19 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
-SA
Dear SA: Excess fluoride can be as bad for the teeth as not getting fluoride. The recommendations for fluoride supplementation were changed in the past 2 years because the recommended doses at the time were high enough to cause fluorosis of the teeth in some children. In areas where the water is fluoridated supplementation recommendations depend on the concentration of fluoride in the water. When the water is not fluoridated a daily supplement of 0.25 mg should be started when the baby is 6 months old, not earlier. The dose should be increased to 0.5 mg at 3 years of age and then 1 mg at 6 years of age. The fluoride supplement should be given until 14 to 16 years of age.
Sincerely,
Dr. Warren
Every year, without fail, one of my players gets a bloody nose. I've received conflicting advice over the years as to the appropriate remedial steps. Years ago, I was told to have the patient lean his head back until the bleeding stops.
Recently, I was told the forementioned "lean back" approach is problematic as the patient can then drown in his/her own blood.
Can you give me your advice as to the appropriate course of action and an explanation as to why this is the optimal approach? Thank you.
-SK
Dear SK: Most nosebleeds come from low down in the nostril along the septum (the part that divides the nose into two nostrils). Since the septum goes only part way up, nosebleeds from high in the nose come out of both nostrils at the same time. A nosebleed can be recognized as coming from the lower part of the nose because it comes out of only one nostril except on the rare occasion that the bleeding is so profuse that blood goes up over the septum and comes out the other nostril as well. The proper way to stop these nosebleeds is to put pressure on the bleeding point just as you would a cut or scrape on any other part of the body. To do this, the entire fleshy part of the bleeding nostril should be pressed firmly closed against the septum for 5 full minutes. This will stop the bleeding and avoid formation of a large clot which can get knocked free easily resulting in more bleeding. Pressing on the upper, bony part of the nose is useless since it can t put any pressure on the bleeding point.
Bleeding which can't be successfully stopped with external pressure may require a nasal pack. The bleeding nostril should be packed with Vaseline gauze. If dry gauze is used its removal will dislodge the clot and the nose will start to bleed again. Bleeding from high in the nose (both nostrils) that doesn't stop spontaneously may require a posterior pack which must be placed by experienced medical personnel. An ice pack over the bridge of the nose may help because the cold will cause constriction of the blood vessels.
Putting the head back will do nothing to stop a nosebleed. It just changes the direction of the blood flow so that the patient ends up swallowing it instead of having it run out his nose. However, if the patient is conscious, I cannot see how he could drown in his own blood. A conscious person would choke and gag on any blood that was going near or into his windpipe, and rather than suffocate, the person would instinctively fight to put his head forward to stop the flow of blood down his throat.
Sincerely,
Dr. Warren
-Britta's Mom
Dear Britta's Mom: The most common cause of a foul brown discharge from a little girl's vagina is a foreign body, usually toilet paper. Sometimes this may be a recurrent problem because of the way the girls wipe themselves.
Inflammation of the vagina, called vaginitis, is fairly common in little girls, but is not generally as severe as you describe your daughter's problem. Even though you may never see any fecal contamination of the vaginal area, the area is always contaminated by bacteria from the stool. The risk of developing vaginitis will be increased by wiping from back to front, wiping back and forth, wearing synthetic rather than cotton underwear, and by taking bubble baths. Antibiotics may also cause vaginitis by killing normal skin organisms and allowing overgrowth of fungi (yeasts) or resistant bacteria.
E. coli is a bacterium normally found in stool. Since the culture was taken from a surface very likely to be contaminated by E. coli the organisms presence in the culture is not evidence of infection. The first antibiotic eliminated the Haemophilus influenza which is why it didn't show up on the repeat culture. Your doctor will have to decide on the basis of the clinical appearance of the discharge and the vaginal area whether this is a nonspecific vaginitis or actually represents bacterial infection, but I must caution that use of antibiotics to treat nonspecific vaginitis based on culture results from contaminated areas may result in finding a different organism which is resistant to the previously used antibiotic each time a culture is taken. Since antibiotics may aggravate vaginitis it may be necessary to give your daughter time off antibiotics.
The best treatment for nonspecific vaginitis is sitz baths. This consists of sitting in a tub or basin of warm water without soap for 10 to 15 minutes 3 or preferably 4 times each day. Application of a bland ointment like Vaseline or A&D may help if there is any discomfort.
Since your daughter has little discomfort, no fever, and no lower abdominal cramps it is highly unlikely that there is any internal infection to be concerned about. It is also not likely to be contagious through casual exposure such as bathing together. However, asymptomatic infections do occur with gonorrhea. Since gonorrhea does not show up on a routine culture, the culture must be done on the appropriate growth medium and the test must be specifically requested. Sexual contact without penetration or physical signs of abuse can result in gonorrhea.
Sincerely,
Dr. Warren
Thanks for your time.
-LO
Dear LO: People inherit their appearance from both their parents. The genetic material that tells the body how to look is carried on chromosomes. Each of the chromosomes is paired. We get one chromosome from each parent for each pair of chromosomes. The chromosomes carry the genes that tell the body what each of its traits such as eye color or skin color will be. For every trait we inherit there are two genes, one on each chromosome of the pair.
Some traits are recessive traits and some are dominant. Light hair and light eyes are usually recessive traits, whereas dark hair and dark eyes are dominant. That means if a person has one gene for dark hair and one gene for light hair his hair will be dark because dark is dominant. In order to have light hair the person needs to have both genes for light hair because light hair is recessive.
Now let's assume that you and your husband have dark hair, but each of you carries a gene for light hair. If you have a child who gets the gene for light hair from each of you, he has tow genes for light hair, so he will have light hair even though neither of his parents do. If his brother got just one gene for dark hair, he will have dark hair and will look different from his light haired brother.
