25 January 1997
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
Do you think this is diet related? She hasn't decreased her bm frequency so I don't think it is constipation.
Please let me know you thoughts on this.
Best Regards,
-G.C.
Dear G.C.: Milk sensitivity or allergy is known to sometimes cause bleeding in the stool in young infants. In an otherwise healthy infant who does not appear ill, certainly the first thing to try with an infant who has blood in the stool is a diet change. Even though the cow's milk protein is digested when a nursing mother drinks it, the smaller digested protein molecules are still cow's milk proteins. They are secreted in human milk and are well known to cause colic in sensitive infants. I am certain that a nursing infant who is extremely sensitive to cow's milk could develop blood in the stool if the mother drinks cow's milk. Since the bleeding seemed to improve when your wife wasn't drinking milk, she should stop drinking milk long term. If the bleeding resolves by eliminating cow's milk from your wife's diet she should stay off milk for the duration of her nursing. If the bleeding does not resolve completely the baby may need evaluation by a pediatric gastroenterologist.
The most urgent cause of blood in the stool of an infant is intussusception. This occurs when one loop of intestine telescopes into another resulting in an obstruction of the bowel. These babies usually pass small bloody, mucousy stools described as a currant jelly stool. Babies with intussusception are sick. They have severe cramping because of the intestinal obstruction. Intussusception is a medical emergency. Any baby who has bloody stools and severe abdominal pain requires immediate evaluation. This does not sound like your baby's situation, but since you described bloody, mucousy stools it is important that you know when those symptoms could be serious.
Sincerely,
Dr. Warren
-Mr. W
Dear Mr. W: By 12 weeks of age it is certainly possible that the baby has a preference for the breast over the bottle. But it not likely that the baby is willing to go hungry because of that preference. After a while of nursing the breast becomes more efficient, and even if your wife's breasts are not engorged and the baby isn't spending a long time on the breast the baby may be getting more milk than you realize. The best way to judge that is to see what her weight is doing over a period of time. If your pediatrician finds that her weight gain is not satisfactory with only 8 ounces per day of formula, then it will be clear that you have to feed her more formula. In that case you can certainly experiment with a different formula or even a different bottle.If the problem continues even with a different formula and a different bottle and the baby is not gaining adequately, it may be necessary to wean the baby from the breast. Sometimes, when the baby has a strong emotional attachment to nursing it may be necessary to have somebody besides the mother to feed the baby in order to get the weaning process started. Eventually, if the breast is not offered the baby will take the bottle.
If your wife enjoys nursing and wishes to continue nursing, the best approach may be to nurse at every feeding and then when the baby is relaxed and finished nursing offer the bottle. You may find, as I said above, that if your wife nurses at every feeding it may not be necessary to feed the baby anything else. Maybe your wife does have enough milk at this point and the baby doesn't want the bottle because she doesn't need it. In that case the best approach would be to stop giving her bottles.
Sincerely,
Dr. Warren
-M&D
Dear M&D: It is quite natural for children to have curiosity about their bodies and the opposite sex. I don't think you should be alarmed about the incident. Your daughter will likely recover from this incident without any psychological scars as long as it was a single incident and was no more involved than you described. Her behavior indicates that she has experienced some stress about this incident. When she starts undressing dolls or acting out she should be encouraged to talk about what she is thinking and feeling. Her difficulties may have nothing to do with the sexual nature of the event. She may be having difficulty dealing with a sense of shame or guilt if she thinks she did something wrong. She may also feel that she was coerced by your nephew even if he didn't threaten or force her. In other words, she may not have wanted to do what they did and may have even felt it was wrong, but went along with what your nephew said because he is the bigger kid.
It is possible that the greater concern should be for your nephew. He clearly knew that what he was doing was wrong and yet dragged your daughter, a much younger child, into it. I say that he knew it was wrong because he told her not to tell anyone. The guilt and shame he put into this event may be more of an issue for your daughter than the body exploration.
My biggest concern is that your nephew may have been the subject of sexual abuse and is just using what he learned in the process on your daughter. While he could have come up with the term "our special secret" by himself, that sounds like something that came from an older person. That does not mean that I think your nephew was abused by a family member. He could have been involved in a sexual situation with an older child, teen, or adult in his neighborhood. This is something that I think his parents must seriously explore.
Sincerely,
Dr. Warren
Sincerely,
Ms. P & Ms. S
Dear Ms. P & Ms. S: Children born of a consanguineous union (one where the parents are related) have a higher risk of genetic defects. The closer the two parents are related the greater the risk. The reason for this increased risk revolves around recessive genes.A human being has 46 chromosomes which bear the genetic material that tells each cell and ultimately the whole body how to develop and function. The chromosomes are paired, so that there are 23 pairs. Each chromosome in a pair has genetic material that has information about the same thing, for example, if one of the chromosomes in a pair has genetic information about eye color, the second chromosome in the pair will have information about eye color. One chromosome in each pair is contributed by a child's mother, and one chromosome by the child's father. So using the example of eye color, a baby has genetic information about eye color from both the mother and father, and the baby's eye color will result from the mixture of the genetic material. In the example of eye color, brown or dark eyes is usually a dominant trait whereas light or blue eyes is usually a recessive trait. (It's actually more complex than that because there are colors in between depending on the mix of genetic information.) A dominant trait such as dark eyes means that if the genetic information from just ONE parent is for dark eyes, the child will have dark eyes. The recessive trait will only be expressed if both parents contribute genetic information for the recessive trait, so in the eye color example, the baby could only have light eyes if the genetic information from BOTH parents coded for light eyes.
