28 August 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
-(unsigned)
Dear Parent: I can't give you any statistics about the incidence (frequency of occurrence) of labial adhesions, but I can tell you it is common. Unless the adhesions are thick or interfering with urine flow there is no urgency to intervene. Often the adhesions will open after one or more courses of Premarin cream. Once open they can be kept open by regular application of a bland ointment such as A&D or Vaseline between the labia. After puberty, the labia will no longer fuse because of the effect of the naturally occurring female hormones.
Sincerely,
Dr. Warren
-S &: C
Dear S & C: Eventually the cord will fall off. In rare instances delayed separation of the cord may be associated with decreased white blood cell factors (Leukocyte Adhesion Deficiency) which are necessary for wound healing and to fight infection, therefore, you should ask your pediatrician about consulting an immunologist.
Sincerely,
Dr. Warren
We took our son to see a Paediatriacian & Paeds Gastroenterologist in Dubai who prescribed various medications over the period of the following months: Duphalac, Sub. For mineral oil, Liquid Parafin (would not take), Suppositry, Castor Oil (would not take), Normacol Granules, Lactulose Solution, Senna liquid, Senokot, Xyloporoct cream, Microlax enema, Lansoyl Jelly.
The above medications gave little or no affect. Our son had somehow perfected the art of holding back when the urge came to pass a stool. Only when the stool became liquid would it pass easily and with no pain. This liquid form of stool was not good on a long term basis as this caused severe sore’s around the hole of his sphincter, but every time we decreased the medication to allow the stool to have some kind of consistency, our son would again stop himself. During a visit to the UK in September a doctor who examined our son and also prescribed Senna and Lactulose solution.
For several months from January of this year we persisted with the Lansoyl Jelly and Duphalac liquid. In June of this year, a full year later, we contacted a Senior Consultant Paediatrician in Dubai. He examined our son and advised that a Gastro Intestinal and Liver Surgeon should carry out a biopsy to check for any internal problems. A large fissure was diagnosed and while carrying out the biopsy the surgeon felt it was necessary to give a slight anal stretch in the hope that this would make it easier for our son to pass a stool. Apparently the fissure looked like it had been there for some time, probably never having had the chance to heal. In the doctor's words "our son's bottom muscles are almost athletic having achieved the art of stopping the stool from passing over the past year." Since the biopsy, we have been administering pediatric Fleet Enemas after Midazolam ( which the doctor advised we use to get our son calm before administering the enema) to help relieve the stress for our son and never allowing more than a day or two to pass without a stool. We stopped the Midazolam as we didn’t want to give this on a long term basis but continued with the Fleet Enemas. We have had discussions with a Psychologist who advised some relaxation techniques and baby massage to help relieve any stress for for our son, but as he is only just 3 yrs old this was to no avail.
At present, our son will not pass a stool without a Fleet Enema. Unfortunately this helps the problem in one way but the trauma our son undergoes while administering the enema then passing a stool seems to heighten his anxiety of the situation. He associates the toilet with pain and therefore will not sit down to pass a stool under any circumstance, and is insistent that he puts on a nappy, - our son is toilet trained with regard to his passing urine, and doesn’t wear a nappy during the daytime -. He now has a fear of anyone in a white uniform and will cry uncontrollably if we try to give him medication of any kind. At the age he is it has been difficult to try and make him understand what we are doing and why it is important for him to pass a stool without our help. We have tried being firm with him, we have tried leaving him in privacy, we have tried a potty, and we have tried praise of all sorts, bribes and other treats all to no avail.
It has been a very stressful period for all of us and therefore we would appreciate any help or advice you can give us on this matter.
We appreciate your time and look forward to hearing from you.
Yours sincerely,
-A & T
Dear A & T: Yours is indeed a difficult problem that will require the long-term management of a specialist whom you trust. Essentially, your child's problem is stool withholding. For a greater understanding of what is going on, please read my article, Fecal Soiling.
Stool withholding may start in toddlers during toilet training as a result of control issues. It may also start in response to a hard, painful stool. In toddler logic, if it hurts, don't do it. Convincing a 2 year old to push out a stool if it is painful is impossible. He only knows it hurts now and he's not going to do it. The possible future consequence of cramps and a more painful stool means nothing to him. If the stool is large enough and hard enough, it may cause a fissure by tearing the anal tissue. This, of course, increases the pain and therefore aggravates the problem.
To the best of my knowledge fissures in infants are always caused by a hard stool tearing the tissue, but as a matter of interest, I learned that in adults a chronic anal fissure is maintained by contraction of the internal anal sphincter. Of course, once a fissure has formed, any bowel movement can aggravate it, but hard stools are more likely to cause a problem. Therefore, the treatment is aimed at keeping the stool soft and moist enough to pass through the anus without reopening a healing fissure. In adults injections of botulinum toxin and application of topical nitroglycerin ointment is used for the treatment of chronic anal fissure because it decreases or eliminates the maintained contraction of the internal anal sphincter which causes the chronic anal fissure. Another option is surgery. I am not aware of these modalities being used in children; however, if your son's fissure is chronic and, as your doctor has stated, his "bottom muscles are almost athletic having achieved the art of stopping the stool from passing over the past year," perhaps he would be a candidate for such treatment. You would need to discuss these options with your specialists since I don't treat these conditions and have no knowledge of these modalities being used in children.
In any event, continued use of enemas will relieve your son's obstruction when necessary, but will not do anything to change his bowel habits. He will need to be having bowel movements regularly without enemas in order for his rectum to shrink down and for him to approach toileting without fear. Effective treatment of stool withholding generally requires making the stool so soft that the child cannot hold it in. In the older child, this results in accidents which many parents find unacceptable causing them to abandon the treatment prematurely. In your son's case, the stool has to be liquid and results in a sore anus; however, the alternative is to continue what you are doing. My advice would be to abandon potty training for stool, give the child a diaper for bowel movements, and keep his stool liquid so that he is going regularly until this nightmare is a dim memory for all of you. I'm sure your doctor can help you deal with the sore skin. It cannot be worse than your current situation, can it?
