9 June 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
-PD
Dear PD: In early infancy true milk allergy can cause chronic congestion which can lead to ear infections and sinusitis. Pneumonia would be an uncommon complication unless the infant's allergies also resulted in asthma.
I'm afraid I don't know what article you are referring to or what milk bacteria might cause a problem. Milk intolerance has been considered in the lay literature and alternative medicine literature as a potential cause of many ills, including diabetes, but no proof has come out of any mainstream medical studies to indicate that milk consumption is unhealthy to the masses. Of course, if your children are milk allergic it makes sense to avoid milk. But the vast majority of people have no problems with cow's milk, and the vast majority of ear infections have nothing to do with drinking cow's milk.
Sincerely,
Dr. Warren
-PD
Dear PD: How unfortunate that your children suffered from symptoms of milk intolerance for so long. Even the majority of pediatricians who are not convinced that milk is an evil food causing all kinds of diseases recognize that some children don't tolerate cow's milk. I and most of my colleagues would very readily try a colicky baby on a milk free formula to see if it helped.
As regards ear infections and allergy, you might be interested in the material at http://home.earthlink.net/%7Emeear/. Dr. Hurst presents a convincing explanation as to the mechanism by which allergy may contribute to ear infections even in the absence of nasal congestion. Even with his explanation and even accepting that some children who are allergic to milk have ear problems as a result, it would be a big step to say there is evidence that milk is the major culprit.
Dr. Oski is a well known and respected pediatrician. When he expresses a controversial opinion, which he is known to do with some regularity, it makes the newspapers and challenges all pediatricians to think critically about their long held views. But when famous pediatricians like Dr. Oski make such statements it doesn't constitute proof. When I did my training at Montefiore Hospital, as I recollect, Dr. Finberg, the chief of pediatrics at the time, and a well known pediatrician, stated that there is never an ear infection hidden by ear wax because the heat of the infection melts the wax. His explanation was plausible, but I've found many ear infections after cleaning out wax that obstructed my view.
The interest in a link between diabetes and cow's milk is old news. The basis for the interest is related to cow's milk antibodies in diabetics. But if a link had been established, the American Diabetes Association would be spreading the news and no physician in his right mind would choose to ignore it. The medical profession demands proof for a good reason, and that proof is lacking.
For those mothers whose children have demonstrated difficulty with cow's milk like yours have, there is no question about what to do. They must avoid cow's milk. I certainly have patients who don't tolerate milk. But for me to take my experience with those patients and jump on some bandwagon warning mothers about the evils of milk would be a great disservice to the significant number of children who tolerate milk and depend on it for good nutrition.
Sincerely,
Dr. Warren
-Ann
Dear Ann: Disposable diapers are quite popular in the USA and are very widely used. It is true that diapers retain heat, and it is also true that the testicles are outside the body because sperm production occurs best at a temperature below body temperature, but I have never heard that Leydig cells can be damaged by using disposable diapers. I am quite certain that pediatricians in the USA are not providing any warnings to parents about any such risk. I know of no link between disposable diapers and impotence.
Sincerely,
Dr. Warren
-AG
Dear AG: The best general scale for child development is the "Denver Developmental Scale." I don't know if it's available on the web, but it should be available in a variety of texts on child development in your library. Although self help skills like dressing and brushing one's teeth are included in the scale, wiping one's own bottom is not. To be honest, I don't know if there is any standard on that matter. But if the child is used to having someone do it for him, he needs someone to guide him gently to do it for himself. In asking him to learn to do things for himself be careful to present it as a benefit to him and to let him know that you will be available if he does need help. Considering his current circumstances he may cling to having things done for him just to feel that someone cares for him.
30 pounds is significantly underweight for a 5 year old, but the significance of this can only be determined by looking at his long term growth. What does his pediatrician say? I realize that the divorce and custody issues create a difficult situation, but the child must be getting care somewhere or the local child welfare agency should be looking into the situation.
By themselves the hygiene issues you raise don't suggest any behavioral issues in a 5 year old. He will learn from the adults around him. If his mother does things one way and you do them another, just patiently explain your way and expect that you will need to continually reinforce it since it isn't what he is used to.
Of course it is beneficial for a 5 year old to have prior experience with socialization, but children don't have to get to kindergarten with a lot of experience. Rather than being concerned about how he will do in kindergarten, consider the opportunity that it will provide him to experience a world other than his mother's on a regular basis. A 5 year old has plenty of time to learn and grow. It will be up to the teacher to help him fit in.
Your job now is to provide a stable, loving environment. That means avoiding involving Kyle in any negative discussions regarding his mother. Right or wrong, she is his world now. He can learn to do things your way and appreciate what you offer him without denigrating his mother. You may not see how much it is doing for him to be with you on weekends but I assure you it is.
Sincerely,
Dr. Warren
-ML
Dear ML: Sometimes the eye drops can sting a little. If that is why your child is fighting you, you may be better off with the ointment. The drops are generally easier to put in. Be sure to put them into the sac formed between the eye and the lid when you pull down the lower lid rather than dropping them directly onto the eye.
To force drops on an uncooperative child take a large towel or sheet and drape it over the child's shoulders with the opening to the back. Crisscross the towel behind the child's back so that it holds his arms against his body. Lay the child down on the floor on his back so that his body weight holds the towel. Sit with his head between your legs or in your lap. If necessary cross your legs over his body. Hold his head steady from the top with one hand. With one finger of the same hand pull up the upper eyelid. Rest the hand that holds the dropper on his face and pull down the lower lid with a finger of that hand. If you succeed in getting one drop past the lids that will be sufficient, but drop at least two to be sure.
Good luck.
