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 physician who knows you and cares about you.
Dr. Warren
17 January 1997
Dear Dr. Warren: We recently noticed slight blood spotting when wiping our 4 yr old. The blood is pink not black. He has had this for about a week. There has been no change in his behavior. We took him to our family doctor, he performed a digital exam and said he felt nothing. He said he believed it was nothing, but since he is not a pediatrician he set up an appt with a pediatric gastro doctor. Is this anything to worry about, or is it most likely some type of fissure etc.?-G.W.
Dear G.W.: It is frightening for any parent to see rectal bleeding in his child, but there certainly are some non-serious causes. When the blood is only on the toilet paper and not in the toilet bowl or mixed in the stool it is almost certainly from the anus (the rectal opening). Most anal bleeding in young children comes from a fissure which is a tear in the anal skin, usually caused by a large, hard bowel movement. This is not serious and can usually be treated with stool softeners, a high fiber diet, and lubrication such as mineral oil. If the child experiences pain on having a bowel movement he may try to hold it in which will aggravate the problem. These children may need higher doses of mineral oil and a behavior modification program to encourage regular bowel movements.
An older child who has been constipated over a long period could have anal bleeding from hemorrhoids. These are not common in 4 year olds.
If a fissure or hemorrhoid bleeds a lot, it could result in red blood in the bowl. This is not serious. Most intestinal bleeding is not bright red and is mixed in with the stool (bowel movement). Intestinal bleeding is also generally associated with some abdominal discomfort, but so is constipation. Intestinal bleeding (blood mixed into the stool rather than in the bowl, on the toilet paper, or streaked on the stool) could be more serious and should be evaluated. Juvenile polyps may also cause bright red bleeding. These are not serious but require treatment. If your doctor is not sure what the cause of the bleeding is he is wise to recommend evaluation by a gastroenterologist; however, the absence of abdominal symptoms and your description of the problem suggest that it is not serious.
Sincerely,
Dr. Warren
16 January 1997
Dear Dr. Warren: My daughter is 8 1/2 months. Six days ago she was diagnosed with an ear infection in both ears. She has been taking amoxicillin 1/2 tsp 3 times a day. Yesterday she started pulling one of her ears. My better judgement tells me this is the ear healing, but I'm concerned that I am overlooking something important. I wouldn't want her have a hearing loss because of me. She isn't running a fever and she is acting fine. She goes back to the doctor in 2wks for her 9 month check up. Should I act now or wait?
-J.L.K.
Dear J.L.K.: You may relax and not worry that anything serious is happening to your daughter as long as she isn't acting sick and she doesn't have fever or drainage from her ear. You are absolutely right that pulling on the ear may sometimes occur when the ear starts to heal.Ear infections often develop as a complication of congestion, such as from a cold. Normally, the Eustachian tube (a narrow muscular tube) allows air into the middle ear to keep the pressure in the middle ear the same as the air pressure on the outside. When the Eustachian tube becomes congested or blocked air can't get into the middle ear and, since the porous bone surrounding the middle ear absorbs the air, a vacuum develops. If that vacuum persists, fluid leaks in from the surrounding blood supply. That tissue fluid provides all the nutrients bacteria need, so, if bacteria get into the fluid, an ear infection may develop.
After the ear infection is treated, if the congestion has resolved and the inflammation in the middle ear has improved, air starts to get into the middle ear intermittently. This results in popping, which may make an older child complain and a baby poke or pull his ear.
Most ear infections are not serious, although they can be extremely painful when they first start. The middle ear fluid may decrease hearing, but that effect is temporary. Hearing loss from ear infections usually occurs only in children who have chronic middle ear problems.
I usually see children for a follow up examination in 2 weeks, so your current plan is just right.
Sincerely,
Dr. Warren
16 January 1997
Dear Dr. Warren: My husband and I are debating having tubes put into our 18 mo. old's ears. He has had atleast 7 ear infections since he was 6 months, and recently he has had fluid in his ears or an ear infection since Thanksgiving ( about 6 weeks). I am up several times a night rocking him and he has been on antibiotics, both preventative and those to treat the infections themselves. It seems once the ear infection is gone, he gets another virus and the infection comes back. I want to ask you what the risks are of getting tubes put in. My husband and I are afraid that we are jumping th gun, that maybe he will soon out grow these infections. However, we are frustrated and upset that he is constantly sick (and he is not in day care.) Do you have and advice for us?
