19 May 2008

1. Prevention of Neonatal Group B Beta Strep Disease
2. Treatment for Gynecomastia
3. Mixed Dominance
4. Childhood Obesity
5. How to Lose Weight
6. Gastroenteritis
7. Won't Chew
8. Bleeding Ear
9. Disclaimer

• Read Questions & Answers in Another Column

Prevention of Neonatal Group B Beta Strep Disease

• My first question has to do with the risk factors doctors ahould look for to determine whether the mother is at risk for the Group Beta Strep disease. In doing research on this disease I have found 8 factors doctors should look for to determine whether the mother is at risk. The 8 factors I found include:

  1. Positive culture for GBS colonization at 35-37 weeks.
  2. Having already had a baby who had a GBS infection.
  3. GBS bacteria in urine.
  4. Membrane rupture more than 18 hours before delivery.
  5. Labor or membrane rupture before 37 weeks.
  6. Developing a fever of 100.4 or higher during labor.
  7. Black race.
  8. Age less than 20.

  • 1st: Are there any factors that I am missing?
  • 2nd: How many of these factors must (or should) exist before a doctor should test a mother for Beta Strep?
• My second question involves the factors a doctor should look for when determining whether a child should be tested for Beta Strep as well.
  • 1st: What are the factors a doctor should look for in determining whether a child is at risk for early on-set Beta Strep?
  • 2nd: What are the factors a doctor should look for in determining whether a child is at risk for late on-set Beta Strep?
  • 3rd: How many of these factors must (or should) exist before a doctor should test a child for early or late on-set Beta Strep?
• My third question has to do with the chances of prevent late on-set Beta Strep by detecting GBS in the mother during the delivery.
  • 1st: What are the chances of preventing late on-set Beta Strep if GBS is detected in the mother during the delivery?
  • 2nd: What percent of children who test negative for early on-set Beta Strep still become infected with late on-set Beta Strep?
  • 3rd: Are there any follow up procedures for children who tested negative for early on-set Beta Strep to make sure they do not eventually become ill with lte on-set Beta Strep?

Again, I greatly appreciate any help you can give us with these questions.

Sincerely,
-CD

Dear CD: The prevention of neonatal Group B Strep disease is a high priority for both pediatricians and obstetricians. In spite of that, there has been no universal agreement on what constitutes the best approach. There are advantages and disadvantages to several of the protocols currently in use. In addition, as stated in Gabbe: Obstetrics - Normal and Problem Pregnancies, 3rd ed., Copyright ©, 1996 Churchill Livingstone, Inc., "Unfortunately, obstetric interventions have proven ineffective in preventing late onset neonatal infection." This is so because most newborns who become ill as a result of maternal colonization will develop, early onset disease. Late onset disease may be a result of colonization with Group B Strep acquired after delivery therefore, interventions before and during delivery have little impact since they can only prevent Group B Strep acquisition from the mother's genital tract or infected amniotic fluid. To the best of my knowledge, you are not missing any risk factors, although the articles I read did not have a list of factors which I could cross reference to your list. You will note that one of the risk factors you listed was colonization with Group B Strep. When you ask, "How many of these factors must (or should) exist before a doctor should test a mother for Beta Strep?" you cannot include colonization as a risk factor since that is the test you are asking about. The question is whether or not universal screening of all mothers should be instituted or whether or not risk criteria should be used to determine who should be cultured. In the area where I practice, universal screening has been adopted. In situations where culture results are positive or unknown, most of the women receive intrapartum antibiotics. If we were assessing risk factors to decide who should be treated, obviously the larger the number of risk factors the higher the risk to the infant; however, I don't know of any algorithm which counts risk factors to decide who should be cultured or treated intrapartum. Risk factors also play a role in deciding afterward how to manage the infant. To give you an idea how complex the matter is the following text is a quote of the complete discussion of prevention from Gabbe: Obstetrics - Normal and Problem Pregnancies, 3rd ed., Copyright ©, 1996 Churchill Livingstone, Inc.

Several different strategies have been proposed for the prevention of neonatal group B streptococcal infection. One of the first interventions provided for antepartum screening early in pregnancy and treatment of colonized patients at the time of identification of a positive culture. Abundant evidence now indicates that this strategy is clearly ineffective. Screening remote from term is not predictive of colonization status at the time of delivery. Women treated early in gestation frequently recolonize. Early treatment exposes up to 40 percent of pregnant women to antibiotics and yet has no significant impact on the frequency of neonatal infection.

