2 February 1997

1. Lethargy, Loss of Eyelashes - What's Is It?
2. Asthma - Please Help
3. Treating Ear Infections with a Single Injection
4. Sleepytime Fears
5. DTP Shot - a Tough Choice
6. Help! My 8 Year Old Still Soils His Pants!
7. Disclaimer

• Read Questions & Answers in Another Column

Lethargy, Loss of Eyelashes - What's Is It?

First of all, my friend has taken her daughter to a doctor but we are puzzled by the lack of a diagnosis.

My friend does not have access to the internet or email which is why I am writing this for her.

The little girl, Brittany, is 7 years old. I have known her since she was 1 and she is just not herself.

Her symptoms include....extreme paleness, loss of eyelashes, tired, lethargic, eyes seem sunk in and dark, appetite is okay but not normal for her, no fever. The teachers have even called her mother to find out what is wrong with Brittany. She was taken to a doctor and these were the tests results as told to her mother...no thyroid problem, no mono, blood was fine, cholesterol is fine, urine is fine, white blood count is fine. She was told that everything looked fine and that if she had any other concerns to contact the doctor.

Anyone who looks at Brittany can tell that there is something not right with her. Regarding her eyelashes, she does not rub them excessively and all of them are gone. She has not lost any other body hair that we are aware of. This has been going on for approximately 3 to 4 weeks. Is there some kind of article we should try to read to get some information? Have you run across these type of symptoms in the past? Is there some test my friend should ask to have run? When I look at this child I am truly worried about her. She says she feels fine but you can tell that she is not herself. Any ideas that you might have as to how we can help her would be appreciated.

Thank you for your attention to this matter.

Sincerely,

A.D.

Dear A.D.: In trying to come up with some answered for you I first considered what was Brittany's most unique symptom - the loss of her eyelashes. Since nothing immediately came to my mind I did a little research. Unfortunately the only things I found which listed loss of eyelashes as a feature were leprosy and AIDS. Considering how rare leprosy would be in this country I don't think it is even a consideration. However, if she has any unusual rashes, most notably, a patch of skin which is lighter in color and has decreased sensation to touch, pain and temperature, this unlikely possibility should be considered. While loss of eyelashes may be seen with AIDS the usual story for AIDS is frequent infections which are hard to clear with antibiotics, and eventually unusual infections including fungal infections. Before considering AIDS one should also ask if there were any risk factors such as a needle stick, a sexual experience, or being born to a mother with AIDS.

Next we have to consider her main symptoms - pallor and fatigue. So many things can cause those symptoms. Mononucleosis is a good thought. Even though the mono test was negative her doctor may have a suspicion of mononucleosis if the white cell count suggests mononucleosis. Sometimes the mono test remains negative and the diagnosis can be made by checking Epstein-Barr Virus titres.

Hypothyroidism has been ruled out. A normal urinalysis rules out childhood diabetes. You don't specify what other blood work was done. To rule out other glandular disorders, liver, or kidney disorders she should have liver function tests, kidney function tests, and electrolytes checked.

Sometimes inflammatory diseases may present with non specific symptoms. These include such illnesses as Juvenile Rheumatoid Arthritis, Dermatomyosistis, and inflammatory bowel disease. A simple blood test called a Sedimentation Rate (ESR), if elevated, might suggest a need to evaluate these possibilities. Dermatomyosistis causes not only fatigue, but also muscle weakness. Her CPK level would be elevated with Dermatomyositis.

Fatigue and decreased exercise tolerance can be seen with cardiac disease. Aside from a clinical exam, an EKG may suggest whether further cardiac evaluation is in order.

Any chronic, low grade infection might cause fatigue. A urine culture (not a urinalysis) is necessary to rule out a urinary tract infection. A skin test for tuberculosis (PPD) might be useful. Even a dental exam to check for an apical tooth infection might be in order.

It is essential to be sure that her sleep and nutrition are adequate. If her sleep is disturbed by either physical or psychological factors that could contribute to chronic fatigue. It is not safe to assume that just because a child is in bed they are sleeping soundly.

Finally, if all physical causes for fatigue have been thoroughly evaluated, one must consider psychological causes. Depression can cause fatigue even without interfering with sleep. Depression can also cause sleep disturbances and loss of appetite. It is also possible that the loss of her eyelashes may be due to trichotillomania which is the compulsive pulling out of hair. Children with trichotillomania may pull out any hair. Those who pull eyelashes may not pull any other hair. This is often a stress symptom. Most children who do this are embarrassed by it and often do their best to keep it a secret.

