26 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
Thanks!
-RD
Dear RD: There are several possibilities regarding what could cause mild diarrhea with occasional vomiting in a 3 month old. As long as the symptoms remain mild, none of the possibilities is serious.
Most children who have vomiting and diarrhea have gastroenteritis, an intestinal virus. It usually runs its course within a few days to a week, but it may sometimes take several weeks for the stools to return completely to normal. The main concern with gastroenteritis is to prevent dehydration. If a child has good fluid intake and little fluid loss then he should not get dehydrated. Since your infant has no more than 4 stools per day and they are not all large watery stools, his fluid loss isn't large. To prevent dehydration when infants have vomiting or diarrhea you should use an electrolyte solution like Pedialyte. Offer him some after each diarrheal movement. He may drink up to 1 quart per day.
If he should start vomiting and not retaining any fluids then he could become dehydrated. In that case you would stop all food and formula and offer small, frequent feedings of Pedialyte. If he continued to vomit even the Pedialyte you would need to see the doctor.
Sometimes babies can develop a formula intolerance which may cause diarrhea. This is not a major likelihood on a soy formula like Prosobee, but if the symptoms persist, a hypoallergenic formula like Alimentum or Nutramigen may help.
Some babies develop diarrhea with colds from swallowing mucus. Others may have slight diarrhea with teething.
Sincerely,
Dr. Warren
-MRO, M.D.
Dear Dr. O: Thank you for your kind words. I have not given much thought to the issues you raised in your e-mail.
When I answer an e-mail from a patient I try to make my answer as general as possible providing as much education to the patient as possible so they can make educated choices. I don't think this constitutes providing treatment or practicing medicine. If it does, it isn't only a matter of state licensing. I've gotten questions from as far away as Hong Kong.
As far as malpractice, I hope that my style of writing doesn't leave room for liability. I give reassurances to patients when it is appropriate, but I always suggest they seek medical care for any persistent or worrisome symptoms, and there is a disclaimer on my page. In fact, I'm more inclined to suggest appropriate specialists for my e-mail questions than I am for my own patients since I know better what's going on with the patients I see. I guess I should consider liability more, but in 20 years of practice, the only malpractice suit I've been involved in was settled for $1. I've never even discussed my web site with my malpractice carrier.
I do not charge for advice. I wouldn't know how. But I wouldn't want to. It's something I do in my spare time which is decreasing as we speak. I enjoy doing it, and, some of the questions force me to research my answers which means I learn in the process.
As a result of my web site I was approached to host a Pediatric web site for the Mining Company. I won't go into details about their project in this e-mail. Let me suggest that you check their site at http://www.miningco.com and see what you think of their project.
Sincerely,
Dr. Warren
Thank you.
-SG
Dear SG: Plantar warts can be treated at home using a wart remover preparation. These are acids that slowly melt the wart. They include products like Duofilm, Transversal, and Compound W. They come as liquids and patches. If the instructions are followed properly a wart can be melted away in 3-4 weeks. It may require removal of excess callous and dead skin periodically with an emery board or pumice stone. Before applying such a preparation you must be sure that the thing on your daughter's foot is a wart.
Warts that don't respond adequately to home treatment can be removed by a dermatologist. Plantar warts can also be removed by a podiatrist.
Sincerely,
Dr. Warren
-Thank You,
S & C A
Dear Mr. & Mrs. A: Every time we use antibiotics, whether for a good reason or not, we risk increasing the load of resistant organisms in the environment. And if a child who has just been on an antibiotic develops an infection, there is a greater likelihood that the infection is caused by an organism that is resistant to the antibiotic that was just used. But children don't become resistant to antibiotics. Only germs do. When there is a sound medical reason to put your child on antibiotics, he should be treated with antibiotics, but when there is no clear indication to use antibiotics, they should be avoided.
If a child has had recurrent infections, prophylactic antibiotics given once daily in a low dose for one to two months can sometimes prevent reinfection for a long enough time to allow complete healing of the middle ear and avoid the cycle of persistent middle ear fluid followed by recurrent infection. Children who do well on this regimen may sometimes stay on low dose antibiotics for 4 to 6 months in an attempt to avoid surgery. The response to antibiotic prophylaxis is approximately the same as the surgery.
Children who have persistent middle ear fluid (not intermittent) for 4 months or more with hearing loss are candidates for tubes. Children who have persistent fluid with recurrent infection for more than 4 months are also candidates for tubes, especially if prophylactic antibiotics have failed to prevent reinfection. A child whose ear infections won't clear after multiple courses of antibiotics is also a candidate for tubes. Sometimes an adenoidectomy is also necessary, and sometimes an adenoidectomy alone is sufficient without drainage tubes.
Four ear infections during the winter may be sufficient cause to consider surgery, but it depends how well your son's ears cleared between infections, how much time there was between infections, and whether or not his hearing is affected. During the spring most children with ear problems start to do better, so you might want to wait depending on your son's status right now. A consultation with an ear specialist is not a commitment to surgery. In fact the specialist may recommend against surgery if this is not the right time to consider it.
