12 May 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
-VKL
Dear VKL: Mouth sores (also known as canker sores) may develop for a variety of reasons. Herpes simplex virus may cause mouth sores. Usually the primary Herpes infection causes mouth sores; swollen, sore, and bleeding gums, and fever. Recurrences of Herpes cause fever blisters.
The inside of the mouth is lined by a membrane which must continually renew itself. During periods of stress or illness this cycle may be interrupted resulting in ulcerations - canker sores.
Trauma is a very common cause of mouth sores. Injury with a toothbrush or dental appliance such as wires from braces can cause canker sores.
Frequent recurrences of canker sores may sometimes occur with chronic disease or immune deficits such as neutropenia. A medical evaluation is warranted for anyone who has an ongoing problem with canker sores.
Most canker sores heal uneventfully. Glyoxide, which is a peroxide preparation, can be used to keep the sores clean and speed healing. The discomfort can be helped with local anesthetics such as the Oragel. Large mouth sores, especially on the tongue, can be painful and slow to heal. Your doctor can prescribe Kenalog in Orabase to apply to speed the healing.
Sincerely,
Dr. Warren
Thank you for any information you could give us.
-KN
Dear KN: Sometimes a large head may be just that, a large head, and nothing to worry about. But the most important thing to be sure it is not, is hydrocephalus, which is excess fluid in the brain. Hydrocephalus develops when too much fluid is produced or fluid drainage is not adequate. Without treatment the excess fluid causes a build up of pressure which can damage the brain. Hydrocephalus is treated surgically by placing a shunt to drain the fluid. Early treatment of hydrocephalus prevents damage to the brain.
Sonograms, also known as ultrasound, are an excellent noninvasive tool to look for hydrocephalus. Ultrasound is used to follow fetal development in high risk pregnancies. Ultrasound is completely harmless.
Sincerely,
Dr. Warren
-(anonymous)
Dear 15 year old boy: Your symptoms may be nothing more serious than migraine headaches, but they could be caused by a variety of things, some potentially serious without appropriate treatment. Four weeks is too long to have severe headaches and nausea. Finding a better pain medicine is not the answer. Proper treatment requires proper diagnosis, and this can only be done by a complete medical evaluation. Call your doctor for an appointment as soon as possible. And let me know what happens.
Sincerely,
Dr. Warren
-AR
Dear AR: Nine years old is early to start menstruating, but not unheard of. Puberty generally progresses in a orderly fashion. For girls, the first sign of puberty is breast development. This is followed by enlargement of the breasts and development of pubic hair. Menstruation occurs after these two steps associated with an increased growth rate.
If a girl appears to be menstruating without having appropriate associated pubertal development she needs evaluation to determine the cause of her menstruation.
Puberty should not start in girls before eight years of age. Occasionally girls will have early breast development without further progression of the puberty and this is not worrisome. If your daughter's puberty started early she should be evaluated to determine the cause. Sometimes no cause is found, but precocious puberty can be caused by glandular and central nervous system abnormalities that would need evaluation to be diagnosed and properly treated.
Early menopause is not a risk of early menstruation, but early cessation of growth is. If your daughter started puberty early she may grow very rapidly, but she will finish growing early and her final height may be short depending on what her height is now.
If you consider the potential concerns I have brought to your attention I think you will agree that your daughter deserves a complete physical by her pediatrician to determine if your daughter needs further evaluation for precocious puberty.
Sincerely,
Dr. Warren
-(anonymous)
Dear Parent: Sleep is a necessity, but how we go to sleep is a learned behavior. If your child were an easy child, he would have learned to put himself to sleep in a satisfactory manner a long time ago. Unfortunately, his current sleeping habits have become ingrained. It will not necessarily get easier to change his sleeping habits when he gets older.
You say you have tried letting him scream and it doesn't work. On that basis, I can assume that you are doing something else to get him back to sleep. Whether you are taking him into your bed, feeding him, walking with him, rocking him, or whatever else, he has learned to depend on that specific intervention to put himself to sleep. He considers it his right and he will continue to demand it. Naturally he screams for what he believes is rightfully his. If he weren't a screamer, you probably wouldn't still be doing whatever it is you're doing. Children's cries weren't meant to be ignored. If a child's cry didn't tear at his mother's heart the human species wouldn't have survived. But children are not always capable of distinguishing between what they truly need and what they want. You as the parent have to make that distinction and set limits. In the middle of the night when all you want to do is get back to bed it's pretty tough to set limits. Naturally, you chose an intervention that got you back to sleep as quickly as possible, but the price you are paying for your choice is that your son still demands the same intervention.
Whatever it is you're doing to get him back to sleep, you have to wean him from it. If you're giving him bottles, cut down the amount and water down the contents until you're just giving him a little water. Then it's time for cold turkey. If he's coming into your bed, switch to comforting him in his bed. If you're comforting him or walking with him, gradually decrease the time spent with these interventions. You will eventually end up putting him into bed awake resulting in protests. You may go back briefly to comfort him and check on him, but you have to make it clear that he is going to stay in his own bed.