As long as you feel she is not well, Brittany should be periodically reevaluated by her pediatrician. If necessary, this should be done in consultation with other specialists depending on the specific symptoms or findings

Sincerely,

Dr. Warren

He has been on Erythromyicin for a week, and Biaxin three weeks earlier. Here I am again making another appointment because he is wheezing and very short of breath. What more can I do? Is there someone out there who can help us find a better approach to making Adam feel better? Some days I feel like the Pediatrician is not helping me at all. Instead of treating his illnesses, I would like to find some sort of prevention. I want my baby to be happy and healthy!!!

Thanks for any help you can give us.

Sincerely,

Mr. & Mrs. D

Many children who develop asthma before the age of 3 improve dramatically after their third birthday. Although there are many things that can aggravate asthma and provoke asthma attacks, most of the young asthmatics have their worst problems when they have colds. It is impossible to prevent colds, but considering the problems they cause for Adam (recurrent ear infections and asthma attacks), friends and family should make an effort to stay away when they are sick. Additionally, careful hand washing at all times should help decrease the spread of respiratory infections.

There are a number of things you can do to help your child. First, based on the frequency of Adam's symptoms, if he is not taking Intal by nebulizer 3 or 4 times every day you should start doing that. Intal works to reduce the inflammation in the bronchial tree that provokes the wheezing, but it doesn't work rapidly enough to prevent wheezing if it is only taken when there is a problem. Second, try to recognize and treat the symptoms of asthma before you hear wheezing or see shortness of breath. Most asthmatics start coughing when they have mild wheezing. When you hear a lot of coughing try giving Adam an Albuterol treatment. You should see an improvement in the cough if he is wheezing. If necessary repeat the Albuterol every 4 hours. Consider giving him Albuterol treatments at least 3 times a day any time he has a cold even if he has no asthma symptoms.

Don't be afraid to treat your son's asthma vigorously, but recognize the danger signs that mean you need to see the doctor: wheezing that requires treatment more than every 4 hours, wheezing that doesn't completely clear with treatments, asthma attacks with difficulty breathing especially if more than one episode, wheezing that disturbs sleep, and finally, persisting wheezing over many days even if it responds well to treatment. Those danger signs mean that an asthmatic needs more treatment for the inflammation in his airways. Albuterol doesn't treat inflammation. It is a bronchodilator - a medicine that opens up the tight airways.

When your child has severe asthma symptoms he will need more potent anti-inflammatory therapy than Intal for quicker and more effective reduction of the inflammation in his airways. The medicines we use for that are steroids like Prelone. We try to use these steroids only as much and as long as necessary because long courses of steroids can have many side effects. Short courses of steroids are usually safe and are often sufficient to improve the asthma.

If a child takes Intal regularly by nebulizer or by spray and his asthma symptoms are not adequately controlled he will need more potent inhaled anti-inflammatory therapy. Even though steroids taken orally should only be taken in the shortest course possible, inhaled steroids can be taken quite safely long term for chronic management of asthma. My 16 year old, who has had asthma since she was 3, has been taking inhaled steroids since she was 4. A 2 year old can take an inhaled steroid such as Flovent if he can be trained to take it through an Aerochamber with Mask. Inhaled steroids for the nebulizer are not available in this country, however, they are available in Canada. The medicine is budesonide. I believe the brand name is Pulmocort. I have dealt with a pharmacy in Montreal called Clayman Pharmacy. If your pediatrician wishes to prescribe the nebulized steroid he can call them at 514 735-5243. If you provide the pharmacy with credit card information they will ship the medication directly to you.

You may want to consult a pediatric allergist and/or Pulmonologist. If your son has allergies contributing to his asthma he would benefit from advice on how to decrease his exposure to allergens in the environment. Simple things like eliminating carpeting and stuffed animals in your child's room can make a difference. Testing for allergies would determine if your child might benefit from allergy injections.

Finally you need to make your pediatrician your ally in dealing with Adam's asthma. Not only will you need him to treat the acute episodes and prescribe Adam's medications, but since asthma is a chronic disease you will need his support and guidance to get you through the hard times. He should do this automatically, but all pediatricians are human, and some will have difficulty dealing with parents who seem to be making excessive demands on their time and most especially demands for cures they can't provide. You can help make your pediatrician your ally by becoming an active partner in Adam's treatment. Become educated about asthma so that you know what questions to ask, when to call the doctor, and what you can do on your own. An excellent source of information for parents is "Children With Asthma: A Manual for Parents" by Thomas F. Plaut, published by Pedipress. It should be available in libraries and book stores. If you have Web access, it is available at Amazon Books at http://www.amazon.com.