-K.D.
Dear K.D..: Ear infections often develop as a result of congestion of the middle ear. When the Eustachian tube (the narrow muscular tube that allows air into the middle ear) becomes blocked by mucus or enlarged adenoids, fluid forms in the middle ear and that can lead to infection. Most ear infections clear with one or two courses of antibiotics. Unfortunately, the ear infection causes inflammation in the middle ear which can further interfere with normal Eustachian tube function. Since it takes 6-8 weeks for the middle ear to heal and the middle ear is more prone to infection during that period, a vicious unending cycle of persistent middle ear fluid and repeated infections can develop.
One strategy that can be used to treat recurrent ear infections is to keep the children on long term low dose antibiotics. Even though prophylactic antibiotics have never been shown to be an effective treatment for middle ear fluid, if they succeed in keeping the middle ear free of infection, that allows time for the Eustachian tube to return to normal function and breaks the cycle of infection. Long term antibiotic treatment always carries the risk of side effects from the medication (mostly intestinal symptoms and yeast infections), allergic reaction, and increasing the load of resistant organisms in the environment.
The other treatment is surgical. Tubes can be placed through the ear drum to bypass the function of the Eustachian tube. This also then allows time for the middle ear to heal. The main risk to the surgery is that it has to be done under general anesthesia. While the vast majority of patients recover uneventfully from the surgery and anesthesia, there are rare, serious complications of anesthesia. And, although the tubes usually come out on their own and then the ear drum heals, the risk of anesthesia will be repeated if the tubes need to be removed or the drum needs to be repaired. Also, keep in mind that children with tubes cannot immerse their ears in water unless they wear ear plugs.
Most of my patients who have had tubes placed because of chronic ear problems were so thrilled with the results that many wished they had done it sooner. But tubes are not a panacea. A small number of my patients continued to have ear infections after the tubes were placed. And some of my patients' tubes came out after only a short time after which their ear problems returned.
If a child is constantly sick with ear infections tubes may be a blessing. Tubes should also be considered if a child's hearing is affected. Even though most children with ear infections don't suffer any permanent hearing loss, if a child's middle ear is always filled with fluid or pus, that will significantly decrease his hearing. Even though that hearing loss is temporary, if it persists a long time during the stage that the child's speech is developing, the effect on the child's language development could be profound and long lasting.
From your brief description of your child's ear infection history, it sounds like you should give serious consideration to the possibility of tubes. A final decision should be made in consultation with your pediatrician who knows your child and an ear specialist.
Sincerely,
Dr. Warren
18 January 1997
Dear Dr. Warren: Our 2.25 year old has had a fever ranging from 101-105 for a week, and our pediatrician has done blood tests for spot mono., negative. Thorough blood work was done and we are awaiting results. In addition an antibiotic was prescribed a week ago for an ear infection which is now gone. However, she has pus on her tonsils and has developed anemia(29) in just the last two days, a test was done Wed. with no signs and yesterday the test showed symptoms. Could this be the onset of Leukemia?-P.B.
Dear P.B.: Of course fever and anemia could be seen with leukemia, but let's not jump to conclusions and become prematurely alarmed. Fever is seen with a large variety of infectious illnesses. Non-infectious causes should only be considered if the fever is prolonged beyond one week or there are other symptoms to suggest a non-infectious illness. The list of causes for prolonged fever is long and most of the causes are rare. If your pediatrician is considering an evaluation for prolonged fever he will proceed through a series of tests in an organized manner since he cannot possibly test for everything at once and you wouldn't want to put your baby through any more procedures than necessary. As for the anemia, any prolonged illness could result in anemia because the body slows down the production of new red blood cells during major illnesses.You say your baby has pus on the tonsils. This is not a symptom of leukemia. It is most likely a symptom of a virus. It is very often seen with Mononucleosis. The test for Mononucleosis may not be positive until more than a week of illness, so the test may need to be repeated. Sometimes young children with Mononucleosis have a negative monospot test but the diagnosis can be made by checking Epstein-Barr Virus titres. Your pediatrician might also want to check for Toxoplasmosis and Cytomegalovirus which can sometimes cause a Mononucleosis like picture. A look at your child's complete blood count and the progression of your child's symptoms will help your pediatrician decide if additional tests should be done.