Another early approach to the problem of neonatal streptococcal infection was described by Siegel and associates. These investigators conducted a prospective study of 18,738 neonates delivered during a 25-month period at Parkland Hospital in Dallas, Texas. One group of infants received a single intramuscular dose of aqueous penicillin G after delivery, and the second group received only tetracycline ophthalmic ointment. The overall prevalence of maternal streptococcal colonization was 27 percent. The incidence of disease caused by all penicillin-susceptible organisms was decreased in the infants treated with penicillin. However, the incidence of disease caused by resistant organisms was increased in the infants treated with penicillin. This latter effect is a sufficiently serious problem to make universal penicillin prophylaxis a risky preventive strategy.

A third preventive approach is the strategy recently proposed by the American Academy of Pediatrics. This organization recommended universal screening of all pregnant women at 26 to 28 weeks' gestation and selective intrapartum treatment of colonized women who have risk factors for group B streptococcal infection. This approach is based on a series of investigations that have been published during the last 15 years. One of the first of these was the report by Yow and coworkers in 1979. These authors treated 34 colonized women with ampicillin during labor; 24 colonized women received no treatment. None of the infants delivered to treated mothers were colonized compared with 58 percent of infants delivered to untreated women ( p < 0.001). In a subsequent investigation, Boyer and associates studied the effect of intrapartum treatment with ampicillin in a much larger series of 575 colonized women. This study included several subsets of women, and treatment was not randomized in all subsets. However, treatment with ampicillin significantly reduced the frequency of vertical transmission in patients with, and without, risk factors.

The most highly publicized investigation was reported by Boyer and Gotoff in 1986. These investigators screened a population of over 13,000 women. Twenty-three percent of women had positive cultures for group B streptococci. At the time of presentation in labor, colonized patients were enrolled in the study if they had preterm labor or ruptured membranes for more than 12 hours. Patients were randomly assigned to no treatment or to ampicillin, 2 g IV every 4 hours, until delivery. Normal infants delivered to treated mothers received four doses of intramuscular ampicillin until surveillance cultures were available. Healthy infants delivered to untreated mothers received no antibiotics. Infants with clinical evidence of respiratory distress syndrome, sepsis, or asphyxia were treated with ampicillin plus gentamicin. ... , intrapartum prophylaxis with ampicillin was effective in decreasing the overall prevalence of neonatal colonization, colonization at multiple sites, and bacteremia.

Several problems may occur during an effort to implement universal screening. First, this approach requires a major commitment of both financial and logistic resources. Second, universal screening at 26 to 28 weeks' gestation may not reliably identify all patients who will actually be colonized at term. Third, depending on the organization of the laboratory, results of antenatal cultures may not be readily available to physicians at all hours of the day and night. Despite these caveats, universal screening clearly will be cost effective in most populations. The Centers for Disease Control and Prevention estimate that universal screening and selective treatment will prevent approximately 3,300 cases of neonatal infection each year and save approximately $16 million. Approximately 4 to 5 percent of all pregnant women will be treated with antibiotics under this protocol. This estimate is based on the assumptions that approximately 20 percent of pregnant women are colonized and that approximately 25 percent of colonized patients have at least one risk factor for infection.

An alternative to universal screening is the intervention strategy suggested by Tuppurainen and Hallman. These investigators recently screened approximately 9,000 Finnish patients with a latex agglutination test at the time of admission for delivery. One hundred ninety-nine women who were heavily colonized were accurately identified by the latex agglutination test. These women were randomly assigned to receive 5,000,000 units of penicillin during labor or no treatment. Of the 88 colonized women who received intrapartum penicillin, only 1.1 percent of the neonates developed early onset infection compared with 9 percent of neonates in the no treatment group (p < 0.01).

Certain pitfalls also exist with this approach. As noted previously, rapid slide tests have poor sensitivity in identifying lightly colonized women, and yet some cases of neonatal sepsis still occur in infants delivered to these women. Not all rapid tests are easy to perform; some are not well adapted for use in a labor and delivery suite. Moreover, rapid tests may not be readily available in all hospitals on a 24-hour a day basis.

Another theoretical solution to the problem of neonatal group B streptococcal infection is universal antibiotic prophylaxis for all women in labor. In an elaborate decision analysis, Rouse et al. recently demonstrated that this strategy was, in fact, the most cost effective of all interventions considered. However, extensive administration of broad spectrum antibiotics clearly has the potential to exert selective pressure for emergence of drug-resistant strains of bacteria. Therefore, this strategy should not be widely adopted until the risk of superinfection in mother and infant resulting from universal prophylaxis has been precisely delineated.