A medically important example of a recessive trait is the sickle trait. If two people with sickle trait have a child, there is a 25% chance that their child will have sickle cell disease. The gene for sickle trait arose and survived in Africa because it provided protection against malaria; however the disease causes a severe anemia, severe pain, and many complications. There are many recessive genes that are much less common than sickle. There are probably many that we don't know about that arose from spontaneous genetic mutations. The fact that chromosomes are paired provides some protection against the effects of defective genetic material. If a defective gene is rare in the population, the odds of two people with the defective gene having children together is small, and if the recessive gene causes no symptoms, the carriers may be unaware that they carry a genetic disease.
In a consanguineous union such as incest, the mother and father of the child already share genetic material because they are related. If there are any recessive genes that can cause disease, just as in the case of a union where both partners have sickle trait there is a 25% chance that the offspring will be affected. But in the case of a consanguineous union there is a much higher risk that the child from the union will have both genes for a RARE recessive trait. In fact there is a chance that such a child will have multiple rare recessive genes expressed.
The most important information you can get is a complete family medical history. Of course, if a serious genetic condition is rare enough, it may show up in a consanguineous union even without a family history. On the other hand, if the family carries no significant recessive genes, the offspring could be totally healthy.
By two years of age it may not be possible to tell this child's medical future, but it certainly should be possible by now to tell if she has any major genetic defects. If the child has been properly evaluated medically and has been found to be healthy, there is no reason to fear adopting her. After all, how many of us get guarantees when we bear children.
Sincerely,
Dr. Warren
An example of how easily he is bruising: He got bruises on his wrist from where the lab technicians held his arm to draw blood.
Any advice you might give would be appreciated.
Thank you,
-C.H.
Dear C.H.: If four physicians have been stumped as to what is wrong with your son, I must be modest enough to tell you that I probably won't have any ideas that they didn't consider. I am glad that cancer has been ruled out. Since you didn't tell me what other diagnoses were considered or what types of specialists you saw, I will share my thoughts with you risking the possibility that all my ideas have already been considered and ruled out.First, there are a large variety of blood disorders that can cause bruising besides cancer. These include platelet defects and clotting abnormalities. If you have not yet seen a pediatric hematologist your son should see one for a thorough evaluation.
Next, the possibility of blood vessel defects which can bee seen with inflammatory diseases must be considered. There are a variety of tests your pediatrician can run to look for evidence of inflammatory diseases, or she might want to consult a pediatric rheumatologist.
Since you describe some of the spots as a rash or discoloration of the skin, perhaps a dermatologist can shed some light on the problem. If there is any unusual rash which is persisting a skin biopsy might provide some answers.
Finally, let's not forget that nutritional deficiencies can lead to rashes and easy bruising. Extreme degrees of nutritional deficiencies are extremely rare in this country. As a result, most modern practitioners, including myself, tend not to think of or recognize nutritional deficiencies when we see them. Scurvy, which results from inadequate vitamin C intake, causes easy bruising.
Sincerely,
Dr. Warren
-J.M.
Dear J.M.: Most children don't run high fevers with simple colds, although some children tend to run high fevers whenever they have fever. Some upper respiratory virus infections (which includes sore throats, colds, and influenza) can cause high fevers. The fevers from most viruses run for 3 to 5 days. Any high fever that lasts longer should be reevaluated. Reevaluation should be sooner if a child seems very ill or has any worrisome symptoms.Virus infections including upper respiratory infections (URI) don't respond to antibiotic treatment. In fact it is a bad idea to use antibiotics for these illnesses because antibiotics won't help and overuse of antibiotics contributes to the load of antibiotic-resistant germs in the environment. Antibiotics are beneficial to treat the complications of respiratory viruses such as ear infections, sinusitis, bronchitis, and pneumonia. Unfortunately, many of the symptoms of the complications are similar to the symptoms of the URI such as cough, head congestion, and fever.
Therefore, it is certainly possible that your daughter could have more than a cold. If she still has fever or has any worrisome symptoms, you should have your pediatrician recheck her.
Sincerely,
Dr. Warren
L.S.
Dear L.S.: I think you may have stumped Dr. Warren! You child's pulse should be slower when he is sleeping than when he is awake. Of course, I have to ask, "How often have you counted his pulse?" If you only counted his pulse once in sleep and once awake, even if the counts were accurate, that wouldn't be a large enough sample to exclude the possibility that the sleeping pulse was higher on that particular occasion because of something going on at the moment you counted it. Also, counting a child's pulse is not a common parental activity. If you counted his pulse because of something going on, that variable would have to be taken into account. For example, if you counted your child's pulse at night because he seemed ill, such things as illness and fever can raise the pulse rate.Assuming that you have taken multiple pulse readings both day and night, and are able to take the sleeping pulse without disturbing your child (which could raise his pulse) and the average sleeping pulse is higher than the daytime pulse, it might be of some interest to have an EKG reading to tell us exactly what the rhythm is. He could be having tachycardia (a rapid heart rhythm) for some reason at night. However, as pointed out to me by my friend, a pediatric cardiologist, when I asked him about your son, the nighttime pulse rate is not rapid enough to be an abnormal rhythm. So maybe I should just reassure you that there is no cause for concern.
Sincerely,
Dr. Warren
-Mr. & Mrs. K
Dear Mr. & Mrs. K: Any physician who gives advice to patients without seeing them must be extremely cautious, therefore, to answer your question, I have to think, "What would I tell a patient of mine who told me their baby turns blue around the lips and nose?." The answer is that I would tell my patient I would like to see the baby. There may be nothing wrong with your baby at all, but cyanosis (turning blue) may be a symptom of heart disease in a baby. You should discuss this symptom with the baby's doctor.Sincerely,
Dr. Warren
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