23 June 2008

1. Refuses to Go Near Potty
2. Make the Diagnosis
3. How Much do Girls Masturbate?
4. 6 Months of Cough
5. Adam's Apple
6. High Fever, Tick Bite, Mononucleosis?
7. Infant Sleep Problem
8. Dealing with a Scar
9. Disclaimer

• Read Questions & Answers in Another Column

Refuses to Go Near Potty

-(unsigned)

Dear Parent: It isn't that an untrained 4 year old is becoming too old to toilet train; however, a 4 year old who is so afraid of a potty or toilet that she won't even go into the room if it's open is not likely to simply get over it. Face it. That's a pretty extreme reaction. So why is she having such an extreme reaction? If you can figure that out, it may lead you to the solution. Questions to consider:

• Is she generally a fearful child, or is the potty the only thing which provokes this extreme reaction?
• Did something happen during the early attempts at training which contributed to the problem?
• Are there other issues about control? Does she need to have everything her way?

Your first goal is to get your child into the bathroom with the potty open. Do it once a day every day at the same time. Do not battle with your child, force her to sit on it, or spend a long time there. You're not trying to make her miserable or show her you're the boss. You're trying to desensitize the situation. Each day she will scream, cry, and what ever else she does, but she will get used to it happening every day at the same time and her reaction will decrease (although it may increase at first when she realizes it's going to happen every day). When her reaction has improved somewhat, start going in every 2 hours. Just be matter of fact. You may soothe her by reassuring her it's okay, but do not threaten or bribe. This is not a matter of how she behaves. It's desensitization. When she succeeds in being near the open potty praise her for her efforts. Then it's time for the next step.

After going into the room with the open potty, close it and have her sit on it with her clothes on. If she won't stay, don't force her, but do it every day and work on getting her to stay sitting on it comfortably.. The next step will be sitting on it with the lid open. The final steps will involve pulling down the pants and progressing to sitting on it with a bare bottom. Each step should be started once daily with the aim of staying there comfortably for a minute or two. Then increase the frequency. Continue doing all previous steps regularly. When she is sitting only once a day she should still go in every 2 hours.

If you cannot make any progress, you should consult a child psychologist to help you get to the bottom of this and devise a treatment approach.

Sincerely,
Dr. Warren

27 years old male has huge abdominal swelling associated with both thigh swelling in flexor group . On clinical examination the patient congenitally blind, abdominal examination multi lipomas in anterior abdominal wall also same finding in flexor surface of thigh . CT finding intact abdominal organs & both recti are normal . All laboratory investigation within normal.

Would you please can comment me on differential diagnosis and management of such a case.

Yours sincerely.
-Dr. AE

Dear Dr. AE: Your letter provides very little information including what your major concerns are regarding this patient. Are the masses known to be lipomas, or is that just conjecture. Does the CT tell us anything about the "swelling," i.e., are there no intraabdominal masses? Is the swelling your refer to simply the bulk of the "lipomas?" What was the patient's presentation? Did he suddenly develop swelling in the abdomen and lower extremities suggesting that one of these masses is compressing the vena cava? Has he had tumors for a long time? Does he have any symptoms which caused him to seek medical attention? Other than being congenitally blind, are there any other abnormalities which might suggest a congenital syndrome?

As I've stated many times before on my web site, I am not a professor, nor am I possessed of greater knowledge than other physicians, and while I attempt to answer questions outside my specialty, my area of expertise is pediatrics. My suggestion would be to answer the questions above for yourself and then do a literature search suing what you know to see if there is a list of possible diagnoses to consider. Regarding management, you need to define what the problems are which need to be addressed. Lipomas are benign tumors. If they are not causing any functional problems for the patient, you must determine what the patient's needs are regarding any intervention. Certainly the tumors could be approached surgically, but you must decide what your treatment goal is before embarking on a course of action.

Sincerely,
Dr. Warren

out of the 10 how much of the girls finger themselves?

-Josh

Dear Josh: Would it surprise you to learn that I didn't learn statistics about masturbation in medical school and that I haven't conducted any surveys to find out the answer to your question?!? I suspect that you might find surveys like that in some teen magazines. In any event, I'm sure that girls desire sexual stimulation as much as boys, so I'd guess that at least 75% engage in some form of self stimulation.

Sincerely,
Dr. Warren

What is wrong with my child?

Thanks.