Yet another strategy for prevention of neonatal group B streptococcal infection is that proposed by the American College of Obstetricians and Gynecologists (ACOG). ACOG does not endorse universal screening; rather, it recommends selective screening of patients who have specific risk factors such as preterm labor and preterm PROM. Colonized patients with risk factors are then targeted for intrapartum antibiotic prophylaxis. Intrapartum treatment is also recommended for women whose colonization status is unknown but who develop a risk factor, such as extended duration of rupture of membranes, during labor. The approach suggested by ACOG avoids some of the problems associated with universal screening. Approximately 10 to 20 percent of women will be candidates for treatment under this protocol, which is a figure greater than that cited for the American Academy of Pediatrics' protocol. However, in two recent decision analyses, this approach compared favorably with that of universal screening.

Antibiotics with specific activity against group B streptococci are listed in Table 38-11 . Ampicillin and penicillin are the antibiotics that have been tested most extensively. The other antibiotics noted in Table 38-11 should be reserved for patients who have immediate hypersensitivity reactions to beta-lactam antibiotics. Prophylactic antibiotics should be administered intravenously as soon as a risk factor is identified. They should be continued until delivery is completed but do not need to be administered in the postpartum period. Only patients who have overt chorioamnionitis require antibiotic treatment beyond delivery.

TABLE 38-11 -- Antibiotics with Activity Against Group B Streptococci

Drug		Dose for Intrapartum Prophylaxis
Ampicillin		2 g q4-6h
Pencillin		2-5 million units q6h
Erythromycin		1-2 g q6h
Clindamycin		600 mg q6h or 900 mg q8h
Vancomycin		500 mg q6h or 1,000 mg q12h

[t]he rate of early-onset GBS disease is also related to the degree of colonization at birth,

Late-onset GBS disease is due to acquisition from maternal and nonmaternal sites (nursery personnel, community) and is not associated with obstetric risk factors.

Selective intrapartum chemoprophylaxis (SIC) has been repeatedly demonstrated to decrease the incidence of GBS early-onset disease but not late-onset disease.

Unfortunately, there is no intervention which can predict or prevent late onset disease. While maternal risk factors or a positive culture for Group B Strep might serve as a warning, the early diagnosis and treatment of late disease is much the same as any other infection in the neonatal period in that it requires careful evaluation of any fever, poor feeding, cyanosis or apnea spells, or irritability. There are no standard follow up procedures that I know of for exposed infants who test negative for Group B Strep and do not develop early onset disease. While late disease is a serious problem, it's dangers and symptoms are similar to most other bacterial infections in early life, therefore, the most useful prevention would be for parents to know what early signs could indicate serious illness in a newborn. Unfortunately, some of these are so vague that excess attention to these could cause unnecessary anxiety in the parents. Under the best of circumstances with the best of care we cannot yet anticipate a procedure or algorithm guaranteed to eliminate late disease or its sequelae.

Sincerely,
Dr. Warren

What I wanted to ask is - is there any other way to solve it -besides- a plastic surgery?! I mean, a plastic surgery like that costs around 2000-4000 dollars and my parents doesn't have so much money, if there's anything that can be possible, please, tell me!

I once read in an article that if you stop masturbating, the swollen nipples goes away. Is that true?

I really hope there's a different solution to this problem except a surgery.. I mean, I have this thing for 3 years now and I don't think it'll go away cuz it usually supposed to go away after 2-3 months.

Please tell me everything you know about this thing and if there are other ways to make it go away. Please tell me, you're the last hope I got before I turn to the hospital and ask them for this.

-S

Dear S: Adolescent gynecomastia can persist from early to mid puberty until late puberty, a process which could take a few years. A lot depends on where you're at in pubertal development. Before considering surgery, it would be reasonable to see an endocrinologist to be sure there are no hormonal imbalances contributing to the persistence of the breast tissue. It is also important to control your weight. Obesity can contribute significantly to the appearance of large breasts and can be treated with diet and exercise.

Surgery is an appropriate treatment for persistent gynecomastia in a healthy young man who has no medically treatable cause of breast enlargement. While plastic surgery is often considered cosmetic, the surgeon may be able to write a letter explaining the medical necessity of the surgery so that it will be covered by insurance. Talk to your parents about it before you decide that it can't be done. And if it's important to you, consider getting a part time job and saving up to contribute to the expense. That could go a long way toward showing your parents how serious this matter is to you.

