3 December 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
Thank you.
-NF
Dear NF: Febrile seizures occur in response to fever in children under 6 years of age, therefore the "spasms" you describe cannot be febrile seizures. You do not say if your daughter is awake or asleep when you kiss her good night. Children's breathing during sleep may be irregular during certain sleep stages. Certain sleep stages may also be associated with movements. I cannot say whether or not you are seeing something normal for a sleeping child or a child drifting off to sleep, or if you are seeing a form of seizure since I have not seen what you are seeing. If you are seriously concerned, you might consider videotaping the "spasms" and showing it to your doctor. My guess is that everything you're describing is probably normal.
Sincerely,
Dr. Warren
-BT
Dear BT: Body odor alone is not an indication of any pubertal change and therefore does not suggest a glandular or pituitary problem. Most body odor comes from sweat. persistent body odor which does not respond to bathing might indicate colonization of the skin with bacteria (all skin is colonized with bacteria) which are producing the odor and may respond to treatment with a topical antibiotic.
Few people go to the trouble to calculate their children's daily calcium intake and assume that if their children are eating reasonably healthy, balanced diets that all their nutrient needs will be met. Milk and yogurt contain approximately 79 mg per ounce so that an 8 ounce serving will provide 632 mg of calcium, a full 3/4 of the RDA. Many children have 2 servings of milk and/or yogurt per day thereby fully meeting their daily calcium requirements. Meat, chicken, and green vegetables are also an excellent source of calcium.
I am reluctant to recommend a specific amount of fluid for a child. Fluid requirements are based on body size and activity level. Keep in mind that fluid is present in many foods. A healthy child who has availability of food and fluids to meet his needs should be able to depend on thirst to keep him in adequate fluid balance.
Sincerely,
Dr. Warren
The heavy cough and fever cleared up within a couple days. However, the throat clearing started again about a week later. It is now very persistent and he does it multiple times a day, sometimes as often as every couple minutes. He doesn't have that phlegmy sound like he is trying to get something out of his lungs, it's just throat clearing. He hasn't developed any further coughs.
Do you have any ideas about what this might be? It is aggravating for both of us. I am constantly worried about him developing something further that I am missing. Please let me know if there is anything I can do or if this could be a syptom of something else. I appreciate any help you can give me.
Thank you so much.
-KF
Dear KF: Two possible causes of chronic throat clearing come to mind. One is that it could be a symptom of irritation from allergy. A trial of a long acting antihistamine such as Claritin or Zyrtec may help. The other possibility is that the throat clearing could be a tic. Tics are behaviors which are repeated frequently, often compulsively. The patient may not always be aware of the tic, but if he attempts not to do the behavior it causes an enormous amount of tension. Tics may be aggravated by stress, but are not necessarily the result of stress. It may help to observe your son while he is asleep. If his throat clearing is a tic, it should be completely absent when he sleeps.
Sincerely,
Dr. Warren
. The family is at the end of their patience. They need help caring for this child. The stress if getting to them. Also he can't be left alone and they need to get back to work. Please respond back ASAP. with any suggestions.
-LR
Dear LR: I wish that I had answers when other doctors fail, but without seeing the child and all his test results, how can I provide answers that other physicians who have reviewed the tests and examined the child cannot find. Since you have not personally spoken to the doctors, you may not be aware of what the doctors have found and what it means. It sounds like he has had a thorough evaluation. If his doctors are stumped, they need to refer him to a pediatric neurologist at a teaching hospital for a second opinion.
The only other thought I have is to look at the child's diet and any medications he is taking and to look for any unusual environmental exposures that could be contributing to these problems. On occasion a cause of severe symptoms may be overlooked simply because it is assumed to be benign. A case in point was a patient of mine who was undergoing evaluation for abdominal pain when Mom noted that her fluoride supplement had abdominal pain listed as a side effect. She stooped the fluoride and the pain went away.
I'm not a proponent of special diets as medical cures, but I've seen kids who defied diagnosis have miraculous improvements with dietary changes. This is not the same thing as nutritional therapy. In addition, I'd be very cautious about using any unproven herbs or vitamin therapies. I feel obliged to point out that overdosage with vitamin A may cause intracranial pressure resulting in headaches.
Sincerely,
Dr. Warren
-MB
Dear MB: It is natural for a child to use her hands to defend herself just as it is natural for a cat to hiss and swat and a dog to growl and bite. An infant's idea of what she needs to use her hands to defend herself from may not make sense to an adult. Beyond doing what comes naturally, the behavior may be inadvertently reinforced or made into a game by the adult responses to it. In addition, children may enjoy the self stimulation from the sound and rhythm when they hit themselves, or may look for the response they get from others. Young children are not bound by adult ideas of what is appropriate behavior or entertainment. They're not concerned about the impression they make on others. They learn acceptable behavior in an attempt to please their parents.
If your daughter hits playfully, if it does not risk injury or pain to another, you have to decide if it's worth making an issue out of. If your daughter hits in anger or strikes out to get her way on something, you should tell her firmly, "don't hit!" and when possible, put her in a brief time out. Be careful not to reinforce the behavior by overreacting to it. You'd be amazed how amusing a crazed adult can be to a child. And if your reaction is severe enough to upset your child, you may find yourself comforting her, resulting in a confusing mixed message.