Sincerely,
Dr. Warren
17 January 1997
Dear Dr. Warren: Is there anything that is safe and effective to give a 7 week old infant that has alot of gas? I have tried Oval and Gripe Water, but neither seems to make much difference. It has to be something available in Ontario.Thanks
-C.D.
Dear C.D.: I don't know what is available in Ontario. In the USA one of the most popular treatments for infant gas is Mylicon (simethicone) drops. It is certainly safe. The question is, "is it effective?" Simethicone is a surface active ingredient which helps to bring small gas bubbles together to make it easier for the infant to burp them up. And so for some infants, it is helpful. Even though most people feel that gas pains contribute to colic, a recent study found that simethicone was not an effective treatment for colic.Often, we ascribe a baby's crying to gas pains when we don't know why a baby is crying. When babies cry, they may swallow air which adds to their gas. Babies frequently stiffen when they cry. They may also pass wind and their bellies will feel firm when they cry. These findings do not tell us that the baby has gas.
All babies have gas sometimes. And all babies cry sometimes. Most newborns have a fussy period, usually between 6 and 10 PM. If a baby spends most of his day crying, then we have to look for a cause. If it is indeed gas, the formula fed baby may benefit from being on a hypoallergenic formula. If a nursing mother's baby is gassy, the first place to look for a cause is the mother's diet. Nursing babies may have gas if their mothers eat spicy foods or drink too much cow's milk.
Sincerely,
Dr. Warren
18 January 1997
Dear Dr. Warren: My six month old grandson had a disturbing incident this past week. While playing on the floor, he suddenly turned bright red, his arms became rigid, and he began to make a moaning sound while appearing to be gasping for air. Within several minutes of being held, he turned white and went limp. His breathing remained shallow for several more minutes. The entire incident lasted for approximately 10-15 minutes. He had a chest x-ray, blood tests, and a urinalysis which turned up nothing. He was seen by three doctors that day. His primary care physicain, although not a pediatrician, was concerned that he had a seizure and sent him to be admitted to the hospital for observation for 24 hours. The pediatrician on call at the hospital did not feel that there was any reason for admission, but suggested an EEG if my daughter did not feel comfortable. He then sent the child home. We are still concerned about this incident and feel that we should pursue it as the baby has had no illnesses and is in excellent health. He did, however, have the typical 6mos. vaccinations on Tuesday of the same week- this incident occurred on Friday. Could there be a connection, and/or should we insist upon seeing a pediatric neurologist just to be safe?-J.N.H.
Dear J.N.H.: Several features of what you described sound very much like a seizure. Specifically, the stiffening of his arms, and his limpness afterwards which lasted for several minutes are features of a seizure. Had you described him as turning blue rather than red, and if it had been provoked by crying you could be describing a breath holding spell.If he had fever at the time then this could have been a seizure provoked by fever, and as long as the physician who evaluated him had ruled out any serious cause of the fever, especially meningitis, seizures with fever are not serious. Most children who have a seizure with fever will never have another, and there are no long term neurological or developmental consequences to a simple seizure caused by fever.
A six month old who has a seizure unassociated with fever deserves a more thorough investigation. I hope the blood work done at the time of the event included a blood glucose, sodium, calcium, and magnesium, so that the more common metabolic causes of seizures can be excluded. If the immunization that your grandson received a few days prior to the possible seizure was a DPT, it is possible that this was one of the rare neurological consequences of the DPT. If the EEG was not done, it certainly should be done. And finally, while I don't wish to sound like I am questioning the judgment of the physicians who treated him since they saw him and I didn't, your brief description of the incident sounds enough like a seizure to me that I think your grandson should definitely see a pediatric neurologist.
