23 March 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
Thanks for your help--modern technology is fabulous!!
-MG
Dear MG: Infants and children can have up to 12 upper respiratory infections (URIs) a year. Since the bulk of these occur in the winter a child may still be recovering from the lingering symptoms of the last URI when the next one begins. Most URI's are caused by viruses. These include the common cold, influenza, RSV which causes bronchiolitis in infants, and croup. Because these illnesses are caused by viruses, they don't respond to treatment with antibiotics. They have to run their course. Cold and cough medicines may provide some symptomatic relief, but they don't cure the cold, shorten the durtion of the cold, or even significantly alter the course of the illness.
URI's may sometimes lead to secondary infections - bacterial complications that require antibiotic treatment. These include ear infections, bronchitis, pneumonia, and sinusitis. Some of the symptoms of these secondary infections resemble the symptoms of the URI. For example, both colds and flu can cause coughing just like pneumonia and bronchitis. The thick green mucus that dries in the nose at the end of a cold is often difficult for parents to distinguish from the pus drainage of sinusitis. Children with ear infections may scream and pull on their ears, but sometimes colds may bother the ears, and any illness may make a child irritable.
A parent may suspect a more serious infection if their child runs a high fever. A secondary infection might be suspected if fever starts in the middle of the illness. But basically, given the overlap of symptoms between viral URI's and their complications, a parent has to seek medical evaluation if they suspect something more than a cold when a child is sick longer than expected or if a symptom such as a cough is worse than expected or lasts longer than expected. While you should come to trust your judgment about when it is "just a cold," anytime you don't like the way your child looks or your parental instinct has you worried, don't hesitate to call your doctor.
Sincerely,
Dr. Warren
-WB
Dear WB: It is important to check for hydrocephalus if a child's head appears to be growing too quickly, but if your child has been healthy, has no neurological symptoms such as early morning vomiting or seizures, and has achieved normal developmental milestones it will not hurt to wait 2 weeks for the CT scan. It is possible that your child just has a big head. This is especially true if other family members have big heads.Hydrocephalus is not very common. Big heads that aren't hydrocephalus are more common, but the most important thing to be sure that you're not missing if a child has a big head is hydrocephalus, so it is wise to take the precaution of checking it out.
If a child has hydrocephalus it can be treated by placing a shunt. Certainly I can understand that this whole idea is anxiety provoking. Keep in mind that if hydrocephalus is detected early and treated properly, damage to the brain can be prevented and these kids can live normal lives.
Sincerely,
Dr. Warren
-WC
Dear WC: A cough which has been persisting almost a month which provokes vomiting could be a number of things, but, with a normal chest x-ray, the first thing to consider is whooping cough. Even if your son has been fully immunized against whooping cough it is possible for him to get it. In fact, an immunized child may have an atypical case which makes the diagnosis harder. Whooping cough is clinical diagnosis. Tests can help in making the diagnosis, but if the doctor doesn't think of the possibility, he will never make the diagnosis.
Whooping cough starts out looking like a normal cold, but after about two weeks it enters the paroxysmal stage where the patient starts having a tight cough. The characteristic thing to make you think of whooping cough is that even if the patient doesn't cough frequently, when he coughs, he coughs multiple times in a row. This is known as a paroxysm. The paroxysms often result in vomiting. If the paroxysm is severe enough, the patient cannot take a breath while he is coughing, and when the paroxysm is finally over, he sucks in a big breath through his throat already tightened from coughing. This breath at the end of the paroxysm causes a noise which is called a whoop. Not all patients whoop, but if they have paroxysmal coughing, the doctor has to consider whooping cough. A complete blood count might suggest the diagnosis because the white count is generally high (in the range of 20-30,000) with a predominance of lymphocytes. Confirmation of the diagnosis can be made by doing a fluorescent antibody test on a slide made from a nasopharyngeal swab. This is generally done by the health department. The slide test could be negative because your son was treated with Pediazole which contains erythromycin. Erythromycin is used to eliminate the Pertussis organism (the cause of whooping cough) from the patient's nasopharynx so he won't be contagious. Antibiotic treatment does not alter the course of the illness once the patient has reached the paroxysmal stage. Eventually the illness ends. The main treatment is supportive including the use of an appropriate narcotic cough suppressant when needed.
The other important diagnosis to consider is asthma. Many asthmatics cough significantly without ever having asthma attacks or difficulty breathing. The examining physician should be able to hear wheezing, but if the wheeze is slight, it might not be audible unless the patient is taking big enough breaths and forcing the air out when he breathes out. A pulmonologist or specialist who deals with asthma can help make the diagnosis by doing spirometry (also known as pulmonary function tests - PFTs). A therapeutic trial of albuterol inhalation may help to see if there is a clinical improvement in symptoms. If a diagnosis of asthma is established there are many treatments which can help. The diagnosis of asthma should be seriously considered if the coughing is provoked by physical activity such as running..
Finally, there is always the possibility that your child has had more than one cold in this period of time. But I wouldn't accept that diagnosis until all other possibilities have been excluded.