-MQP

Dear MQP: I cannot tell you what is wrong with your child since I haven't examined him. Chronic cough including nighttime cough could be a symptom of asthma. Since your son has a stuffy nose at times, his cough could be due to allergies or post nasal drip. He might even have a sinus infection. After 6 months of coughing, he should have a thorough evaluation by his pediatrician.

Sincerely,
Dr. Warren

Sincerely,
-Eric

Dear Eric: The Adam's apple is the cartilage and bony structure of the windpipe where the voice box is. Every person, male or female, adult or child, has one. The adult male Adam's apple is larger than that of women and children. The thyroid gland sits below the Adam's apple. If the area looks unusually large, you might be looking at enlargement of the thyroid gland. If so, the child should be checked by a doctor.

Sincerely,
Dr. Warren

Sincerely,
-AR

Dear AR: Virus infections can cause high fever for 3 to 5 days, rarely longer. Mononucleosis is a virus. I have seen it cause fever up to 2 weeks. Although mononucleosis is not a serious illness, it can make patients quite sick with some very worrisome symptoms including tonsillitis, high fever, swollen glands, extreme fatigue, dizziness, jaundice, and enlargement of the spleen. The diagnosis usually can't be made until at least a week of illness since many other upper respiratory viruses have similar symptoms and the blood test takes time to become positive. There is no specific treatment for mononucleosis. The main reason to make the diagnosis is to help the patient and family understand what is happening, deal with their symptoms, and rule out more serious conditions.

Since there are so many things which can cause fever which may be high and may persist at least a few days, the decision regarding when the patient needs to be reevaluated depends on how sick the patient is (gauged by other symptoms besides the height of the fever). If you are uncomfortable with your daughter's appearance, then you should bring her back to the doctor sooner. Of course, since I answer all my e-mails on Thursday, by the time you get this response, it will be time for her Friday appointment. For more information about fever you might want to check my article about fever.

Tick-borne diseases generally do not start while the tick is still attached; however, if you live in an area where there are ticks, your daughter could have had a previous, undetected tick attachment. Tonsillitis is not part of the usual tick-borne diseases, but if your doctor does not believe the fever is associated with a throat infection, he may want to test for rickettsial diseases and Lyme disease.

Sincerely,
Dr. Warren

Thank you.

-L

Dear L: Sleep problems are fairly common among infants and rarely indicate any serious problem. Since your 5½ month old previously slept through the night, you should try to determine if anything is disturbing the baby's sleep. Has there been a change in feeding, perhaps associated with a change in bowel habits? Did he learn to turn over and is unable to turn back to the position he wants to sleep in? Is he teething? Is he ill? Did he learn some poor sleep habits during an illness which may already have resolved? You may want your baby checked by the pediatrician to be sure that everything is okay.

Your infant could be developing separation anxiety. This usually starts between 6 and 8 months. It is manifest by crying in response to any separation from Mom. It may also be associated with stranger anxiety. It may affect sleep since a child who would previously fall back to sleep by himself if he woke slightly, now demands parental intervention.

Since you originally thought your baby was waking for feedings due to a growth spurt, he may have developed the habit of feeding to put himself back to sleep. This is known as trained night feeding.

For more information about sleep problems, please read my article Helping Your Child to Sleep Through the Night.

Sincerely,
Dr. Warren

Please help me.

-Agnes

Dear Agnes: It does not hurt to consult a plastic surgeon. The consultation does not obligate you to have surgery. The plastic surgeon can explain what the natural course of the scar will be, i.e., how it's appearance will change over time, and what you can expect the final appearance to be without treatment. He can tell you if there are any non-surgical treatments which might improve the appearance of the scar, and finally, he can tell you what the surgical treatment options are and what the risks associated with those treatments are. Then you can make an informed decision.

The only advice I can add, as a pediatrician, is that appearance becomes an important issue if it is hurting a child's self esteem. If other kids are not making comments about the scar and your son is doing well emotionally, you can certainly wait until he is older and can participate in the decision. If your son's self esteem is suffering because of the appearance of the scar, it becomes more urgent to seek treatment.

Finally, as a practical matter, since this was related to an auto accident, it may be necessary for treatments to occur within a certain time frame in order for them to be covered by the auto insurance. At the very least, it may be necessary to establish the need for such treatment by having a consultation with a plastic surgeon in the near future.

Sincerely,
Dr. Warren

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

ask Dr. Warren a question?!?