Sincerely,
Dr. Warren

-Alex

Dear Alex: It is easy to see how a left handed person who is forced to write with his right hand would develop a mixed dominance; however, mixed dominance can develop naturally. Mixed dominance is certainly seen in learning disabilities and other neurological problems, but this does not imply that mixed dominance causes these problems. A person who is right handed who has subtle neurological problems interfering with function of a right leg or eye will develop a mixed dominance. Since I am not athletic, I couldn't tell you which of my legs is dominant. I am right handed, but have a dominant left eye. My left arm is stronger, but it doesn't strike me as strange that my left arm would develop strength from carrying leaving my right hand free for fine motor functions.

Sincerely,
Dr. Warren

-Kate

Dear Kate: Over the long haul, the increased obesity in childhood will translate into an increased incidence of severe obesity in adulthood with it's associated increase in diabetes, cardiovascular disease, and all their complications.

Childhood and adolescent obesity is a serious problem. Kids don't have to wait until adulthood to pay a price for it. While it creates medical problems and is a medical problem in it's own right, society tends to blame the obese person for his condition. To be sure, the parent of the obese child, and the overweight adolescent does contribute to his own problem, but society's attitude toward obesity contributes to a significant loss of social status and self esteem for the afflicted individual.

What are the causes of this current epidemic of obesity. Television is number 1 on my list. Hours which used to be used for outdoor play and other more physical activity which burned calories have been replaced by TV. If that wasn't enough to increase the weight problem in the US, there are countless advertisements for snacks. You couldn't possibly munch a bag of chips mindlessly during a game of tennis or while cycling, running, swimming, etc., but you can pack away lots of calories while watching TV. Unfortunately the role of TV is complex in today's world. Many children are home alone after school and their parents prefer to have a TV for a baby sitter so they know where their children are rather than have them playing outside. TV has also become a comfortable source of entertainment for families at the end of a stressful day of work. Few families think about playing board games, imaginative games, musical instruments, etc., as a form of family entertainment. If you're not brought up with it, it doesn't even occur to you. The last generation to have even a few years without TV are now senior citizens. The answer is, of course, to limit TV. More public funding for after school activities for families where both parents have to work might help.

Next on my list is video games. While the greater degree of involvement in the activity than TV and the absence of snack advertisements decreases the likelihood of excessive snacking associated with TV, video games also consume time in a way that burns very few calories. The answer, once again, is to limit children's time with video games and encourage more physical activity in its place.

Diet, which is third on my list, is an obvious cause of obesity. Diet habits develop early in life and the factors which have contributed to the current diet trends in the US are complex. Even though women's work has always been endless, the current need for many mothers to work out of the house along with the ready availability of pre-prepared meals has significantly decreased preparation of meals from scratch. Many of the pre-prepared meals are high in fats and hidden calories. In addition, fresh vegetables and fruits are significantly more expensive than the alternatives. Children learn meal preparation based on the way it is in their own houses so as the trends in meal preparation change, a new generation is formed whose expectations for meals and their preparation moves away from basic healthy ingredients. Fast food is a fact of life. The price of a Happy Meal and the ease of satisfying a child's taste for higher salt and fat content (which, many children love) provides little motivation to prepare fresh, healthy, lower calorie meals which many children will refuse, demanding the readily available junk food instead. Few parents have the conviction and self assurance that their children will be okay if they miss a meal, so they give in. The question is, 'Who will provide the current generation the necessary information about preparing healthy low calorie meals for the entire family starting early in childhood and how can we combat the temptation of advertised fast foods when it is quick, easy, relatively inexpensive, and, without question, enjoyable?" TV would be a great place for that, but TV is run by advertising dollars, and the purpose of advertisements is to sell, not to educate or provide the best alternatives. I think it falls to the current generation of pediatricians to educate parents about nutrition, but unfortunately the regular visit does not afford the amount of time necessary to truly review and evaluate the family's eating habits. As a result, most discussions of nutrition with regard to obesity take place after an excess weight gain problem has been identified.

Sincerely,
Dr. Warren

Oh and I'm 15

-Josh

Dear Josh: Whether or not you need to lose weight at 160 pounds depends on your height more than your age. Unfortunately, there is no safe or reasonable way to lose weight quickly. Whether or not you can achieve your goal in 1 month depends on how much you want to lose. There are several things you can do which should make a difference.