Sincerely,
Dr. Warren
-SB
Dear SB: An allergic reaction to a medication can start any time during the course of treatment including after completion of the treatment. Since it is a form of immune reaction, it may persist many weeks after discontinuing the medication which provoked it. Allergic reactions require prior exposure to sensitize the patient, so, by definition, all people who have an allergic reaction would have been exposed to the medication previously without reaction. The exposure may occur without the patient being aware of it, for example, antibiotics may be present in the food chain due to their wide spread use in the farming industry. To add to the confusion in determining the cause of a patient's allergic reaction, many infectious diseases may cause hives, so the medication may be blamed when, in fact, the infection is the cause of the reaction.
Your son ought to be taking an antihistamine to control the allergic reaction. If he should develop wheezing, swelling of lips or tongue, or fever and swollen joints, he will need reevaluation for emergency treatment. Escalation of the reaction is unlikely after this length of time.
Sincerely,
Dr. Warren
-JP
Dear JP: There are so many possible causes of fever that without examining your child and getting a complete history, it's hard to know where to begin. Most childhood fevers are due to infection so an infectious disease consult is reasonable. Three fevers in 3 weeks could have been simply 3 separate illnesses. I would be most concerned about the possibility of a urinary tract infection causing recurrent fever with no findings on physical examination. A urinalysis is not sufficient to rule out a urine infection. Your daughter must have a urine culture done. At 18 months, she may need to be catheterized to get a reliable specimen.
Recurrent fevers may be due to non-infectious causes as well. This can run the gamut from inflammatory disorders like JRA (juvenile rheumatoid arthritis) and inflammatory bowel disease to malignancies. These diseases generally cause other findings on exam and abnormalities of certain blood tests. One doesn't generally look for these possibilities unless the fever is persistent or recurrent over a long time.
Sincerely,
Dr. Warren
We have a (now) 7½ month old boy who for the past 8 weeks has had a recurring constant raspy hacking cough. You can hear the "raspy" noise when he breathes. He sometimes coughs so much after drinking his bottle that he vomits as the mucus is draining into his throat at the same time.
We have been to the DR's several times.
Originally we were told it was a virus, a cold, and might last all winter - not on the chest.
Went back and it had gone to the chest and amoxicillin was prescribed. It did nothing.
We went back again and had a different Dr look at him - virus - keep a vapourizer going. We have been doing this all along.
As our daycare provider says, "Your son sounds like he has a fur-ball stuck in his throat".
Went back 1 week again, and saw another DR., who said she didn't like the sound of him. Tightness in the chest. Recommended Triaminic (sold out - cannot find it in our vicinity) and prescribed an inhaler for 2-3 times only to loosen the chest. Continue use with the vapourizer. Said he had a bronchial virus and that the cough wasn't bronchial or croup but that it was similar.
Have used Tylenol cold, the inhaler twice and the vapourizer.
The coughing is getting worse - he turns red in the face and seems like he is having trouble breathing - used the "inhaler" again last night and have him sleeping in his car seat.
The first appointment we can get is next Tuesday and then their will be a wait for a referral (which we are going to ask for) to a paediatrician.
Funny thing is last weekend it finally seemed to be breaking. Then the little girl at our babysitters had the flu and the "virus" was back with a vengence.
Our concern is that
a) this has lasted way too longWe have 2 cats which we have wondered if they were part of the problem, but he has the same problem where ever we go in pet free homes as well.
b) it will develop into something more serious (although it, to us, is already serious)
c) does he have allergies?
d) could he be asthmatic?
Any input would be appreciated.
-DM
Dear DM: I am curious about what kind of inhaler you are using for your infant and what response he has had to using it. Does he improve, even if briefly, after the inhaler? If you are using a bronchodilator like albuterol administered through a spacer with a mask and your son's symptoms improve when he takes it, that could suggest asthma. It would be important to make the diagnosis. First, while spacers with masks can work with infants, I think nebulizers are significantly more effective. Second, chronic asthma symptoms should be treated with preventive medications. Third, cat allergy could play a significant role if the baby is asthmatic, although a recent study suggested that exposure to cats in early infancy decreased the risk of becoming allergic to cats.
The experience you had with your son's symptoms getting worse after exposure to another child's flu is consistent with asthma. Colds and other upper respiratory infections can trigger or aggravate asthma symptoms and are often the cause of asthma symptoms in young infants. Your son's symptoms in a cat free environment do not rule out the possibility of cat allergy causing or aggravating asthma symptoms since the symptoms do not turn on and off instantly with exposure or the lack thereof. For more information about asthma, read my articles about asthma starting with What is Asthma.
I have focused on asthma because the information you gave me suggested that possibility, but it is by no means the only possibility. Since your son coughs to the point of vomiting and turns red and has difficulty breathing with the cough, I have to ask if he was immunized against pertussis (whooping cough). Even immunized children may get whooping cough. If the doctor doesn't think of it, he'll never make the diagnosis. With whooping cough, the coughing fits may be infrequent, but once the child starts to cough, he coughs in long spasms during which he cannot catch his breath. The spasm ends with a big breath which can cause the characteristic whooping sound.
Other possibilities include recurrent URIs. Since your child is exposed to other children at a baby sitter, there may be times when he goes from one cold to another without any break. Given the persistence of the cough, your son needs a complete reevaluation and perhaps a chest x-ray.
Sincerely,
Dr. Warren
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