5 May 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
-KR
Dear KR: The answer is that you can take a 1 month old into the swimming pool for a very brief time, but I'm not sure that it's a good idea or why you would want to. Water can conduct heat away from the body and a 1 month old could become hypothermic quickly if immersed in a pool (even partially immersed) for too long. I generally advise keeping infants out of crowds, even of people you know, until at least 8 weeks of age in order to minimize exposure to infectious disease. Some diseases, including summer viruses, can spread through swimming pools. Chlorination is primarily aimed at protecting against bacterial contamination. Chlorine is a bit harsh for a young infant's skin, but I wouldn't want the baby in unchlorinated water in which others bathe.
Sincerely,
Dr. Warren
Thank you.
-V
Dear V: Yogurt is not harmful at 6 months. For babies drinking cow's milk formula, it isn't even a new protein. Most 6 month olds will want to nurse at least 3 to 4 times daily. It is almost impossible to tell how much milk a baby gets from nursing. He may be taking a lot more than your realize in those 3 feedings. I have no problem with your offering your son 3 solid meals a day; however, breast milk should be the mainstay of his nutrition. I'd be reluctant to see you cut down to 2 nursings a day. If you must eliminate something, get rid of the juice. A six month old does not need 16 ounces of water and juice a day. Give the juice in a cup as a way of introducing the cup as well as limiting the intake.
Sincerely,
Dr. Warren
-Grandma & Grandpa
Dear Grandma & Grandpa: You are wise to be aware that all medications, even the safest ones we use every day, carry some risks. For years we used baby aspirin until we learned that children who take aspirin for flu or chicken pox may develop Reye's syndrome.
Both Tylenol and Motrin are metabolized in the liver. In high doses they are liver toxic. Even in the usual dosage prolonged use may cause an elevation of the liver enzymes indicating some inflammation; however, in healthy people this is generally reversible by discontinuation of the drug. If the correct dose of either acetaminophen (Tylenol) or ibuprofen (Motrin) is taken for the frequent fevers, earaches, and teething pains that most infants have, and the medication is discontinued as soon as the symptoms are resolved, most children should do fine. No cumulative effect would be anticipated. You'll notice I didn't give a 100% guarantee. Life has none. Even one dose of a safe medicine could result in one of it's rare side effects. Allergic reactions running the range from hives to anaphylactic shock can occur with any medication. Still, these medications are generally safe and I wouldn't withhold them from a feverish child or a child screaming with pain.
How much is too much? Are you worried about the amount your grandchild needs medication or are you questioning the parents' judgment about when medication is needed? Just be aware that the question can come across either way. The best intentioned, concerned, and loving grandparent is treading on thin ice when his concerns imply a lack of trust in the grandchild's parents. Since all medications risk side effects none should be given when it's not needed, so the crucial question becomes one of who determines the need and how.
Sincerely,
Dr. Warren
-V
Dear V: Pacifiers are initially used to satisfy an infant's sucking need; however, because an infant can be comforted by sucking, many parents and infants learn to use the pacifier for calming the baby. A 6 month old who uses a pacifier to go to sleep has already learned to depend on it to soothe himself. Whether he can get it for himself or you have to go in to give it to him during the night is not the issue. The question is, "Do you want him to depend on a pacifier this way, and if not, what is the optimal time to get rid of it?"
There may certainly be some crying when you try to eliminate the pacifier. The same thing could be true if you try to do it 1 or 2 years from now. Or your son may give it up on his own. There's no way to predict. Only you can decide if it's worth trying to make a change now. Things to consider:
Sincerely,
Dr. Warren
Sincerely,Dear Readers: Since this response was written another study showed a decreased incidence of SIDS in babies who sleep with pacifieres.
Dr. Warren
-Ms. R
Dear Ms. R: First the question of whether or not there is an increased association of GERD with autism. In the article, Gastrointestinal abnormalities in children with autistic disorder by Karoly Horvath MD, PhD, John C. Papadimitriou MD, PhD, Anna Rabsztyn, Cinthia Drachenberg MD, J. Tyson Tildon PhD, published in the Journal of Pediatrics, Volume 135 • Number 5 • November 1999, Copyright © 1999 Mosby, Inc., they report the following:"
The most frequent histologic finding was the presence of reflux esophagitis in 25 of 36 children (69.4%). Twenty-two of these 25 children (88%) had symptoms such as nighttime awakening with irritability, signs of abdominal discomfort, or pushing on the abdomen, which are typically reported by non-autistic children with esophagitis. Chronic inflammation of the gastric mucosa was present in 15 children. None of the patients had H pylori infection. Chronic nonspecific duodenal inflammation was found in 24 children (66.6%).While these incidence figures sound high keep in mind that the children recruited for the study were children who appeared to have abdominal complaints. No comparison was made to the frequency of these findings in the general population. According to the authors,
Many parents report gastrointestinal symptoms in their autistic child; however, until recently, gastrointestinal symptoms of these children received little attention.The authors' interest is more directed at whether or not some autistic behaviors could be the result of these gastrointestinal symptoms.
They state,
In addition to the abnormalities in communication and language skills, these children frequently have aggressive and self-injurious behaviors. Sudden unexplained irritability or aggressive behavior, nighttime awakening, and pushing on the abdomen are usually considered part of the behavioral problems associated with autism.