Sincerely,
Dr. Warren
16 January 1997
Dear Dr. Warren: My 9 month son has recently been diagnosed with neutropenia. On 1/13/97 he came down with a fever and our doctor ordered a CBC. The CBC showed his neutrophil to be at 730. On 1/15/97 my sons fever broke. 1/16/97 we repeated the blood work, the result came back with a decrease in neutrophil (300). My son looks, feels and acts better so our doctor recommended that we sit tight and protect him from any secondary illness (our doctor proscribed antibiotic just in case) and come Monday we will repeat the CBC. My question is - is there anything we can do beside wait and why should I wait? Is not a 300 neutrophil count low enough to act on? Where can this go? Is waiting until Monday 1/20/97 too long? Please help us see some light.-A & R
Dear A & R: Neutropenia means a low neutrophil count. Neutrophils are the type of white blood cell which is most important in helping the body to fight infections caused by bacteria. So people who are neutropenic (have neutropenia), have more risk of developing bacterial infections, more risk of complications of bacterial infections, and more difficulty getting rid of bacterial infections than people with normal blood counts. Bacteria are the type of one celled organisms that cause strep throat, ear infections, pneumonia, skin infections like abscesses, etc. Bacterial infections can be treated with antibiotics. Many of the common childhood illnesses such as colds, chickenpox, and flu are caused by viruses. Virus infections do not respond to treatment with antibiotics. People with neutropenia do not have difficulty with virus infections; however, they may develop secondary bacterial complications more easily.As long as your child is not acutely ill, your doctor can prevent any serious problems resulting from the neutropenia by treating him with antibiotics, which is just what your doctor has done. If your child become acutely ill with high fever in spite of the antibiotics then he will need immediate evaluation and perhaps hospitalization for intravenous antibiotics.
Your doctor has recommended that you wait and repeat the blood test Monday because he knows that he can't offer you a simple treatment to just make the problem go away and there is little risk in waiting a few days for further evaluation. Your son may have neutropenia as a result of his recent illness, in which case it will improve on its own. He may have cyclic neutropenia in which his neutrophil count will drop periodically. He may be like a patient of mine who will always be neutropenic. My patient has to be very careful about cleaning wounds because he gets skin infections. My patient always has a prescription for antibiotics to take if necessary; however, if he is sick, he knows I must see him right away. My patient is now an adult and has become a police officer. Unfortunately, neutropenia may sometimes be a sign of something more serious like leukemia.
If your doctor repeats the blood test Monday and finds that your son still has neutropenia, he will refer you to a Pediatric Hematologist for complete evaluation. While it's important to know that neutropenia could be serious and requires thorough evaluation, it doesn't have to be serious. My patient is doing quite well.
Good Luck with your son. Please let me know what happens.
Sincerely,
Dr. Warren
16 January 1997
Dear Dr. Warren: Perhaps you can shed some light on what I think is an interesting problem. The question concerns the son of my boyfriend (I have no children so I have no clue about raising them).The boy turned 13 in August of last year, and both his father and I are concerned about his physical growth (or lack of it), and his emotional growth as well. He is about 4 foot 9, very slim ( approx. 80 pounds??) and seems unusually small for his age. He is showing no signs of growth whatsoever. Most, if not all, of his friends have entered puberty, (growth spurts, emergence of facial and body hair, deepening voice). One of his friends, the exact same age, is already 6 feet tall, shaving, with a size 13 foot!