Sincerely,
Dr. Warren
-KJ
Dear KJ: A stuffy nose can be very unpleasant for a 3 week old. Babies that young are obligate nose breathers. That means that no matter how difficult it is for them to breathe through their noses, infants that young will try to breathe through their noses and will not breathe through their mouths. Medication is undesirable because at this young age the side effects can also make the baby miserable.The best approach to a young infant's stuffy nose is to suction the mucus with a bulb syringe. To do this first put normal saline (salt water) nose drops into the nostril you wish to suction. The squeeze the bulb and insert the tip into the nostril. Squeeze both nostrils gently closed around the tip of the bulb so that no air can enter the nose. The baby will be unhappy about this and will cry which will result in his breathing through his mouth. When the nostrils are pinched closed around the tip of the bulb release the bulb slowly so that it suctions mucus from above. Do the same for the other nostril and repeat as necessary.
Saline drops can be used between suctioning to help keep the mucus moist. In addition, a vaporizer or cool mist humidifier will help keep the mucus moist. This makes the nose less stuffy.
Sincerely,
Dr. Warren
-Worrying
Dear Worrying: You may relax. It is common for children to have infectious illnesses as frequently as once a month. Unless there is something unusual about the illnesses it doesn't suggest any serious underlying problem. With regards to who gets sick and how often they get sick, the key ingredient for infectious diseases is exposure. Since you son is with other children in preschool there is plenty of opportunity for him to be exposed to infections.Fever is one of the most common symptoms that pediatricians see kids for. Fevers that last less than 5 days a common with all infectious illnesses. Vomiting may occur simply as a reaction to being sick. If your pediatrician has never found anything unusual and your son has fully recovered from each illness, and additionally he has been found to be healthy and growing normally at his checkups, then he is a healthy child.
Cystic Fibrosis is a genetic disease that causes the body to produce excessively thick mucus. Since all membranes in the body have mucus glands that produce mucus for lubrication and protection many organ systems can be affected. The most common problems for CF patients are lung problems including infections, intestinal problems including difficulty digesting fats because of damage to the pancreas, and liver complications. For more information about CF point your web browser at the Cystic Fibrosis Foundation's home page at http://www.cff.org/.
Sincerely,
Dr. Warren
-BB
Dear BB: 26 pounds is a perfectly good weight for a two year old. If your son hasn't gained any weight in 4 months it could be due to variations in the scale or weighing technique, recent illness resulting in some weight loss, or a slow down of his growth. Some children grow in spurts rather than on a smooth curve. There is no need for alarm about his not gaining weight in 4 months, but it is important to recheck his weight and growth in just a few moths to be sure there is no need to look further.Most children have variable appetites, eating well one day and not eating another. Nutrition doesn't have to happen at every meal or even every day as long as it happens over the long haul.
Sincerely,
Dr. Warren
-JKP
Dear JKP: Rashes of any sort generally require a look for a proper diagnosis, so without any visual clues I won't hazard a guess as to your grandson's diagnosis. If he doesn't seem sick, you shouldn't be alarmed. But after 6 weeks your doctor should either be telling you a diagnosis and explaining to you what the course is, including such information as to whether the symptoms should be persisting so long and why, and what the treatment options are, or, if your doctor does not have those answers, he should refer you to a dermatologist.Sincerely,
Dr. Warren
-T
Dear T: There is no question that some children are more prone to some infections while others are affected more often by different infections. Over the years we've seen families that are constantly doing battle with strep throat while other patients of ours have never had strep. Some children have constant ear infections and others never have them. I could go on with examples. There are probably differences in people's immune systems that may account for some of the differences regarding infections, but immunity is not the only factor.Some children are more prone to bronchitis and pneumonia because of hyper-reactive airways. As time goes by it may become evident as asthma.
Many children who have recurrent ear infections have parents or siblings with a similar history. Their facial structure may contribute to malfunction of the Eustachian tubes making them prone to ear infections.
Since the three primary problems, sinus infections, pneumonia, and ear infections may be complications of upper respiratory viruses, environmental factors may play a role in the baby's risk of catching these upper respiratory infections (URIs). Exposure is the most important issue. URIs spread readily in daycare. Young infants who have older siblings often have greater exposure because the older kids come home from school with colds. Careful hand washing can help decrease the spread of URIs. So can limiting your daughters exposure to people with URIs. Often friends and relatives object to being kept away. They say, "It's just a LITTLE cold," or they say nothing at all about having a cold. But in your daughter's situation, catching little colds risks big time secondary bacterial infections.
Perhaps your child deserves reevaluation by a Pediatric ENT specialist to determine if there are any sinus or facial abnormalities or adenoid enlargement contributing to the problem. If allergies have been conclusively ruled out it might be wise to have a sweat test done to check for Cystic Fibrosis. Although there is a real downside to excessive use of antibiotics, your daughter may be a candidate for prolonged treatment of her sinuses to be sure they are fully clear, or for long term low dose prophylactic antibiotics to prevent reinfection of the ears to allow time for complete healing.
Sincerely,
Dr. Warren
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