23 July 2007

1. Pupils Not the Same Size
2. Persistent Fever - a Doctor Asks
3. Pulling and Eating Hair
4. What Milk at What Age?
5. Recurrent Bronchiolitis
6. A Teacher Asks: Name That Syndrome
7. Hair Pulling
8. Insomnia
9. Disclaimer

• Read Questions & Answers in Another Column

Pupils Not the Same Size

Thanks for your help.

-Pam

Dear Pam: Anisocoria, an asymmetry of the pupils, may vary from day to day, or even from hour to hour, and is visible in about one fifth of the normal population. While it need not be associated with any disease, pupil asymmetry may be associated with problems anywhere in the complex pathway that causes the pupil to respond to light. Thus an abnormality of the iris, the muscles controlling the iris, the nerve pathway controlling those muscles, the retina (affecting light reception), or the central nervous system may be responsible for pupil asymmetry. If the pupil asymmetry is small and the pupils are round and respond normally to light it is probably normal.

Determining the cause of pupil asymmetry is a complex matter which is best initiated via a complete eye exam by an ophthalmologist.

Sincerely,
Dr. Warren

Investigations

• Hb--12 gms
• TLC--23500
• DLC--P88,L10,M-2
• ESR--78 1st hour WG
• CRP--48 mgm %
• x-ray chest--normal
• ultrasound abdomen and hip joint normal
• Blood culture--No growth of pyogenic organism

TREATMENT

What should be the next course of management?

-Dr. R

Dear Dr. R: Once again I'm concerned that your e-mails are arriving when I cannot take the time to answer them because if you really need my answers you are asking questions which sound like they cannot wait a week for a response.

After 21 days of fever I can understand the desire to get this child on treatment that would get him better, but starting him on antibiotics without knowing what you were treating may have compromised your ability to isolate an organism if you find the source of infection. I think it would have been reasonable to wait with antibiotics until a more thorough investigation had been completed. Of course, since I didn't examine the boy, I cannot know how toxic he appeared and with what urgency action was needed, but it seems reasonable to conclude that he could not have been septic for 21 days.

Since the only complaint you have told me about relates to the child's hip, an orthopedic consult to fully evaluate his hip should help clarify your diagnosis. A bone scan or MRI of the joint may show something not visible on ultrasound. If the problem is in the joint, aspiration of the joint may provide the answer you need. If the child has an osteomyelitis, surgical treatment may be necessary to clear the infection and to isolate the organism. Since your current choice of antibiotics is effective against the common causes of osteomyelitis, if that should be the diagnosis, you will need to check for tuberculosis as the offending organism.

If no infectious cause can be found, let's not forget that both rheumatic diseases and malignancy could result in limb pain and a significant elevation of the ESR. Lyme disease would have responded to amoxicillin but non-infectious rheumatic diseases such as JRA, rheumatic fever, and lupus would not have been affected by antibiotic treatment. Blood work: ANA, ASLO, Rheumatoid Factor, and a consultation with a rheumatologist may help. Imaging studies (MRI or CT) may help in the search for malignancy as might the bone scan. Consultation with an oncologist might provide additional tests with which I may not be familiar. If the pain is bone pain, a bone marrow aspirate may be warranted.

I assume that you find my answers useful in spite of the fact that I'm not a brilliant professor. I make this assumption since you have written back to me several times. I'd appreciate some feedback from you regarding my responses and the patients we have discussed so that I may learn from these cases as well.

Sincerely,
Dr. Warren

-ML

Dear ML: In case you wish to read more about the subject, pulling one's hair out is called trichotillomania. It may occur as a benign habit primarily associated with thumb sucking, in which case behavioral management including eliminating the thumb sucking may help. The fact that your granddaughter eats the hair and even eats hair she finds suggests that her trichotillomania is not simply a benign habit. Trichotillomania is closely related to, and may be an expression of, obsessive-compulsive disorder in some children. As such, it responds to some of the medications used to treat OCD.

The primary risk of pulling out hair is that it could cause scarring resulting in permanent hair loss in the affected area. The risk of eating the hair is that it could cause a hair ball (trichobezoar) which could cause intestinal obstruction and require surgery.