Sincerely,
Dr. Warren
-Love,
Kim
Dear Kim: The job description for a doctor may vary considerably depending on whether he works in an emergency room or an office. The job description will also change depending on the doctor's specialty. A doctor who is a surgeon may spend a lot of time in the hospital and the operating room. A radiologist would spend his time doing special x-ray procedures and reading the x-rays. Most of the doctors you have seen work in an office seeing patients which is what I do.
I see children for checkups. I examine them and give them shots to keep them healthy. I examine sick children to find out what is wrong with them and prescribe treatment to make them better. I suture lacerations in my office and give children with asthma breathing treatments to relieve their wheezing.
I start seeing patients in the morning after answering questions on the telephone for 1/2 hour. At lunch time I make hospital rounds if I have any patients in the hospital. Then in the afternoon I see more patients. I also have a lot of paper work to do. I have to fill out referral forms and insurance forms and write notes in charts so that I remember what I've done with each patient when they come in again.
Sincerely,
Dr. Warren
Developmentally, she seems fine. She is slow with her gross motor skills but she is a very big baby (24 lbs). She sits, reaches, attempts to pull up. She does not have good strength in her legs as when pulled to standing position, her legs buckle. I use a GP and thought before I take her in, I would ask you.
One other area of concern is that she is very very difficult to feed solid food. She refuses it 80% of the time and eats very little. I have tried just about every kind of baby food, which she really hates. I can get her to eat table food but she usually gags and chokes and then refuses to open her mouth. She can pick up cheerios and small finger foods and does fine with them. She can drink from a cup as well.
Thank you for any advice you can give. I am a busy mom and this is one way to communicate! Please email your response as I don't get much time to search message boards right now!
Thanks
-DH
Dear DH: The problem you describe may be nothing at all to worry about; however, tics and mannerisms are very unusual in a child as young as 8 months old. If, in your experience as a mother of six children, you feel your daughter is exhibiting some strange movements and these are more than occasional, she should be evaluated by a neurologist to be sure she doesn't have a movement disorder.
Since your daughter weighs 24 pounds (which would be excessive for most 8 month olds, but it depends on her height), I don't think you need to worry about her nutritional status. Since she prefers table food you should continue to offer it as her skills in handling it will increase. In the meanwhile, she must be getting the nutrition she needs from whatever she does eat plus what she drinks. Milk is a complete food.
Sincerely,
Dr. Warren
-MHR, Cairo, Egypt
Dear MHR: 1. Giardia may persist in the intestines of adults and older children for years without causing symptoms and may disappear spontaneously. Younger children often have gastrointestinal complaints related to Giardia. The most common complaints seen in both children and adults with Giardia are diarrhea and bloating. These symptoms may be intermittent, resolving spontaneously and recurring months later. Usually the infection can be completely eradicated with medication. The persistence of cysts means the persistence of infection. The issue of treatment depends on whether or not your son is symptomatic. But be aware that as long as he is shedding cysts he could spread the disease to someone else.
2. It is certainly possible and therefore likely that his intestinal symptoms were caused by Giardia.
3. If glandular fever is the same thing we call Mononucleosis in the USA, the blood results are certainly compatible with that diagnosis. However, the rash of scarlet fever is quite distinctive and not at all typical of Mononucleosis. There is a high carriage rate of Streptococcus with Mononucleosis, and Streptococcus causes scarlet fever. Since your son did not complete his course of antibiotics, if he is still sick his throat should be cultured for Strep to determine if more antibiotics are needed. A blood test for Mononucleosis can confirm that diagnosis. There is no special treatment for Mononucleosis, but knowing his correct diagnosis will help you know what to expect regarding the course of your son's illness.
His cracked lips could be the result of having been ill so much and may respond to Vaseline Lip Balm; however, cracked lips could also be seen as part of Kawasaki Syndrome. This illness is characterized by a persisting high fever for 5 or more days, a scarlet fever type rash, conjunctivitis, edema of hands and feet with subsequent peeling, cracking of lips, swollen glands. If your son's course fits the description of Kawasaki, he should see his doctor again for reevaluation including evaluation by a cardiologist. For more information about Kawasaki please check the letter about it in the first Ask Dr. Warren column.
Sincerely,
Dr. Warren
-ST
Dear ST: The range of normal heights for children is quite large so that a big 4 year old may be taller than a small 6 year old, and yet both of them may be experiencing normal growth. Since you didn't give me any measurements, I cannot be sure whether or not your nephew is really short or just at the small end of normal. To determine if there is a problem, it would also be useful to know what his past growth pattern has been. His pediatrician should be plotting his height and weight on a standard growth chart to see if his growth pattern is satisfactory.
The treatment of short stature is dependent on the cause. If it is familial, there is nothing to be done about it. If a child is abnormally short, he needs evaluation to check for chronic infection, cardiac disease, and endocrine gland diseases such as hypothyroid and growth hormone deficiency. The simplest place to start such an evaluation is with a wrist x-ray for measuring the bone age. If the bone age is abnormally delayed, further evaluation will be needed.
Sincerely,
Dr. Warren
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