem if the baby is not gaining well, is irritable, or wheezing. Since there are medications which can help GER, if you and your pediatrician feel there is a significant problem, you should consult a pediatric gastroenterologist for diagnostic evaluation and treatment advice. Before you rush off for testing and treatment keep in mind that all infants have some degree of reflux so the issue becomes one of "when is it abnormal or a problem?" As I said above, I would be most concerned if the baby was gaining poorly, uncomfortable, or had a chronic cough. If the baby is doing well, you may just be chasing your tail trying all these formulas when the only thing that really needs to be done is to clean up the mess.
One thing that can help in dealing with the excessive spitting associated with reflux is to thicken the formula. This can easily be done by adding rice cereal to the formula. This does alter the carbohydrate content of the formula, so a better option might be to try a formula like Enfamil AR which is thickened with rice but has been adjusted to have the same amount of carbohydrate as other formulas.
Sincerely,
Dr. Warren
Thank you in advance
-University of Xxxxx Students
Dear Students: The growth chart can tell us if a child is growing normally or not. If a child's growth is adequate you can infer that his nutrition must be adequate since children who are not well nourished cannot grow well. You cannot tell whether or not the diet has all the vitamins and minerals in the recommended amounts; however, if a child has a reasonably varied diet and eats enough calories for adequate growth (weight and height gain) his diet should meet all his nutritional needs. It may still be an undesirable diet if it has too much sugar, salt, or fat, but even a diet too high in those nutrients is preferable to one that does not adequately meet the child's nutritional needs.
If you plot just one point on a growth chart you can be reasonably reassured if that point falls within the normal range for both height and weight, and you can see how the child's weigh compares to his height (overweight, underweight); however it is most useful to see the growth trend by having a few points plotted on the growth chart. Suppose a child's height and weight are in the low normal range but you review the chart and find that a few months ago he was in the average range and a few months before that he was well above average for height and weight. Even though his height and weight are normal now, he is not growing adequately. At that point an investigation into the cause of growth failure is needed. You cannot tell the cause of failure to thrive from a growth chart. Most important, you cannot tell if a child is growing poorly due to inadequate nutrition. You might suspect that if the decrease in weight gain precedes and exceeds the decrease in height gain. A review of the child's diet might help, but you must keep in mind that a child who is growing slowly for any reason requires fewer calories to support his growth and so will have a smaller appetite.
Another example: A child's height and weight are both within the normal range; however, his height remains steadily on the 25th percentile whereas his weight has increased the percentile at each visit and is now in the 90th percentile. That child is gaining excessive weight. If he levels off and continues to gain on the 90th percentile that's not too bad, but his current trend suggests that he will continue to gain more weight than height and become progressively more obese. Since a young child really has no control over his food intake other than demanding feedings, his parents need to be counseled to furnish a diet which provides adequate nutrients for growth without providing excess calories. They may also need to be counseled about how to meet the child's need for comfort without responding with food.
Next example: A child's weight is above the 95th percentile (above the normal range). His height is in the 90th percentile. His growth has continued consistently on those same curves for some time. This is a large child who is experiencing normal growth.
Similar example: A child's height has been steadily in the 10th percentile and his weight steadily in the 90th percentile for a long time. The child is overweight. There is a large disparity between his height and weight percentile. However, his current growth is normal since he is maintaining his growth percentiles. It would not be desirable to alter his feeding pattern now in an effort to decrease his weight. Below the age of 3 providing adequate nutrition is a higher priority and he will probably slim down as he gets older as long as he is encouraged to eat a healthy diet that isn't too high in fat.
Last example: A child is small. His height is consistently at or even slightly below the 3rd percentile. His weight is below the 3rd percentile but has been increasing steadily along the same curve just like his height has. Essentially his growth is normal even though he is very small. Unfortunately, parents tend to equate weight gain with health, and when their child is smaller than all the others it's essential to be sure that there is no medical problem interfering with growth. In addition, the child's appetite will most likely be small because his nutritional needs for growth are small. As a result the parents have a great deal of anxiety about whether or not the child is being adequately nourished. A review of the family growth patterns can help since one or both of the parents was probably small as a young child. A review of the growth chart can reassure the parents of the normalcy of the child's growth.
Discussion: Obese children tend to be tall, so there is no question that overnutrition stimulates growth. Not all obese children consume the same type of diet. Excess weight gain in infancy is often a result of too much dependence on bottles. These children may not "eat" much at all. Others may consume too many sweets or too much fat and have an inadequate intake of vitamins, minerals, and sometimes even protein (rare in the USA except in areas of extreme poverty).
Small children often eat less than their peers, but it is more often their slow growth which results in a poor appetite rather than their poor intake resulting in slow growth. Some small children are small in spite of having voracious appetites. A review of the growth chart for the growth pattern along with a comparison to the family growth history can help determine what medical evaluation is needed.