Even more disturbing is that along with his small size, the boy's attitude and demeanor are those of a VERY young child. He still clings desperately to his father (his parents are divorced and the father raised him with help from his grandmother), is very jealous of his father's and my relationship (I am very nice to the boy, get along well with him, and do a lot for him). This boy will say things as "why do you kiss her and not me (he gets PLENTY of hugs and kisses) why do you want to sit with her and not me, will you PLEASE sit and watch tv with me daddy, you don't love me you love her...etc. etc.. I won't get too far into this aspect of the boy's behavior except to say that his grandmother is also a heavy influence in the boy's life, she waits on him hand and foot (she basically raised him). The boy will not even get up to make his own tea or toast, he'll call up his grandmother who lives up the street to come over and do it for him. Shouldn't kids this age be able to do certain simple thing for themselves,. and be more concerned with members of the opposite sex than with spending every waking minute with daddy? He seems to have lost a great deal of friends in the past year because his friends are now interested in things that he is not. (for a number of reasons I also think there is a possibility that this child may have homosexual tendencies, but that is a discussion for another day)
Obviously I can go on, but I think you get the picture. I'm sure you can glean from the above that I have problems with the way they handle this kid, but I assure you that I stay out of it, he's not mine so I don't want to get involved . So, my question is, are the enabling actions of the boy's grandmother and father somehow keeping him in a perpetual "baby" stage, so much so that his physical stature is being adversely affected in that he has not even begun to enter puberty? I am a scientist by training, so I always try to look for solid answers, but I realize in this case that there are many contributing factors, including an unstable emotional environment at home. Can you offer any tangible insight to this interesting problem? Thank you,
-D
Dear D.: The normal range of pubertal development in boys is extremely variable. I have had patients (boys) who showed the first signs of puberty at 10 and by 11 looked like mature older teens. I have also seen boys who didn't show the first sign of puberty until 16 years of age. I've seen boys go from looking like little boys to men in a year, and I've seen boys whose pubertal changes progressed over a 3 to 5 year period. All of these boys experienced normal pubertal development. The growth spurt you refer to occurs around mid puberty. Facial and body hair occur even later. The earliest signs of puberty involve genital changes: first enlargement of the testicles, then enlargement of the penis along with development of pubic hair. You would only know about these changes if your boy speaks about them or is undressed in your presence. It is possible then, that your 13 year old has already started puberty without your knowing it. But even if he hasn't, his body development is still within the range of normal for a 13 year old. The figures you quote for his height and weight are in the 10th percentile for both height and weight which is at the lower end of the normal range.The interactions of physiology and psychology are complex and there is much we don't know about them, but it is highly unlikely that this boy's pubertal development has been significantly effected by his state of mind. Body maturation and hormones certainly have a profound effect on the brain, the maturation of thinking processes, and psychosexual development, but human socialization is far too complex for primal instincts to be the only driving force. Children must be ready to take each step in psychosocial development and each child does that at his own pace. As a result, some children are deeply involved in boy/girl social interaction and dating, even before they show signs of pubertal development while other children with mature bodies are simply not ready.
One of the main tasks of adolescence is to move away from the family and establish oneself as an independent human being with his own ideas and values. In essence, it is a time to find oneself. This process is often accomplished by rejecting or appearing to reject, in whole or in part, many of the family values. This may result in some considerable parent/child conflict. At this time friends of the same sex as well as the opposite sex become more important than family. Adolescents often look to their friends for approval while they experiment with life and values that differ from their family's. While they look to become unique individuals they find a safe haven in conformity with their friends. Often, by the end of adolescence they have found much that they like in the values they grew up with. When the job is accomplished successfully, it is possible to return to the family with shared values and goals and still be an independent thinker with one's own unique ideas and values.
Your young man may simply not yet be mature enough to take the next step into adolescent psychological development. By your description of the situation, however, it is possible that psychological conflicts prevent him from separating from his father at this time. Because of the divorce he has lost his nuclear family. And since he was raised by his father and grandmother, he apparently lost his mother to some extent. Therefore he may subconsciously find any separation from his father too risky since he fears losing him as well. The psychological drama being played here is a two way street. His father and his grandmother may have been overindulgent to this young man in order to make up for the divorce. But their need to salve their consciences may also play a role. While the child should certainly be able to take care of some of his own needs, he sees their ministering to him as an expression of their love. No matter how much they do for him his need to feel loved and secure is so great that he will always need more. In essence, his need to feel loved and secure, and perhaps even to some extent in control of his family, is greater, right now, than his need to grow up.
You did not ask for any advice, but rather asked me to shed some light on the subject. But I sense that your interest in this matter is more than scientific curiosity. You don't say how long you and the boy's father have been dating or how serious your relationship is. And you say that since the boy is not your child you stay out of it and don't want to get involved. But if you have a serious relationship with the boy's father, you are already quite deeply involved. Any unresolved conflict between you and the boy or you and the father regarding the boy could seriously impact on the relationship between you and the father. It is clear from what you say that this boy sees your relationship with his father as a threat to his relationship with his father, and as we've already discussed, this boy still has an overwhelming need to secure his relationship with his father. Your forming a loving relationship with the child can help, but as long as he continues to see you as a competitor and as long as you feel you must approach it as an outsider I see the potential for serious problems in your relationship with the boy and his father. If the problem is as severe as you describe it, not only might the boy benefit from some counseling, but it may be wise for all three of you to go for some group or family counseling.
Sincerely,
Dr. Warren
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