Not all kids with trichotillomania need to be on potent psychoactive drugs. Intervention could range from simply ignoring it to behavioral management to medication. Ignoring it and dealing with potential sources of stress contributing to it may be a reasonable course of action in a child who is otherwise well adjusted and successful both socially and in school. Behavioral management (discussed below) is best accomplished under the guidance of a psychologist. Behavior modification programs must be designed with reasonable goals and be applied consistently to succeed. A psychiatric evaluation would be necessary to determine which children are candidates for medical therapy.

It might be hard to categorize a two year old with regard to severity. I'm no expert on trichotillomania, but even though these kids often eat the hair they pull out, this is the first time I've heard of a child with trichotillomania eating hair she finds. On that basis I have a bit more concern about your granddaughter and would suggest first that her health be reviewed by her pediatrician to be sure there are no medical factors contributing to the problem.

Next, I would consult a child psychologist to see if an effective behavioral management program can be designed to solve the problem. Such a program involves "reward" and "punishment" applied consistently and avoids battling about the problem which could increase the stress and thereby increase the problem. I have put quotation marks around the words "reward" and "punishment" because rewards are more in the form of stars or stickers on a chart for positive reinforcement than material rewards. Punishment is really a negative consequence applied consistently each time the behavior occurs such as a brief time out. Too much attention paid to "punishment" may actually reinforce the behavior by giving the child additional attention for the behavior. In addition, it may help to provide substitute behaviors for the hair pulling as well as distractions from it. Finally, the psychologist might explore the stresses which contribute to the behavior. The parents will need a lot of support to find the best techniques and maintain consistency of approach as there is no quick fix, therefore I would really encourage professional counseling.

Finally, if the child's pediatrician or psychologist feel that medication is warranted, or no progress is made with maturity and behavior management, I'd recommend consulting a child psychiatrist for medication.

Sincerely,
Dr. Warren

-WS

Dear WS: Because the developing nervous system requires adequate dietary fat, the American Academy of Pediatrics recommends breast milk or formula until 1 year of age, and whole milk from 1 to 2 years of age. At 2 years of age it is safe to lower the fat content of the diet so the American Academy of Pediatrics recommends switching to skim milk for cardiovascular health.

Sincerely,
Dr. Warren

-Concerned Mom

Dear Concerned Mom: Bronchiolitis is an upper respiratory infection caused by RSV (respiratory syncitial virus). While it is possible for an infant to have it more than once, multiple times during the year seems an unlikely possibility. The relationship between RSV, hyperreactive airways, and asthma remains unclear. While RSV may be the cause of an infant's first episode of wheezing, some of those children will go on to have recurrent episodes of wheezing. Bronchiolitis may certainly leave the airways hyperreactive for some time after the RSV infection so that many of these children wheeze with their next URI (upper respiratory infection - common cold). Those children who have the most severe wheezing with RSV may be the ones who have more reactive airways and an inborn tendency to develop asthma. In any event, those children who have multiple episodes of wheezing after a bout of bronchiolitis most likely have asthma rather than recurrent bronchiolitis. If there is a family history of allergy, asthma, or eczema, it becomes even more likely that the wheezing infant is an asthmatic. While allergy may play a role, the most common trigger to provoke asthma symptoms in these infants is a URI.

Home management of a wheezing infant is the same whether the baby has asthma or bronchiolitis. The wheezing is treated with albuterol by nebulizer. If the patient has asthma, then management can also include medication to prevent recurrent wheezing. Currently available medications for infants include the Pulmicort Respules and Intal (cromolyn) which are administered by nebulizer. To be effective, these medications must be taken regularly even when the baby is symptom free. If the baby only has symptoms at certain times your doctor may be able to devise a strategy of when to start preventive medication leaving the baby off all medication in between. For more information, please read my articles about asthma starting with What is Asthma?

Sincerely,
Dr. Warren

At birth Sean had: low muscle tone over entire body - slack jaw, late in talking, legally blind, only began walking unassisted this month - still needs walker when going long distances - however, his eyes and speech continue to improve as he matures. He has word retrieval problems so his answers are 4-5 words max. He is often completely off topic and cannot answer questions appropriately.

