16 February 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
-BT
Dear BT: Because you describe an unusual medical problem which has been evaluated by several physicians it is difficult for me to advance an opinion without more information. I don't know what types of specialists were consulted or what tests were run, and what if any abnormal results were found.
The first thing the boy's parents should ask their doctor about the diagnosis of abdominal migraine is, "Is the diagnosis on firm footing or is it conjecture?" Along those lines, "Was the diagnosis made by excluding other reasonable possibilities, or were there any tests that pointed toward or confirmed the diagnosis?" Assuming for the time being that this is the working diagnosis, the parents will want to know, "What is the treatment plan?" and "Where do we go from here?"
Abdominal migraines and abdominal epilepsy are both fairly rare and for that reason the diagnosis is often overlooked. I have no personal experience with either of these illnesses, but both share many features of their non-abdominal counterparts and I'm not too sure that it makes sense for a significant fever to be part of that picture. These diagnoses would probably be best made in consultation with a pediatric neurologist.
When a child has recurrent symptoms it is quite reasonable to look for an underlying cause, but when there is a span of a month between episodes, in spite of their similarity, it is possible for each illness to stand on its own. One possibility then, is recurrent Strep throat. Sometimes the abdominal pain, nausea, and fever are such a prominent part of the picture that the sore throat is not even noticed. Both Strep and virus sore throats may be accompanied by abdominal pain, and both may lead to mesenteric adenitis, which is a condition where the lymph nodes around the intestines became inflamed causing abdominal pain. The pain with mesenteric adenitis may be severe enough to mimic appendicitis.
Since the main organ in the abdomen is the intestines one would tend to look there for a cause with such tests as stool culture and looking for parasites. Since the liver is in the abdomen blood tests to look at the liver might be useful. We mustn't forget the urinary tract as a source of abdominal pain. A urinalysis and urine culture should be done. A blood test for serum amylase might look at pancreatic involvement. Imaging studies such as ultrasound or CT scan might be useful to look at the organs and rule out the possibility of an abscess in the abdomen.
Recurrent abdominal pain and fever may be seen with inflammatory bowel disease. Both symptoms may be seen concurrently, but they may also be seen separately. These conditions tend to be chronic, and although there may be periods symptom free, until the diagnosis is made and treatment is begun or the patient goes into remission, the patient will usually have some symptoms on a daily basis. Often the diagnosis is not considered until the patient has some bloody diarrhea. Further evaluation for an intestinal cause of the fever and pain can be done in consultation with a pediatric gastroenterologist.
Please let me know what happens.
Sincerely,
Dr. Warren
-CJ
Dear CJ: The first thing I must say is that if your baby looks sick enough or is acting sick enough to even consider meningitis, no matter how much you want to avoid thinking the worst, I urge you to have her reevaluated by her pediatrician. Most children with meningitis run fever, are irritable, and vomit. Older children complain of a severe headache. But if a child is on antibiotics he may have a partially treated meningitis and may not show all the signs of meningitis. I'll never forget my one patient with partially treated meningitis. The baby was on antibiotics for a pneumonia and was recovering when the mom called me and said, "There's something terribly wrong with my baby. She just isn't acting right." When I saw the baby she just lay where you put her without moving and stared. It's hard to describe, but when you know what normal children act like, the lifelessness of this infant was scary. It was just before the HIB Vaccine came out, and this little girl had HIB meningitis. This was determined by spinal tap. The baby was treated with IV antibiotics and is a healthy little girl today.Of course, if your baby isn't that sick there are other possible explanations. Antibiotics may sometimes upset the stomach and children may not recover from the side effects until they are off the medicine for several days. If you baby is on a medication for wheezing such as albuterol that can make children jittery and alter their behavior. And she may still not be feeling well from her illness.
The key issue here is that you're upset because your instinct as a parent tells you something is wrong. My advice: Check it out! It's better to visit the pediatrician, even several times if necessary, and find out everything is okay, than to miss something serious.
Sincerely,
Dr. Warren
-RS
Dear RS: 19 lbs. for a 6 month old places the baby at the 50th percentile for weight which is right in the middle of the average range. That is excellent weight gain. To be sure that the weight gain is right for your baby I'd have to know her height, because weight gain in children represents mostly growth. We're not anxious to see our children get fat. Based on the information I have, the baby's weight gain is most likely right for her.
Human milk is an excellent source of protein and serves as a complete source of nutrition during your baby's most rapid growth. Taken along with the other foods she is receiving and taking into account your baby's weight gain I'm sure she is well nourished.
Boys generally tend to be larger than girls and to grow faster than girls, but the range of normal is so large that there are plenty of healthy girls who are larger than numerous healthy boys.