Sometimes brothers can look very similar, but other times they can look very different because of how the genes combined. Same with blood type.
One other variable is spontaneous mutation. Sometimes the genes we inherit change so that a child can have a gene that neither parent has. This can occur with albinism, a disorder of pigment which results in very light skin, white hair, and very light eyes.
Sincerely,
Dr. Warren
-SL
Dear SL: Alphafetoprotein (AFP) is produced by the neural tube. Elevations of AFP can be associated with neural tube defects such as meningomyelocoele and anencephaly. Low AFP can be associated with Down's syndrome. What one must keep in mind is that the association relates to an increased risk, but not a guarantee of a problem. If your friend has a 1 in 100 chance of having a Down's baby, she has a 99 in 100 chance of having a healthy baby. She must decide, based on those risk factors, based on what she would do if she knew she was having a Down's baby, based on the fact that the risk of Down's is lowest with young women and highest with older women, and based on discussion with her obstetrician, whether or not she wishes to have an amniocentesis.
For an excellent article on AFP please check http://www-leland.stanford.edu:80/~holbrook/X-AFP.html on your web browser.
Sincerely,
Dr. Warren
-K & R
Dear K & R: Don't worry about norms such as 12 hours of sleep being average. If your son slept 10 hours every night you can plan around it and that would be fine. Children vary in their need for naps, but since your son isn't sleeping at night, he needs more nap time. But if he gets lots of naps, he needs less nighttime sleep. Try to find just the minimum amount of nap that will make daytime livable and nighttime sleepable.
Two year molars may sometimes come in as early as 18 months, but even if teething is aggravating your child's sleeping problem, it isn't the cause of it.
Remember to be consistent in your approach to your child's sleeping. Whether you find the advice I gave you or the advice you find in a book your favored approach, stick with it over the long haul. Desperate people often jump from one approach to the other looking for a quick fix, but this doesn't give the difficult child a chance to settle into a routine.
Don't let child problems affect your marriage. Parents of difficult children need each other's support. You both need to agree on your approach to your child, but you also need to be realistic about what you can accomplish and how quickly it can be accomplished. This is nobody's fault. And remember, some difficult infants can turn into real joys as children. You also need to find some time for just each other if the stress of parenting is getting to you and between you. Enlist the help of a grandparent or hire a baby sitter and get out of the house together. After you become comfortable with that, do it overnight. If you really can't agree on the management of your child and it's causing marital problems, consider joint counseling before things get worse.
Sincerely,
Dr. Warren
how is this possible?
i'm 22 years old....
i'm very afraid of cancer..... when you do a blood test can they see
if you've cancer?????
when a blood test is ok.... am-i healthy then?
greetings from holland...
-michiel.
(my english is not that good,sorry for that)Dear Michiel: What a doctor can tell from a blood test depends on what test is done. There are many things a doctor can test for in blood, but there are so many tests it would require a lot of blood and cost a lot of money to run them all, so doctors only order the blood tests that are needed for a particular situation. The tests to be ordered have to be determined from the patient's complaints and the findings on examination.
A normal blood test or two can help a doctor rule out certain conditions, but by itself cannot tell a doctor that a person isn't sick. Abnormalities in blood tests can help a doctor make a diagnosis or point the direction for further investigation, but all test results require interpretation by the physician based on the patient's clinical findings.
Some cancers can be tested for with blood tests, but most are diagnosed from other tests which are ordered based on a patient's complaints and findings on examination. You should know that cancer is fairly uncommon in 22 year old men. The most common cancers can be detected by physical examination. Hodgkin's disease causes persisting and progressive enlargement of lymph nodes. Testicular cancer causes a lump on the testicle. Young men should examine their own testicles periodically so that they notice any unusual change.
If you have a specific symptoms that is worrying you, discuss it with your doctor or write back to me.
Sincerely,
Dr. Warren
He did have some sort of eye infection previous to this, and and he was prescribed Gentamicin .3% for his eyes. We put the drops in his eyes for five days, and it was after this point that he remarked about his funny vision. It also turns out that when this happens, he has difficulty with his peripheral vision.
The pediatrician at this point has no clue what this could be, but told us to keep an eye on this. Do you have any clue what this could be? The doctor mentioned a syndrome called Alice in Wonderland Syndrome, but that this occurred for those recovering from mononucleosis. To my knowledge, my son has not ever contracted mononucleosis.
My son is otherwise a very healthy and active child. Any advice or direction you can give me would be very helpful.
Thanks!
-Jo Ann
Dear Jo Ann: Since three of the occasions your son mentioned things looking far away were after sleep it is possible that he is not fully awake. He may be in a dissociative sleep state where his brain is still responding to a phase of sleep even though he appears to be awake. Examples of dissociative sleep states include sleep walking and hypnogogic hallucinations (hallucinations that occur just as you fall asleep or struggle to stay awake while the brain enters an early stage of sleep).
The term "Alice in Wonderland Syndrome" refers to the distortion of sizes seen in the story. This syndrome is associated with migraine headaches and, in fact, the writer of "Alice in Wonderland" was a migraine sufferer. This has also been reported with mononucleosis. Since mononucleosis doesn't always cause a full blown clinical picture, blood work can be helpful in establishing or ruling out that diagnosis.
If the symptoms persist, the possibility of a seizure disorder must be considered. A neurological evaluation including an EEG would be in order.
Eye conditions are not likely to cause these symptoms, but since your son's symptoms started right after conjunctivitis and his complaints are visual, a visit to an ophthalmologist can rule out the possibility that he has some distortion of vision that he is not explaining properly.
Sincerely,
Dr. Warren
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