Sincerely,

Dr. Warren

We have a four year old that ended up with tubes after reoccuring ear infections. Now that my wife is pregnant with our second child, I'd like to know as much as possible to hopefully prevent the same with our new child.

Thanks for you time,

-B.S.

Dear B.S.: The study you refer to was written by SM Green and SG Rothrock from the Department of Emergency Medicine, Riverside General Hospital, CA 92503. The study was published in Pediatrics 1993 Jan;91(1):23-30

The following is an abstract of the study:

This study evaluated the efficacy of a single dose of intramuscular ceftriaxone for acute otitis media in children, using amoxicillin as a control. (There is currently no established single-dose treatment for this condition.) In a prospective, randomized, double-blind, clinical trial, 233 children, aged 5 months to 5 years, with uncomplicated acute otitis media were randomly assigned to receive either a single intramuscular injection of ceftriaxone (50 mg/kg) plus placebo oral suspension for 10 days, or a placebo injection plus amoxicillin oral suspension (40 mg/kg per day divided three times per day) for 10 days in a double-blind fashion. Demographic and clinical characteristics were similar in both groups. Treatment was successful in 107 of 117 given amoxicillin (91%, 95% confidence interval 86% to 97%) and 105 of 116 given ceftriaxone (91%, 95% confidence interval 85% to 96%). Rates of improvement, failure, relapse, and reinfection were similar in both groups, as were the otoscopic and tympanometric evaluations at the 14- and 60-day follow-up visits. It is concluded that a single intramuscular injection of ceftriaxone (50 mg/kg) is as effective as 10 days of oral amoxicillin for the treatment of uncomplicated acute otitis media in children.

Essentially the study showed that a single injection of ceftriaxone was AS GOOD AS a 10 day course of amoxicillin. There was no evidence that the injection was a better treatment; however there are clearly circumstances where the injection would be better such as: the child who refuses medicine, the child who is vomiting, a schedule which won't accommodate giving medicine for 10 days, a caretaker who forgets to give doses of medication, or any other situation which may interfere with taking all the doses of antibiotics for 10 days. As regards your interest in the single injection treatment for ear infections, the treatment has not been shown to have any greater benefit than oral antibiotics for treating children with recurrent infections or for avoiding tubes. Another study on the subject did show that parents preferred the single injection treatment.

Sincerely,

Dr. Warren

Then we asked him if he was ready to move out of his crib and into a "big boy bed." He was excited as we moved the mattress from the futon onto his floor, and made a big deal out of preparing it for him. However...

Every night since then, he has come into our room and begged, BEGGED to sleep in our bed. We have relented often, and we have also tried to get him back into his bed once he has fallen asleep. It works just fine, provided he doesn't wake up on the way into his room, because if he does, he freaks out.

I think it is a good idea for him to learn to sleep in his room by himself, but neither of us feel that his fears or questions should go unanswered. Any suggestions?

-Mr. & Mrs. M

Max was certainly excited about the changes you proposed. You did everything you could to make it a wonderful experience. But until he was faced with the reality of the situation, he was in no position to understand what he had agreed to.

Now your job is to make his new bed a comfortable place for him. The problem is, he'll never learn that it's safe there if you can't get him to stay in it. Unfortunately, it's pretty hard for any bed to compete with the security of sleeping with Mom and Dad. People who live in societies where children routinely sleep with their parents may question the wisdom of my opinion, but I advise strongly against parents taking their children into their beds. It isn't that I feel it would be harmful to the child. But it only takes once for a child suffering any anxiety to discover the comfort of his parents bed and decide that's where he wants to be...forever. I get a lot of cries for help from parents trying to figure out how to get their kid out of their bed. Perhaps I've formed my opinion because I don't hear from the parents whose children easily go from parent's bed to child's bed. The best way I know to get a kid out of your bed is to never let him sleep in it in the first place.

Now, what to do with poor Max. Perhaps a new arrangement for his bed. Maybe you have something from the old crib to add to the familiarity of the surroundings like a mobile or a busy-box. Maybe you can expand your bedtime routine - find things that relax Max: a book, a song. Talk about the bed during the day. Lie in it. Play in it. Help him stay in it at night by sitting with him until he falls asleep. Lay with him in the bed if necessary. Then gradually wean him from your presence by decreasing the time spent with him. But whatever you do, make sure he goes to sleep in his bed, otherwise it will never become HIS bed.