By 9 months a baby should have been sleeping through the night for a while already. Some babies may never sleep more than 8 hours at a time, but you should be getting at least that. If your baby is waking during the night for feeding she may be a "trained night feeder." That means that she is used to using the breast to relax and put herself to sleep so that if she wakes up even slightly she doesn't know how to go back to sleep without nursing. With patience and persistence (if I can convince you not to feed her when she wakes during the night) you can teach her to go through the night without feeding.
Sincerely,
Dr. Warren
-MJS
Dear MJS: Young children who have severe eczema generally have many allergies contributing to their condition. Avoidance of those allergens is the main preventive treatment; however, if many basic foods are involved it can be difficult to nourish your child. Many times those allergens are hidden in other foods. If you have a list of foods that seem to aggravate your daughter's eczema, it may be worth consulting a nutritionist.Eczema is a dry, inflammation of the skin. Steroid creams are used for their anti-inflammatory effect. Often, if you can get the inflammation under control you can minimize the use of the steroid cream. I certainly understand your concern about prolonged use of steroid creams; however, if your concerns prevent you from using the steroid cream when the inflammation is mild you may end up using more once the inflammation becomes severe. Early treatment will also minimize you child's symptoms. If you have to use a strong cream to get the inflammation under control you should be able to switch to a milder cream for maintenance.
Dealing with the dryness of eczema can often be the most important aspect of treatment. It is no surprise that your daughter's eczema is worse in cold weather. When it is cold out there is generally less humidity, plus, heating our homes dries the air inside even more. It would be very helpful to have a room humidifier in your daughter's room if not the whole house. Room humidifiers are not the same thing as cool mist vaporizers used for treating colds and are not meant to be at the bedside.
Skin oil is the main thing that holds moisture in the skin. Soap removes skin oil allowing moisture to evaporate from the skin. Even water without soap removes some oil so bathing should be kept to a minimum. Children with severe eczema should use Cetaphil cleanser instead of soap. After bathing moisture should be locked into the skin with a moisturizer such as Eucerin or Cetaphil Lotion.
An antihistamine can help relieve the itching. Unfortunately antihistamines can cause drowsiness, but if itching is keeping your daughter awake an antihistamine would be particularly useful at bedtime. Benadryl is a good over the counter antihistamine. I prefer the prescription antihistamine, Atarax, for treating itching.
Eczema is a condition which is routinely treated by pediatricians. But if your daughter's eczema remains refractory to treatment, you should consult a Pediatric Dermatologist.
Sincerely,
Dr. Warren
-AM
Dear AM: Your child most likely has an intestinal virus. That illness will probably last a few days. Usually the vomiting is most severe at the beginning of the illness until the stomach is completely empty. When a child continues to vomit even clear liquids it becomes necessary to introduce the liquids very slowly. The more there is in the stomach, the more easily the child will vomit. The best thing is to give the child an electrolyte solution like Pedialyte. Give your child at least 1 hour without any vomiting before trying to introduce the Pedialyte. Start with 1 teaspoon every 15 minutes. After your child holds down 3 in a row you can increase to 1 tablespoon every 15 minutes. 15 minutes later you may offer 1 ounce every 1/2 hour. After 3 in a row without vomiting 1/2 hour later you may increase to 2 ounces every 1 hour. Again 3 in a row and then 1 hour later 4 ounces every 2 hours. After 3 in a row at the 4 ounce level you may finally offer fluids any time your child is thirsty.Vomiting is the most urgent symptom associated with gastroenteritis. There are medications to help control nausea such as Tigan given by injection or suppository, but while they may be used cautiously in an older child, anti-emetics are not recommended in infants. If the vomiting doesn't come under control quickly a small child can dehydrate, therefore, if your child is unable to hold down even the small amounts of clear fluids initially offered you should contact your pediatrician.
Sincerely,
Dr. Warren
-KJ
Dear KJ: The newborn head was designed to fit through a birth canal. The bones can overlap and move so as to fit the shape of the birth canal. If the head is in the birth canal for a long time the head molds to that shape. There also may be some swelling of the skin of the scalp which adds to the cone-head appearance. None of this is dangerous. The shape of the head will improve rapidly, but final remolding may take a few weeks. It will return to normal.Sincerely,
Dr. Warren
-L
Dear L: Most upper respiratory infections (URIs) cause sore throats and swollen glands. A URI may be anything from a simple cold to influenza. Since these are all caused by viruses, and viruses don't respond to treatment with antibiotics, your doctor can avoid prescribing unnecessary antibiotics by doing a throat culture when you have a sore throat and only prescribing antibiotics when the culture is positive for Strep Throat. In addition, since Strep is sensitive to plain penicillin, your physician need not prescribe broader spectrum antibiotics like amoxicillin or augmentin unless he finds other complications such as a sinus infection.Most children get 6-12 URIs per year, and most of those are in the winter months. There is no question that some people are more susceptible than others, probably as a result of differences in their immune response; however, while your frequency of URIs may be a nuisance it is no cause for alarm. While there is some evidence that vitamin C may shorten the duration and decrease the severity of colds, there is no evidence that it decreases the attack rate. Probably the most useful thing a person can to avoid URIs is to avoid other people with URIs. The next most important thing is to wash your hands a lot. All you need to catch a cold is to touch your eye or your nose with cold germs on your finger. It always amazes me how people will say "Don't kiss me. I have a cold." and then they offer to shake your hand with the hand they just coughed into or sneezed into (tissues let the germs through).