If you're not putting him into bed at night awake, you might want to try teaching him to go to bed in his own crib before you try to teach him to go back to sleep in the middle of the night. It might seem like looking for trouble to put him into the crib awake, but the whole concept you're trying to teach your son is that he can fall asleep in his own crib, and it's easier to deal with the inevitable tears and screaming at 9 PM than 4 AM. If your son doesn't know that he can fall asleep in his own crib he has to experience it to learn it.
Most parents who tell me they've tried letting their child scream and it hasn't worked don't have realistic expectations regarding what they can accomplish and how long it will take. You can teach a child to stay in his crib. You can eventually teach him to be calm while he's there. And eventually he will learn to fall back to sleep. But you can't teach him not to wake up. However, once he learns to calm himself and to fall back to sleep in his crib, his awakenings will be brief and he will be on the road to developing good sleeping habits.
Many parents ask me how long it's okay to let their child cry. Once you've weaned your child down to the minimal intervention and face protests and tears you can't set an arbitrary time limit for yourself. If you decide that you can't let your child cry more than half an hour, he will learn to cry for at least half an hour in order to get your intervention. If you have a real screamer on your hands you could be in for several hours of screaming, and the first few nights there may be multiple awakenings with very little sleep. You can't afford to take that step unless you have the resolve to see it through. Any halfhearted efforts will teach your child to scream longer and for more days. During this phase you must make your intervention only long enough to make sure your child is okay and to make it clear to him that he isn't being ignored but he is staying in his bed. From that point the length of time crying will decrease progressively over a period of days to weeks. The number of awakenings will also decrease once he adjusts to not being taken out of his crib. But if your son's natural sleep rhythm includes one or two awakenings per night it could continue for a few years with some brief crying. Your response should be to check him briefly and tell him, "Everything is okay. Go back to sleep."
It won't be easy. If it were you would have done it months ago. It isn't a matter that you've done something wrong, because you haven't done him any harm. But you are clearly asking for a change. When you are ready, do it and don't turn back, no matter what.
Sincerely,
Dr. Warren
-DSO
Dear DSO: For more information about Kawasaki Syndrome you might like to look at the first letter ever sent to "Ask Dr. Warren." Please note the information about NORD as a source of additional information for you.
The diagnosis of Kawasaki is made clinically since there is no specific test to make the diagnosis. To make the diagnosis certain clinical criteria have to be met. These include a minimum of 5 days of fever, conjunctivitis, rash, strawberry tongue, swollen glands, peeling of hands and feet usually after edema of hands and feet. Not all signs need to be present to make the diagnosis. There are probably patients who have mild cases of Kawasaki who will not be diagnosed since the diagnosis requires meeting certain criteria.
Kawasaki is not known to be contagious. Your son's exposure to a child who had Kawasaki some time ago does not increase his risk.
Thrombocytosis is a nonspecific finding which follows many illnesses as a part of the inflammatory response. Since the thrombocytosis associated with Kawasaki is generally significant finding thrombocytosis helps corroborate the diagnosis.
Since Kawasaki is an inflammatory disease most Pediatric Rheumatologists are experienced at diagnosing and treating it. Since Kawasaki has many features of an infectious disease, Pediatric Infectious Disease specialists are also well versed in dealing with Kawasaki. If you are seeking a second opinion you should seek consultation with one of those specialists soon. If your pediatrician has even the slightest inclination to consider the diagnosis of Kawasaki, he should send you to a Pediatric Cardiologist and obtain a baseline echocardiogram to measure the coronary arteries.
Sincerely,
Dr. Warren
-DH
Dear DH: 14 to 16 hours of sleep a day is certainly above the average for an 8 month old, but some children need more sleep than others. The question you need to ask is, "How alert and active is your child during the 8 to 10 hours he is awake each day?" If your child is vigorous, happy, and playful, if he has a good appetite and is growing well, and if your pediatrician has found him to be healthy at his check ups, then there is no cause for concern.
Sincerely,
Dr. Warren
Thanks is advance
-LW
Dear LW: The risk of disease from traveling to Israel is small; however it is advisable to be protected against Hepatitis A. This is different from the Hepatitis B vaccine. An injection now will protect him for his trip to Israel. An booster injection 6 month to 1 year later will provide him with at least 10 years of immunity.
In the USA routine polio boosters are not given after the 4-6 year booster, however, boosters are recommended if there is an outbreak. A few years ago polio boosters were recommended for travel to Israel. At this time, polio has almost been eradicated in most of the world; however, the CDC still says to consider a polio booster for travel to the middle east (not specifically Israel). See http://www.cdc.gov/travel/mideast.htm. Currently the WHO lists the middle east as one of the six emerging polio-free zones in the world. See http://www.intmed.mcw.edu/ITC/PolioRisk.html.
Sincerely,
Dr. Warren
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