31 March 2008
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
My sister's baby was born August. I love him dearly and he's practically mine as I live next door and take care of him a lot as she is a single parent. My sister's water broke at 34 weeks and her son was born 36 weeks , 2 day (they kept her in hospital on IV and she went in labour on her own) - during delivery cord was wrapped around her son's chest and his heart rate dropped so they had to do a high-forceps delivery. Her son was 5 lbs, 8 oz when he was born. He left the hospital when he was 4 days old and was 5lbs, 2oz (I want to give you his history as it may help with the questions) - He was a healthy baby - small... but not respiratory problems.
In March of this year he developed pneumonia and an ear infection. Had antibiotics and was fine. Since April he has had gastro-like symptoms on and off. Mostly the vomiting. He can be perfectly fine - then scream and then throw up - and throw up he does - I'm sure he throws up bucket fulls. Anyway... we recently had him to the ER because he had diarrhea and vomiting and a strange rash (which at first they thought maybe shingles but they concluded it was viral) - At that time he was weighed and he weights 17 lbs, 6 oz. (He was 19 lbs, 13 oz in April) - he is sooooo tiny. Little legs and arms and his back is no wider than my hand. Although he's small - he right on track with his development - feeds himself, walks holding on to things... says Ma-Ma and so on. The past few weeks I have noticed that his lips went blue on three different occasions... but once I picked him up and cuddled him they went back to normal. He seems to have dark circles around his eyes as well - almost like bags around his eyes. My Mom (who lives with my sister and her son) thinks that some times he breaths fast. His Mom is a nurse and sometimes I feel that she knows too much and needs to be a Mom - not a nurse and have him checked out. I'm worried that there's something wrong with his heart of something. Do you have any advice for us?
I'm sorry this is so long. I didn't want to leave anything out.
Oh - I should mention that we're in Canada and have to be referred to a Pediatrician so we're waiting on that now.
-Janet
Dear Janet: There are two separate problems with your nephew which are probably not related. Cyanosis (turning blue) could indicate a cardiac or respiratory problem. Without an examination, I cannot tell you which; however, respiratory problems severe enough to cause cyanosis usually cause respiratory symptoms. Breathing fast could be either cardiac or respiratory. My first thought would be for him to see a pediatric cardiologist.
The second problem is gastrointestinal. If your nephew has not been able to recover from vomiting and diarrhea symptoms for over 2 months, he could have a food intolerance, inflammatory bowel disease, or even parasites. Even liver or kidney problems could cause vomiting and failure to thrive.
There are too many possibilities to decide by e-mail. While it would be reasonable for your nephew to see a gastroenterologist, he really needs to start with a thorough exam by a pediatrician with appropriate blood, stool, and urine tests determined by the doctor's findings. The next step would be referral to specialists for additional tests such as an echocardiogram and for treatment recommendations.
Sincerely,
Dr. Warren
-SB
Dear SB: A child's repeated experience with separation provides him with a learning experience in which he sees that Mom returns after each separation. This is a good thing for both Mom and child; however, there can be no doubt that your son's experience at the summer program was the first time he wanted you and could not have you for a prolonged period of time. This made the separation anxiety real for him, and no he will have to learn to be comfortable with separation. It takes time. Each time your son is separated from you even briefly, he relives the horror of the first time he realized that you weren't there and he could not get you by calling out for you. With time, he will learn to relive your return to pick him up each day.
As to why separation anxiety exists, it's a part of the inborn instincts necessary for survival. Those instincts are unique to each species. A newborn human screams loudly for his needs to be met. Calling attention to oneself in a prehistoric jungle full of carnivorous wild animals might seem counter to good survival sense; however, a human infant cannot fend for himself, so he must make his needs known. His screams cannot be ignored, so his needs must be met quickly. At first, any human in the tribe will respond to his cries, but even then, his mother must be available to nurse him. As he gets older, since he will become independently mobile, it becomes crucial for him to know where his mother is at all times. Independent mobility significantly precedes the ability of a child to fend for himself, thus, the survival benefit of separation anxiety. Go out and explore the world and start learning to be an adult human, but don't stray too far from Mom until you're ready.
Separation anxiety starts around 6-8 months before real mobility begins and persists anywhere up to 4 to 6 years of age depending on the child's personality and experiences. Most children learn to tolerate people other than mother whom they've come to know and to tolerate separations from mother between 1½ to 3 years. Your son's current situation is a result of an exaggeration of his normal separation anxiety caused by his reaction to separation in his summer program.
Will this discussion help the boys father understand and accept what's going on? I hope so. But unfortunately, bonding is an emotional 2 way street, so that even if Dad understands what's going on, if he feels rejected it may be hard for him to keep their relationship going. Dad needs to understand that his son's current Mom crisis has nothing to do with him, and in fact, is not a rejection of him. However, to keep their relationship going strong, you may need to make a point of doing things with Dad and son together when you can. It's too easy for Dad to draw away when you're around, but that's exactly when he needs to work on bonding with his son since he won't be screaming for you. When you are gone, Dad should deal with meeting his son's needs which includes reassuring him about your return. As difficult as it is, rather than withdrawing from the situation, Dad should make every effort to keep his son amused and distracted during your absence, even talking to him about your return - showing him the door you will come in, telling him what Mom will say do when she returns, making a game out of it. And Dad needs to remember that sons grow up and often form the kind of strong relationship with their fathers that he would like, but the foundations have to be built early on and can never be taken for granted. Your son is having a separation problem, and even though it has an effect on Dad it has nothing to do with him, so he must not take it personally.