Q: "What are Native American TP's made out of Sean?"
A: "Steering wheels".

Thanks much!

-RB

Dear RB: There are many syndromes which cause low muscle tone associated with learning disabilities. While many syndromes have been characterized and their causes found, the myriad of things which could possibly go wrong in human development sometimes creates symptom complexes which don't fall into any known pattern. If your student's syndrome has not been identified by his doctors during his 6 years of life he may not fit any identifiable syndrome. In any event, without seeing him and with so few details, I cannot hazard a guess regarding diagnosis.

The benefit of a diagnosis is that it can provide a prognosis, and realistic expectations can help devise a treatment plan; however, when it come to education, there is a risk in allowing the prognosis to limit intervention and expectations. We walk a fine line between demanding too much and lowering self esteem, and demanding too little limiting progress to our low expectations. Years ago the prognosis for Downs syndrome was dismal. While many Downs kids are profoundly retarded, with early intervention programs we have seen some exceed our wildest dreams for intellectual accomplishment. The take home message is that we have to help kids with disabilities to be the best they can be, and regardless of diagnosis, each child is a unique individual with different potential.

I applaud your interest in your student. Caring teachers are our best hope for the future of our children's education. Your instincts about your student may be right on target, but I urge you to be cautious about taking any direct action on them. This child's diagnosis is unknown and he has made significant progress in the past year. The parents may have good reason on the basis of what they have been told by professionals involved in his care and evaluation, to believe that he is progressing toward normalcy. I have had patients with severe language problems whose difficulties significantly resolved with maturation of their nervous systems and appropriate educational intervention. In addition, the parents may have a greater understanding of what hurdles their child faces than is apparent to you. They may have deliberately chosen to treat him as normal as possible so that he doesn't grow up seeing himself as a disabled person. As I said, there's a fine line between demanding too much and too little from a child. A good self image can go a long way toward excelling in the future.

Your role is to push the child to excel, yet you must recognize if he is feeling too much pressure; to provide an honest assessment of his work without judgment about his potential; to request further evaluation by the school psychologist, committee on special education, or outside sources if you feel he needs additional services which are not provided in the regular classroom; to find out any special education recommendations which will assist you in meeting any of his special needs; to ask the parents to provide you with any information which will help you teach him including the ability to contact specialists involved in his care and evaluation. Since you are new to teaching, it is possible that a meeting with the principal and/or school psychologist would provide you with essential information about how the school district deals with special students and what your role is beyond teaching him.

Sincerely,
Dr. Warren

-Kathy

Dear Kathy: Unfortunately there is no simple solution to pulling out hair. When your child goes to pull out her hair see if you can gently lead her hands away from it, distract her, and help her express what she is feeling in other ways (for example: hitting a punch toy when she is upset). Avoid getting into a battle about the hair pulling as this may backfire if it increases her stress. If she continues to pull her hair as she gets older or exhibits any other compulsive behaviors you may need to consult a psychologist.

Sincerely,
Dr. Warren

She does not eat chocolate or have any form of caffeine. Are there any other known foods that may cause sleep problems. At times, it is 11:30 PM when she finally falls asleep. This is a problem because she needs to wake up at 6:00 AM to get ready for school. Of course, weekends are no trouble, since she can sleep in.

-K

Dear K: Eleven year olds vary in their need for sleep. She should probably get at least 8 hours a night, but may do fine on less. Your daughter may just naturally be a night person - unable to get up early in the morning, unable to fall asleep early at night. Make sure she is not taking any daytime naps which will interfere with her developing a normal sleep pattern. In addition, avoid any stimulating activities prior to bed. This can include television shows which may be over stimulating, and even reading if the story is exciting or frightening.

Don't insist on a dark, quiet room if this has not helped. Some people fall asleep more easily with a TV or music on in the room. Reading in bed may also help (as long as the story is not stimulating). Establishing a bedtime ritual which your daughter finds relaxing will help eliminate the bedtime stress associated with insomnia.

Sincerely,
Dr. Warren

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