The desert climate may not be ideal for your respiratory tact. If the air where you live is too dry that can be irritating to your throat and nose and will aggravate a cold. You might want to use a humidifier.
Sincerely,
Dr. Warren
-W
Dear W: Temper tantrums are certainly one of the most difficult behavior problems to deal with in young children. And if a child is hurting himself during the tantrum it is hard to ignore, but your pediatrician is fundamentally correct when he says to ignore tantrums. The worst thing you can do is to give a child what he wants just because he throws a tantrum. That teaches the child to use tantrums to get his way. Even if you don't give a child his way because of tantrums, if you offer bribes or undue attention to stop the tantrum, that teaches a child to use tantrums for attention (secondary gain).Since you say that ignoring the tantrums isn't working I feel obliged to point out that sometimes it takes a long time of using the correct approach consistently to see results. Often, when parents read child care books or seek child care advice they worry that they are doing something wrong if they don't see immediate results. Then, they look for a different approach. But frequent changes in approach are confusing to children. They need to learn what our response to their behavior is. When adults are consistent in their response to children it provides stability and avoids confusing the child.
Let's explore the problem in a little more depth now. If we agree that we should avoid secondary gain in dealing with tantrums, you must still find a way to do this with which you are comfortable. Some parents find it best to be stern in dealing with tantrums while others may need to be gentle but firm. Either way it is important to be flexible. You're not trying to prove you are the boss. You know that you're ultimately in charge. If a tantrum starts over something small and you rethink the situation and decide it would be no big deal to grant your child's wish then don't let the tantrum prevent you from doing what you think is right. If you can distract your child or lead him to something acceptable that will satisfy his needs, do it before the tantrum is in full swing. If there are certain issues that regularly provoke tantrums, rethink your approach to those issues and see if you can make a change that avoids the problem. Some children just have a shorter fuse than others. Eventually they get past the tantrum stage as long as it isn't encouraged by secondary gain. But remember, even the most difficult child can sometimes be feeling hurt or legitimately disappointed. When it seems appropriate, don't be afraid to comfort your screaming child. If his disappointments regularly result in tantrums, during the calm periods you may try to help the child find age appropriate ways to express how he feels.
Sincerely,
Dr. Warren
The doctor mentioned two possible reasons why my son's head would not
grow:
1. The plates in his head fused together prematurely.
2. His brain is no longer growing.
Neither of these possibilities appear to be the problem because my son's mental development seems to be on-track and the shape of his head doesn't appear to be changing. The doctor suggests we wait six months and measure again before assuming one of the two problems exist.
So, my questions is, given the fact that my son's head has not grown in 13 months, does this suggest that there is a problem or isn't it that unusual?
Any thoughts you have on the subject would be greatly appreciated.
Thank you
-LP
Dear LP: The following is a growth chart of the head which shows that at 15 months your son's head circumference was at the 98th percentile which is the upper limit of normal while at 24 months his head circumference was just above the 50th percentile which is the middle of the average range.
If your son's brain had not grown from 15 months to 28 months it is likely you would have seen developmental delays. Fusion of the bones in the head (craniosynostosis) usually results in an odd shape to the head, but that depends on which bones are fused. Therefore, a normal skull shape does not entirely rule out craniosynostosis. If your son's head has truly not grown for 13 months it would be important to be sure if there is craniosynostosis because if there is, it should be surgically repaired with out delay to prevent neurological complications. A CT scan of the head should tell whether or not the brain is normal an if there is fusion of any growth lines in the skull. The CT is a non-invasive test. The amount of radiation is not significantly more than an x-ray. Basically, the only risk to the test is that your son may need to be sedated for it.
So how do you decide? Look at the head circumference growth chart with your doctor. If the 15 month point is way out of line with the other measurements, do another measurement in 1 month, and if necessary in 2 months as well, to determine if your son's head is growing steadily at the 50th percentile. If so, don't worry. If his head growth is lagging, do the CT scan. If the 15 month measurement was consistent with all the prior measurements, your son's head is not growing normally and the CT scan should be done without delay.
Sincerely,
Dr. Warren
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