Sincerely,
Dr. Warren
-SB
Dear SB: Oromotor dysfunction may be seen with generalized hypotonia or certain neurological problems. Otherwise, it has no outstanding symptoms other than drooling, poor facial muscle tone which may effect sucking and feeding, and speech problems. The diagnosis is best made by a speech pathologist. A high arched palate may be seen as part of a number of syndromes but as an isolated finding may have no special significance.
Sincerely,
Dr. Warren
I hope this makes sense.
Thanks so much.
-ME
Dear ME: Your question is a bit too broad for me to answer because I have no experience with emergency medicine and so have difficulty knowing under what circumstances you would encounter a child. For example, reassuring a child and trying to get his cooperation is certainly different than dealing with an adult. While the 3 year old with Down's Syndrome may require an even more sensitive approach than the average 3 year old, dealing with the mentally challenged adult will require the same skills. On the other hand, if the child is unconscious or requires resuscitation, those skills are not as crucial as your knowledge of pediatric resuscitation. The child is unique in that one size does not fit all. Drug doses and ET tube sizes are tailored to the size of the child. The Down's child may have some specific medical issues such as cardiac defects which may add to the challenge, but so might any patient who is essentially an unknown in a crisis. The facial structure may make intubation more difficult. While atlantoaxial instability is an issue with regard to contact sports, I have no knowledge of it being an issue with regard to intubation, and since I don't deal with these matters, I challenge you to look it up and let us both know.
I think any age group has a set of most likely problems for which EMS will be called. Parents are more likely to panic about their kids' fevers and rush to a hospital while older people tend not to run high fever even with serious illness and will often use other criteria to determine if their needs are emergent. Young children may have seizures with fever. Unless a child is in status, by the time EMS arrives the child is likely to be post ictal and there really is no emergency. Dehydration can occur much more quickly in a child than an adult. Starting a line in any child, dehydrated or not, requires skill, and just like with medications, one size does not fit all when it comes to calculating fluids. The smaller the child, the more easily he can become fluid overloaded by too much IV fluids. SIDS is one of those awful problems that only occurs in infants. Of course every effort must be made to resuscitate unless it is clear that it is too late. Most medical personnel take the death of a child much harder than any other death. It is something you have to be emotionally prepared for, but it's never easy. In general, children are healthy and rarely have the multisystem disease that older adults have. Therefore, many of your calls will be about accidents, injuries, and drownings. You won't be getting emergency chest pains in kids. Actually you probably will, but you can be almost certain it's not cardiac. The most common respiratory emergency in children will be asthma; however, you may see some croup, which doesn't happen in adults. Most croup is more frightening than serious and will respond to an inhalation of vaponefrin (racemic epinephrine). Most cardiac arrests in kids are secondary to respiratory arrest and if caught early enough the rhythm will return just by oxygenating the child.
I don't know if this was the type of info you were seeking. I hope it helps. Otherwise, please ask me more specific questions and if I don't know the answer I can try to find it.
Sincerely,
Dr. Warren
His symptoms cause him alot of distress. He has severe stomach ache which will last for days at a time which make him unable to move. The stomach pain gets worse after going to the toilet. He also has nausea, his temperature goes up and he runs a fever .
At the moment he is taking movical 2 sachets twice aday, ethyromyicin3 times aday and sodium picosulphate 10 mls at night. With all this medication he still only goes to the toilet once a week. His doctor has now said he still has no idea why he is in so much pain.
I would be very grateful for any ideas you may have as it is extremely upseting seeing your child in pain knowing that nobody seems to be able to any thing to help.
Thank you for your time.
-Mrs. P
Dear Mrs. P: I have said many times that I wish I had the answers when the specialists didn't, but unfortunately, that's not what Ask Dr. Warren is about. I am a practicing pediatrician, not a professor. I am not possessed of any greater knowledge or intellect than any other pediatrician and certainly do not have greater knowledge than the specialists treating a patient who have, not only the expertise in their field, but also have evaluated the patient and have the full picture of the history, examination, and test results. When a patient has gone through an extensive evaluation and has not been helped, the next step is to ask the specialist to refer the patient to the tops in the specialty, in your case a pediatric gastroenterology professor.