When your son no longer has a great fear surrounding bowel movements and no longer appears to be fighting to hold them in, then it is time to slowly decrease the medication allowing his stool to take a more normal consistency.
Sincerely,
Dr. Warren
Thank you for your willingness to help us out. Hopefully our son will be breathing easier soon. By the way he has had to use his nebulizer at least once a day due to asthma symptoms; we are hoping that the co2 was making it flare up so we can decrease the need or eliminate the need for his nebulizer.
-SS
Dear SS: I assume that you're talking about carbon monoxide and not CO2 (carbon dioxide). Carbon monoxide is harmful because it binds the hemoglobin in the blood depriving tissues of oxygen. It is not an irritant and is odorless which is why it may go undetected. Patients may complain of headache and fatigue but may be unaware of exposure to the gas. Of course, if your furnace was flooding your house with carbon monoxide, it may also have been filling your house with fumes which did act as an irritant. Elimination of the irritants should allow the inflammation in your son's lungs to subside over a period of a few weeks. The purpose of the inhaled steroid is to reduce inflammation; however, it cannot do the job as well when the cause of inflammation is always present. Some inflammatory changes may not fully resolve. This is true for asthmatics who have not been exposed to fumes.
If your son continues to have a need for the nebulizer, his does of inhaled steroid may need to be increased. He might benefit from being on Singulair if he is not currently on it. He might also benefit from using Serevent spray to keep his airways open.
Sincerely,
Dr. Warren
Note to Readers: Serevent is a form of long acting beta agonist [LABA] used to provide prolonged bronchodilation (prolonged opening of airways). LABAs are not recommended for treatment of asthma without using concomitant anti-inflammatories such as inhaled steroids. Serevent can be found combined with an inhaled steroid in the medication Advair. Prolonged use of LABAs is no longer recommended since statistically it is associated with an increased risk of asthma related deaths, therefore LABAs should be discontinued as soon as the asthma symptoms can be controlled adequately without them.
-(unsigned)
Dear 16: I can understand your concern about the size of your penis, but there is a range of normal, and not everyone can have the biggest one. In addition, at 16 years, your penis may still be growing, even if you don't see any recent change. Before you even consider any treatment which may not be appropriate for you and may have undesirable side effects, you need a complete examination by your doctor in which you discuss your concerns about the size of your genitals and find out whether or not everything is normal. If you have any hormone deficiency, hormones would be appropriate treatment and should help.
You may be focusing attention to your genitals out of concern for the testicle which is smaller. Let me assure you that you need only one normal testicle for normal sexual development.
Sincerely,
Dr. Warren
-Mr. M
Dear Mr. M: You may require a longer course of medication. I cannot recommend a higher does if you are being treated with the correct therapeutic dose. Higher doses of medications sometimes cause more side effects with no additional therapeutic benefit. Topical antifungals can be used in conjunction with medications taken by mouth. Topicals are not effective in the treatment of nail or scalp infections.
If you keep having recurrences, beside consulting a dermatologist or infectious disease specialist about treatment, you need to be sure you have eliminated possible sources of reinfection. If you have a pet that has untreated ringworm or do gymnastics or wrestling on mats which have not been disinfected you may get reinfected from those sources.
Sincerely,
Dr. Warren
-TF
Dear TF: There are so many possible causes of fever and fatigue that I couldn't guess what is causing your son's symptoms without examining him. Most of the time these symptoms are caused by virus infections which are self limited and not serious, but again, I cannot provide you any assurance that that is what your son has.
It is not unusual for children to have more than one illness in a short period of time. For a brief period after an infectious illness a person may be more susceptible. It is also possible that both fevers were from the same illness since there were only 4 days between.
While I have no reason to think your son's illness is serious, I cannot know what he has since I haven't examined him. Therefore, if he seems sick to you, take him to his doctor (even if he tells you he is fine).
Sincerely,
Dr. Warren
Doctors say it's normal for children this age. I need another opinion. Can u help ? Thanks.
-(unsigned)
Dear Parent: There is no medicine which can cure a runny nose. Medications for runny noses treat symptoms but do not cure anything. Is your child's nose running due to allergies? The doctor may be able to tell by examination: the nasal membrane will be pale and the mucus will remain clear. There may be other findings on examination which suggest allergy. Although antihistamines may relieve allergy symptoms they can make a child drowsy. None of the long acting non-sedating antihistamines are approved for use below 2 years of age. The primary management of allergies in such young children is allergen avoidance. A consultation with an allergist might help you determine if this is the direction you should take.
Upper respiratory infections (colds, URIs) are caused by viruses. Children in school or daycare may have frequent colds because of exposure to other children's colds. There's no limit per customer. Children average 6 to 12 URIs per year, but may have more depending on exposure. Careful hand washing can decrease exposure, but nothing can be done to cure the common cold. For more information about colds, read my article, Upper Respiratory Infections (URIs).
Environmental factors besides allergens may contribute to runny noses. Dry air is irritating to the nasal membrane and will cause increased mucus production. A vaporizer or humidifier can help. Cigarette smoke and other irritants can also contribute to runny noses.
Sincerely,
Dr. Warren
Note to Readers: Clarinex, a long acting, nonsedating anthihistamine, is approved down to 6 months of age. Zyrtec, also a long acting antihistamine, is also approved down to 6 months but may cause some sedation. Many of these medications are not covered by insurance or require a high copay.
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