The normal range (from the 3rd percentile to the 97th percentile) is a statistical derivation. A child whose height or weight is outside the normal range has a greater risk of having a nutritional or medical problem as the cause, but some perfectly normal children will have a height or weight outside the normal range. On the other hand, children may have abnormal growth (excessive weight gain or inadequate weight and height gain over a period of time) while remaining within the normal range. Therefore the growth pattern is the most important thing to look at to evaluate growth.
In most instances you can assume that the obese child and the child with a normal growth pattern are adequately nourished, but that may not always be the case. Likewise, the small child may be adequately nourished. Even the child whose growth has decreased may have a medical problem such as infection, a gland disorder, a heart condition, or a genetic cause for poor growth so that nutrition cannot be blamed without a thorough investigation. Review of the growth chart is a crucial part of the evaluation of a child's growth, but all these children require a dietary history to determine the adequacy of their nutrition and it's contribution to their growth pattern.
Sincerely,
Dr. Warren
Note to Readers: Today's revised growth charts also include curves for BMI (Body Mass Index) to help in the diagnosis of obesity.
Thank you.
Sincerely
-Dr. O
Dear Dr. O: Simple measurements of growth hormone levels are not useful to rule in or out growth hormone deficiency. Growth hormone levels are generally low during the day and rise during sleep. Measurement of somatomedin C levels may provide a little more information as a screening test, but diagnosis of growth hormone deficiency requires provocative testing with serial measurements of growth hormone levels. These must be done in a hospital because of potential reactions. Since I am not a specialist in this area, I only vaguely remember the details and would suggest consulting an endocrinologist if you need to pursue this possibility.
Since you describe your son's height as "a little under average compared to his friends," I'm not sure that any medical intervention is appropriate. You need to look at your son's growth plotted on a growth chart. If his growth has been steady on a normal percentile, even if it is at the lower end of normal, both you and he should be reassured that you can expect a normal final height. You cannot promise him that he will be tall. Not everyone can be. A review of your family growth pattern would be most helpful here. A common pattern of growth called "constitutional delay of growth" causes normal growth along a low percentile curve and a delayed growth spurt due to a delay in the onset of puberty. Most of these children start puberty at the normal time, but toward the end of the normal range. Since the growth spurt typically occurs during mid to late adolescence, in early adolescence the disparity between the affected child's height and his friends' heights may increase as they go through their growth spurts, but since children with constitutional delay continue growing for a longer period of time, they may end up taller than their friends. A lot depends on their genetic potential. At 13, your son could have no signs of puberty or be in early puberty while friends of his who are the same age may be well into puberty and already have started their growth spurts. You would need to examine your son's genitals to determine his pubertal status. If he is well advanced in his body development and is short you have more cause for concern about his final height, but again, must be realistic about your expectations based on the size of his parents and where he actually is on the growth chart. We can't all be tall.
Use of growth hormone in short children who have normal growth (and even slow growth without growth hormone deficiency) still remains controversial. While there is evidence that it will accelerate growth, it still remains unknown whether or not it can affect final height. It is most effective when therapy is instituted before puberty. Even though it is readily available through recombinant DNA technology, it remains expensive. It may not be the answer for your son. If your son is extraordinarily distressed by his height and has not had much of a pubertal change, he may benefit from giving puberty a little push. To explore this avenue, you should consult an endocrinologist as well. However, if your son's growth is normal and he is either in early puberty or has not yet started puberty, if you can both be reassured that he will get there in his own time, it would be best to just let nature take its course.
Sincerely,
Dr. Warren
If there is anything you can tell me regarding this my husband, daughter and I would be greatly appreciated.
-SS
Dear SS: Unfortunately, the numbers which you quoted to me do not mean much to me since, in my practice, I don't deal with enzyme levels in tissue biopsies and have no information regarding the normal levels. In addition, I'm unclear about what is baffling the specialist about your daughter's results. Since he did the test, he must know the significance of it. If he has never seen a child with multiple enzyme deficiencies, he should refer you for another opinion. He should know who the top experts in your area are, and they in turn should know who the top experts in the country are. No patient should stop with one opinion when that specialist says he has no answer.
Since I have not treated any child with multiple enzyme deficiencies, I cannot speak from experience, but my experience with lactose intolerance (resulting from lactase deficiency) leaves me a little surprised that no help has been offered. The enzyme to break down lactose (lactase) is readily available without a prescription under the brand name "Lactaid." While that would not solve all your daughter's problems, it should help. The drug companies may not be producing the other enzymes if there is not much call for them, but perhaps similar help can be found for the other enzyme deficiencies from a physician conducting research in this area. These physicians are generally found at major teaching hospitals. Finally, a consultation with a nutritionist would help you determine which foods have only simple sugars which your daughter could tolerate and which foods have no sugars at all. She may require a supplement made with glucose to meet her carbohydrate needs, but a diet limited in the foods that cause her problem should provide her adequate nutrition with some relief of her symptoms.
Sincerely,
Dr. Warren
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