The other thing you need is a better explanation from the treating physicians about what they have ruled out, and how, and what possibilities and options remain. For example, you say that Hirschsprung's disease has been ruled out, but you also say "various biopsies have proven inconclusive [they have found no nerves in samples taken but his doctor says this does not mean they're not there]." True enough, Hirschsprung's disease cannot be diagnosed by a single biopsy lacking ganglion cells unless the specimen is adequate to be sure that no nerve cells have been missed, but if they haven't found any on any biopsies, how was Hirschsprung's disease ruled out? What is your doctor's explanation for the fever and what is he treating with erythromycin? If there is a specific infection being treated, erythromycin may be appropriate; however, antibiotics should not be used for treating undiagnosed fevers. In addition, many antibiotics can upset the stomach. Erythromycin is well known to cause abdominal pain, nausea, and even vomiting.
As a general rule, I would treat a child with severe constipation with a lubricant (mineral oil), a fiber supplement (Metamucil [psyllium], Fibercon, Equalactin), and a mild laxative (Senokot [senna]). I don't know how this approach might apply to your son since I don't know what treatment he has had before, nor do I know much about your son's bowel movements other than that he has pain, trouble going, and goes infrequently. Unfortunately, the medications in the USA are different than the medications in England. The sodium picosulphate is a laxative, to the best of my knowledge. I have no idea what movical is.
Sincerely,
Dr. Warren
Note to Readers:Add Miralax® (Glycolax) to today's treatment options for constipation.
We're at wits end. Too much time is being spent talking to him about his toilet hygiene with no progress. Any suggestions would be greatly appreciated.
-DM
Dear DM: After having had encopresis, a condition in which your son had to ignore the smell and feel of stool in his pants regularly, why does it surprise you that he claims he doesn't feel it or smell it when his bottom is not adequately clean? First, you need to be sure that's what the problem is. Even if your son is having regular bowel movements on the toilet, if he was previously a stool withholder, he may still not be emptying himself completely at each sitting and may be leaking fecal material from his anus after the BM. There is only one way for you to know, and that's to inspect his bottom after he has cleaned it every single time. If it's clean and ends up dirty, then he's leaking stool. If it's not clean, then make him clean it again under your supervision. Don't do it for him, but don't let him leave the bathroom until he is clean. He's already demonstrated that he can't be depended on to be clean without supervision, so you have to take this approach until proper bathroom habits including clean up have become routine for him. If he objects, all he has to do to end the inspections and supervision is stay clean. Too much trouble for you? Can't be worse than dealing with his mess and smell. Your situation is not normal, and talking to him about it won't change it, so take charge. In addition, make sure your son is getting the proper psychological counseling. In fact, family counseling may be necessary since the problem involves all of you. Encopresis is not simply a bowel problem. There is an enormous psychological component. If none of those issues have been addressed, your son's dirty bottom may just be a substitute for the encopresis.
Sincerely,
Dr. Warren
-LW
Dear LW: I don't do wart removal in my office. I refer problem warts to a dermatologist. There are a number of techniques used for removing warts including application of liquid nitrogen, removal with an electrocautery, and application of stronger wart removal medication with paring of the warts. Some warts may be amenable to treatment with application of Aldara, an antiviral cream. I have seen oral cimetidine (Tagamet) used to treat multiple warts around the nail bed. You should consult a dermatologist to find out what the best treatment choices are for your daughter's situation. Discuss the risks (including pain) and benefits of each option before making a decision. Remember that the consultation with the dermatologist does not obligate you to any course of treatment.
Sincerely,
Dr. Warren
-Elizabeth
Dear Elizabeth: You've certainly come up with a problem which I've never confronted before and which doesn't make a great deal of sense to me. Has any family member with this complaint had any kind of medical evaluation for it? If so, what tests were run and what were the results? Pain associated with a fatty meal suggests a gallbladder problem, but I cannot think of any sensible reason why the problem would start at 10 years of age, peak in the twenties, and improve in the fifties. If your family had some rare enzyme deficiency that effected the digestion of fat, why would it get better in one's fifties?
In the article, "DIFFERENTIAL DIAGNOSIS OF ALLERGIC DISEASE: MASQUERADERS OF ALLERGY GASTROENTEROLOGIC DISORDERS PRESENTING AS FOOD INTOLERANCE" by John G. Lee MD, Kenneth Ellis MD, and Clifford Melynk MD, in Immunology and Allergy Clinics of North America Volume 16 • Number 1 • February 1996, Copyright © 1996 W. B. Saunders Company, it says, "Gastroesophageal reflux, pancreatitis, or delayed gastric emptying may be misdiagnosed as fatty food intolerance."
There was an article about recurrent pancreatitis in familial lipoprotein lipase deficiency, however, the description did not fit yours. I only mention it to suggest that some familial problem may cause fat intolerance as a result of the gastrointestinal pathology associated with the condition. One would expect that any familial problem which would cause such long-term symptoms would also cause some biochemical abnormalities which could be found in the blood. An inability to digest fat would cause the stools to be fatty and foul smelling, and the patient to be quite thin from fat malabsorption. In any event, I cannot fathom why such a condition would improve in the patient's 6th decade.
If you were to search further, I'd guess the best search phrase would be "fatty food intolerance." But perhaps the best place to start would be an examination by a physician to determine if there are any findings which would point toward a diagnosis or any medications which could relieve specific symptoms.
Sincerely,
Dr. Warren
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