This report describes several gastrointestinal abnormalities in low-functioning autistic children and underlines the importance of comprehensive gastrointestinal evaluations.The authors conclude:
Although gastrointestinal symptoms frequently accompany the manifestations of autism, little attention has been paid to this aspect of this developmental behavioral disorder, and a gastrointestinal workup has not been part of the regular medical evaluations. Sudden unexplained irritability or aggressive behavior, mood change, discomfort, and nighttime awakenings in these children were considered to be part of the brain dysfunction and not manifestations of organic problems. A significant percentage of children with autistic disorder are reported to be low functioning and have only prelinguistic communicative behavior. A plausible reason for the paucity of gastrointestinal evaluation of these children may be their inability to verbalize and describe their abdominal pain or discomfort and a lack of cooperation in non-invasive studies, such as breath tests.
The most frequently detected abnormalities in children with autistic disorder included a high prevalence of reflux esophagitis, hyperplasia of duodenal Paneth's cells, intestinal carbohydrate digestive enzyme deficiencies, and an unusual hypersecretory response to intravenous secretin administration.
A significant portion (25/36) of autistic children had gastroesophageal reflux and reflux esophagitis. There are no age-related data on the prevalence of gastroesophageal reflux disease in the 2.5- to 10-year-old group. The prevalence of reflux esophagitis is low (estimated 2%) in Western countries. It is known that both neural and humoral factors can have an effect on the lower esophageal sphincter. People under stress are more likely to have dysmotility and reflux. It is known that secretin has a suppressive effect on gastric secretion. Whether a low secretin level may contribute to the high prevalence of acidic reflux in these children warrants further investigation.Okay, I've quoted quite a bit from the article so you know what your doctors are disputing. Based on the prevalence figures for reflux in the Western countries, it would appear that the incidence of reflux in the group studied was high, but the group studied was a group of autistic kids who appeared to have abdominal complaints and thus cannot be compared to the general population. The more important issue was whether or not GI complaints were missed, inadequately evaluated and treated, and whether or not they contributed to the autistic symptoms. The fact that trials of secretin were disappointing, should not be taken as a reason to dismiss the article.
In this light, I hope you see that the question of whether or not autistic children have a higher incidence of GERD is irrelevant. If your son has GERD, and he has symptoms secondary to inadequately controlled GERD, you need to consult the gastroenterologist about further management of the GERD. Treatment of his GERD is not competing with other treatments or specialists he needs.
As far as medications doing more harm than good, since you did not provide me details of your son's medications, my advice would be to make sure you discuss side effects and drug interactions with the treating doctors.
Finally, keep in mind that the autism may complicate the GERD if your son has a tendency to swallow air, bring refluxed material forward or hold refluxed matter in his mouth, or voluntarily forces material up into his esophagus.
Sincerely,
Dr. Warren
If a pump is not advisiable then tell me what should I use?
-Josh
Dear Josh: I have no experience with techniques for enlargement of the penis, but I can tell you that there are a lot of gimmicks out there for sale. Before you do anything you should be examined by your doctor. Teenagers should have an annual exam which should include a genital exam. At 15, even though you already have advanced through some stages of puberty, your penis is still probably growing. If your penis has not grown normally, your doctor can do the appropriate evaluation or refer you to a urologist for treatment. If your development is normal, the best thing is to be patient and give nature time to do its work.
Sincerely,
Dr. Warren
Thanks,
-Worried Mom
Dear Worried Mom: As stated clearly on my web page, Dr. Warren cannot answer questions in a timely enough manner to deal with emergencies. By the time you receive this response, I hope your son's vomiting has ceased or you have brought him for medical attention.
There are medications which can sometimes help control vomiting. They require a prescription. In my opinion, any child who requires medication to stop vomiting should be evaluated by a physician before the medication is prescribed. Severe or persistent vomiting can be caused by a variety of unrelated conditions such as diabetes, appendicitis, increased intracranial pressure, and infection. The most common cause is gastroenteritis, usually caused by an intestinal virus.
When a child starts vomiting all food and fluid should be stopped until the vomiting has ceased for at least an hour. Then the child should be allowed to take an electrolyte solution like Pedialyte. This should be given in small amounts, frequently. A child who has had severe vomiting may have to start with 1 teaspoonful every 15 minutes. Soda is not a desirable clear fluid since it doesn't have the correct amount of salts to replace what has been lost with vomiting. Soda may also aggravate the vomiting because of the gas. Crackers should not be offered until much later, after the child is tolerating clear fluids. Any food sits in the stomach and can provoke vomiting in a sick child.
Sincerely,
Dr. Warren
-Ms. W
Dear Ms. W: Alimentum is a formula, not a medication. It does not have side effects. Your doctor probably started your baby on Alimentum, which is a hypoallergenic formula, because he believed your baby was having a problem with the regular formula. If your baby is still not doing well on the Alimentum after a reasonable period of time, she should be rechecked by your doctor to see if something else is wrong. It is possible that your baby does not tolerate Alimentum and needs an even more elemental formula like Elecare.
Sincerely,
Dr. Warren
If your questions haven't been answered here, perhaps you would like
to
question?!?