Sincerely,

Dr. Warren

I would love to hear your opinion on this matter.

Thank You.

-S.A.

It is not time to second guess or regret your original choice. Had your daughter had a severe reaction to DTP you could not undo it. The risk of whooping cough has always been around. I see an average of one every two years. And many cases go undiagnosed and unreported. Doctors are aware that the immunity to whooping cough wanes over a period of time. As a result, teens and adults are susceptible to whooping cough and serve as the main source of spread to infants. Fortunately, the level of immunity in most communities is such that most cases remain isolated. Epidemics occur only in communities with low levels of immunization.

You are right that whooping cough is a serious disease, but it is most dangerous in infants. While the course of the illness can be quite long, most older children will recover unscathed. With the development of the Acellular Pertussis Vaccine there has been a renewed interest in immunizing teens and adults, not so much to protect them as to try to eliminate the reservoir of Pertussis (whooping cough) in the community.

The reason that teens and adults do not get immunized against Pertussis is that the risks outweigh the benefits. Older children, teens, and adults have much more severe reactions to Pertussis vaccine. As a result, there is no form of Pertussis vaccine recommended or approved for use after the 7th birthday. That is why your pediatrician has correctly advised you that your daughter should not receive Acellular Pertussis Vaccine. But, that may change. Immunization of older children, teens, and even older adults with some form of Acellular Pertussis Vaccine is being studied. Some time in the near future we may all be advised to get our Pertussis boosters.

Sincerely,

Dr. Warren

-B.R.

No matter what initially causes the child to withhold stool, the end result is the same. Stool that sits in the rectum becomes harder with time. And as time passes with out a bowel movement the child becomes more and more constipated. It becomes more painful and more difficult for him to have a bowel movement voluntarily on the toilet. Eventually there is no more room in the rectum to hold stool and liquid stool begins to leak out around the hard stool in the rectum. As a result, even though the child is severely constipated, he starts to have diarrhea in his pants. In addition, some formed stool periodically escapes into his pants when he has a cramp, but only enough stool comes out to relieve the pressure because the child is still working so hard to hold it in.

How can your son not feel it or smell it when he sits in a mess in his pants?!? The answer is simple - denial. Denial is one of the most potent of human ego defense mechanisms. If he believes that he can't feel it and he can't smell it, then he doesn't have to deal with the problem. And he is not lying to you. He believes it. If you can't imagine anything much worse than dealing with the constant mess in your son's pants try to understand that to your son there is something infinitely more frightening and awful, namely, sitting on a toilet and having a bowel movement.

The treatment is difficult. But after eight years of dirty pants you couldn't have expected a simple solution. You must be prepared to devote an inordinate amount of time to the solution, and you must be committed to sticking with the program, even when it doesn't seem to be working. You will need the guidance and support of a pediatric gastroenterologist or a child psychologist who deals with encopresis (fecal soiling). He will set up a treatment program which he will constantly review with you to provide reinforcement for you. The elements of the treatment will most likely be as follows:

• An enema may be necessary at the start to clean your son out. This may need to be repeated periodically.
• Your son will need to take a stool softener like Senekot and a lubricant like Mineral Oil. This will make it more difficult for him to withhold stool. This is often the most difficult step for the parents because at first it will increase soiling and it will cause oil staining of the underpants. Many parents can't understand or accept the concept of giving these medications to a child who is already soiling and will give up at this point.
• Your son needs to become acclimated to the toilet. Sitting on the toilet several times a day must become a regular part of his day, even if he doesn't have any bowel movements on the toilet. This must be done with no pressure to perform. For some children it is necessary to start with the lid down and the pants up.
• You must positively reinforce your son's successes. At first success will be nothing more than coming into the bathroom with you willingly. Eventually it will be sitting on a toilet with his pants down and the lid up. Even when he is finally having bowel movements regularly on the toilet you must continue to focus on his success. Failures, accidents, messes: they are not important. Success is important. Reward it with praise. Keep track with stickers or stars in a calendar or log. Plan a celebration for big steps or multiple successes. Don't let any messes distract you from his successes. Your son would like nothing better than to please you. But he doesn't even try because he doesn't believe he can succeed. It may seem a simple matter to you to poop in a bowl. You see younger children than your son do it. But you are, after all, an adult who probably doesn't remember the last mess in your pants. He is a child whose mess is so much more comfortable to him than the toilet that he is willing to risk your constant scorn.

Sincerely,

Dr. Warren

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