• Exercise. Do aerobic exercise like running, bicycling, swimming 3 times each week. On the alternate days, workout with weights or machines to build muscle.
• Eat only at meals. If you must have snacks, plan no more than 1 or 2 a day. Avoid eating just because you are bored, watching TV, food is available, someone else is eating, etc. You'd be amazed how many calories you can consume by having small snacks if you snack frequently.
• Only drink non-caloric beverages like water or diet soda. Milk, juice, and sweetened drinks have lots of calories. One or two glasses of skim milk or juice a day is fine, but drinking those when you're thirsty can pack away lots of calories.
• Eat slowly and limit portion sizes.
• Eat lots of fresh vegetables, salads with low fat or no dressing, and clear soups with your meals to help fill up without eating excess calories.

Sincerely,
Dr. Warren

My baby age about 2 month, Wt - 4.5 Kg , Normally active and healthy and takes only breast milk.

He had problem of passing motion 10 days back. Afterwards enema was applied as per doctor's advice and motion was clear. Three days back he had watery motion with yellow + green color with lots of mucus 7 / 10 times a day. Doctor had advised 25 mg Norfloxacin 3 times a day for four days. 25 mg Norfloxacin was given then stopped on advice of another doctor. We had done a stool examination yesterday and it is showing Color as Brownish Yellow , Semisolid , Mucus ++ , Occult Blood Negative , Reducing Substance + , Pus Cell 1 -2 HPF , Fat Droplet - Few , Ph is acidic. Yesterday He had passed motion four times with almost normal water content and tint of Green color, today the situation is much better.No abnormality detected in his behaviour , he is playing as usual and stool color is almost yellow ( with a tint of green ) with almost normal water content and passed 3 times today.

Local doctor adviced to Stop Breast Feeding and convert to a special infant feed ( with No Lactose / Sucrose ).

Other Symtomes : Baby is also not much interested to take milk ( although taking ). He also have White coating on tonge, some red spots on his back( as if he has itched his body but no ), slight increase of temperature ( Not detected by Thermometer )- Local doctor ignored all such symtoms.

Question :

1. Should we change Breast Feed to Formula feed ?
2. Is there any cause to worry ? How to detect early signs of problems ? No good doctors available nearby

With Regards,
-MC

Dear MC: There is rarely any good reason to stop nursing and switch to formula. If an infant is vomiting, nursing must be interrupted and replaced with an electrolyte solution until the vomiting has fully resolved. It is true that human milk has lactose in it; however, even though most babies develop a relative lactose intolerance after a bout of diarrhea, as long as the diarrhea is not severe, the benefits of human milk outweigh any potential benefit of eliminating lactose. From your description, it sounds like your baby is getting better. Even if it takes a long time for the stool to return completely to normal, there is no risk of dehydration if the stool is not watery and if the baby's intake is sufficient.

As to the other symptoms, I cannot comment without seeing the baby. The rash could be viral or non-specific. The white coating on the tongue could be thrush, a yeast infection, but it may not be. If the thermometer does not detect an increase in temperature, then the baby does not have a fever. Any temperature under 100ºF (38ºC) is within the normal range. A decrease in appetite while recovering from an intestinal illness is not unusual.

If the baby starts to run high fever, becomes lethargic or extremely irritable, decreases urine output, is vomiting and unable to retain fluids, or has a significant increase in diarrhea, then you should be concerned.

Sincerely,
Dr. Warren

-SR

Dear SR: While most children are willing to chew food by 2½ years of age, some children do not. Most will develop enough of an interest in other foods to eventually start chewing. You should have your daughter evaluated by a speech pathologist who has experience dealing with feeding problems. The speech pathologist can evaluate the mouth, tongue, and jaw to determine if there is any problem which would interfere with normal chewing. She can then recommend a therapy program to help your daughter get used to solid food.

Sincerely,
Dr. Warren

I would really appreciate a response as I live in a small town without access to a larger hospital or any specialists. Thank you for your time.

-TB

Dear TB: A fracture of the base of the skull can result in bleeding behind the ear drum or drainage of blood from the ear. Given that your daughter has tubes in her ears and complained of her ear being plugged, and additionally had no history of head injury, a local process in the ear is a much more likely explanation of the bleeding. I cannot imagine a scenario in which a person suffers a basilar skull fracture and only becomes aware that there is a problem when he has blood draining from his ear. Since your doctor has taken the added precaution of doing a head CT and no signs of injury were found, I see no reason to pursue the unlikely possibility that your daughter suffered a significant head injury without anybody having the slightest clue that it happened.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

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