Sincerely,
Dr. Warren
-LW
Dear LW: The rash of chicken pox starts as oval patches that blister, crust, and then scab. As they go through these various stages new ones continue to come out for 4 or more days so that the patient has pox in all stages of development. By your description your daughter could NOT have had chicken pox. She may have had hives, but since I didn't see them, I cannot be sure.
Sincerely,
Dr. Warren
Up to about 2 weeks ago everything was going fine - she was taking about 700ml per day (ie. 26 oz). We also added in a heaped teaspoonful of cereals in the morning and night feeds. At about this time we also started trying to start her on solids (cereals).
However, suddenly she just lost her appetite. It started with possetting a large portion of her some of her feeds one day. The next day she had her DPT (2nd round). Ever since that time her appetite has been poor - by that I mean that she only takes about 400 - 500 ml (13 - 16 oz) per day and up to now she is still taking that quantity. She also takes a small portion of solids, about one tablespoon of cereals or carrots a day.
I have tried to feed her more but each time she just cries and keeps pushing the bottle away or not sucking / swallowing her feed. Now I'm very worried that she is undernourished.
She does seem to be putting on weight and is currently about 6.7kg (15 pounds). She also continues to wet her nappies and pass motion. She is also the same in terms of personality which is quite active and very responsive.
Initially I had thought that it was just a phase she was going through, but now that it's gone on for so long I'm concerned that there may be a problem. What should I do??
-Worried & Stressed Mother
Dear Worried & Stressed: Sometimes, after an illness, babies take a while to regain their appetites. At the age of 6 months the growth rate slows down somewhat, and so there may be some decrease in appetite anyway. Still, at 6.7 kg., in order to gain weight your infant would need around 700 ml. or more per day.
The best way to gauge whether or not an infant is eating enough is to follow their growth and weight gain over a period of time. If she is gaining and growing properly and is otherwise happy and healthy, there is no reason to worry. If her intake remains low, you will have to be sure to have her growth checked periodically.
There is no special method to get babies to eat more. If your child is not growing adequately, then you and your doctor will need to look for a reason. If a baby doesn't consume enough calories, of course it will affect growth, but it is also true that if a baby isn't growing, he will need, and therefore consume, fewer calories.
If there were any changes in the diet just before the change in appetite this may serve as a clue. It is possible that your baby isn't tolerating the cereal. Or if the cereal has made her constipated that might decrease her appetite. Perhaps you should consider eliminating the solids and see how she does on just formula.
In the end, it will really depend on what her growth and weight gain is doing. So have her weight followed carefully by your pediatrician.
Sincerely,
Dr. Warren
She seems to always want her bottle in her mouth but never actually sucks on it. I have tried a pacifier but did not succeed. When she wakes up if I give her a bottle she goes directly back to sleep but when I take it out of her mouth she wakes right back up. Her pediatrician recommended giving her a bottle of water, which worked temporarily. I am at my wits end. Do you have any suggestions?
She was diagnosed with reflux (urinary) at about five weeks. She takes Septra every night at bedtime. Does this have anything to do with the waking up since she has been taking the same medication since about six weeks?
Thank You.
-VB
Dear VB: Septra has a number of side effects which might make a child uncomfortable, but this should be evident during the day. Insomnia is also listed as a side effect of Septra, but strictly speaking, your daughter is not an insomniac because she goes right to sleep when you give her a bottle. An insomniac can't fall asleep, whereas she doesn't stay asleep. Even assuming that her sleep is disturbed because of a side effect of the Septra, the problem at hand is that since she developed this sleep disturbance she has become a "trained night feeder." That means that she uses drinking a bottle to put herself to sleep. The only way to stop giving her bottles in the middle of the night is for her to learn to go to sleep with out one.
Sleep is a necessity, but how we go to sleep is a learned behavior. Whether you are taking your daughter into your bed, feeding her, walking with her, rocking her, or whatever else, she has learned to depend on that specific intervention to put herself to sleep. She considers it her right and she will continue to demand it. Naturally she screams for what she believes is rightfully her. 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 daughter still demands the same intervention.
Whatever it is you're doing to get her back to sleep, you have to wean her from it. If you're giving her bottles, cut down the amount and water down the contents until you're just giving her a little water. Then it's time for cold turkey. If you need to comfort her or walk with her, gradually decrease the time spent with these interventions. You will eventually end up putting her into bed awake resulting in protests. You may go back briefly to comfort her and check on her, but you have to make it clear that she is going to stay in her own bed.
If you're not putting her into bed at night awake, you might want to try teaching her to go to bed in her own crib before you try to teach her to go back to sleep in the middle of the night. She is just about at the age for separation anxiety to add to the problem. It might seem like looking for trouble to put her into the crib awake, but the whole concept you're trying to teach your daughter is that she can fall asleep in her own crib, and it's easier to deal with the inevitable tears and screaming at 9 PM than 4 AM. If your daughter doesn't know that she can fall asleep in her own crib she 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 her crib. You can eventually teach her to be calm while she's there. And eventually she will learn to fall back to sleep. But you can't teach her not to wake up. However, once she learns to calm herself and to fall back to sleep in her crib, her awakenings will be brief and she 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, she 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 her that she isn't being ignored but she is staying in her 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 she adjusts to not being taken out of her crib. But if your daughter'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 her briefly and tell her, "Everything is okay. Go back to sleep."
Since the Septra may be contributing to the problem, you might ask your doctor about trying a different antibiotic, but since all antibiotics have side effects, you may find the Septra to be the best alternative. In any event, I think that your daughter has gotten into a bad sleeping pattern habit. Even if that was precipitated by side effects of the medicine, it would probably require retraining her sleeping habits even if the medicine were stopped or changed.
Sincerely,
Dr. Warren
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