16 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
-CM
Dear CM: Infants are prone to yeast infections in the diaper area because their immune response is less than an older child's and because the diaper area is moist and warm which is the perfect environment for growing yeast. Antifungal creams don't just mask the infection. If the entire area is treated the cream should cure it, but you must cover the entire rash or it will continue to grow beyond the current border. If the rash is resolved for a few weeks but recurs, your child is having a recurrence because she is more susceptible.
There are a few things that will make a child more prone to recurrent yeast infections. If you are using cornstarch in the diaper area you are providing food for the yeast. Antibiotics increase the risk of yeast infections by killing skin bacteria and allowing overgrowth of yeasts. Yeast infections may be recurrent and difficult to treat in children with immune deficits; however those children generally have other problems with infections to point toward that diagnosis.
Even though yeast infections look very red, they are generally not painful. If your daughter's diaper area is raw, try to clean it without water, soap, or premoistened wipes. Use a dry wipe or tissue to clean most of what needs to be cleaned and then use a tissue with baby oil to complete the clean up.
If her rash is especially resistant to treatment and has been confirmed to be a yeast your doctor could try treating her with a systemic antifungal medication like Diflucan.
Sincerely,
Dr. Warren
-KB
Dear KB: Since most children with HSP have renal (kidney) involvement and your daughter has blood in the urine she should see a nephrologist (kidney specialist), preferably a pediatric nephrologist. This is even more imperative given your family history or renal disease. Since HSP is a multisystem inflammatory disease your doctor might also wish to consult a pediatric rheumatologist regarding her management.
For more information about HSP consult the NORD database at http://www.pcnet.com/~orphan/.
Sincerely,
Dr. Warren
He is 3 yr old and has had small bags under his eyes from birth. The bags have progressively become darker and darker, wrinkles have developed under his eyes, wrinkles have developed over his eye lids, and my wife has found a gray hair on his head.
This seems odd to us and are wondering if you could tell us about the symptoms of Werner's Syndrome, related aging desiese, or possibly something else to consider.
I hope this is enough to at least let me know where to start or what to think of what is happening to him.
Best Regards,
-J
Dear J: Children with Werner's syndrome generally appear normal in early childhood. In later childhood they are slim with a slow growth rate. They have no adolescent growth spurt and generally reach their final height around 13. They develop gray hair around 20, cataracts around 25, and a general appearance of old age between 30 and 40. The diagnosis is usually made in young adult life.
If your child has had bags under his eyes since birth I'm inclined to think that is just one of his facial features. None of the so called "aging diseases" show symptoms of aging at birth. The darkening could be a sign of allergy.
If your child's growth is normal and your pediatrician has found him otherwise healthy you shouldn't worry. If his growth is not normal, since short stature is part of most of these syndromes, your pediatrician might need to check further.
Sincerely,
Dr. Warren
-GP
Dear GP: Children may have greener stool when they have diarrhea, but the color green in otherwise normal stool is not worrisome. The green color comes from bile, but so does the yellow and brown. Formula with iron or an iron supplement tends to make the stool green. It is hard to explain why two children with the same diet don't have the same appearance of their stool, but it happens. If you child is having diarrhea, cramping, loss of appetite, or otherwise seems ill, you should contact your pediatrician. But if your only concern is the color of the stool, you need not worry about it being green.
Sincerely,
Dr. Warren
-ALC
Dear ALC: The best way to determine if there is a problem is to have your doctor review your daughter's actual measurements with you. It would be most unusual for a head to be large enough that a two year old could not put her hands together over her head. Are her legs also short? If you look at her body does she appear to have short limbs with a normal sized trunk? If the answer is yes plus your daughter has a large head, your doctor should consider the diagnosis of achondroplasia. This is a genetic form of short stature. Since I haven't seen your child you must discuss this with her pediatrician. A diagnosis of achondroplasia is not serious; however, it is not treatable and the affected children remain short.
Sincerely,
Dr. Warren
-JS
Dear JS: The math involved in practicing pediatrics is pretty basic. In adult medicine most medications have standard doses, but since children come in such small sizes al the way up to adult sizes medication doses are based on weight. Usually dose information is available in mg/kg, so first I must compute a child's weight in kilos from his weigh in pounds. Then I figure out his dose. Not done yet. The medication will come as a certain number of milligrams/teaspoon. Before I call the pharmacy I have to figure out the instructions for the patient.
Intravenous fluids can be figured out using a table of caloric expenditure, or on the basis of body surface area. I'm sure there's a formula for body surface area, but most pediatricians would just use a nomogram to look up the surface area in meters squared based on height and weight. Of course, if a patient has healthy kidneys you don't have to be so exact. The daily fluid requirement is approximately 100 ml/kg for the first 10 kg body weight, 50 mg/kg for the second 10 kg body weight, and 20 ml/kg for every kilo over 20 kg body weight.
If I read a research paper in a journal it helps to understand the statistical methods they use to draw their conclusions, but I don't use statistics in actual practice and never really studied it.
Sincerely,
Dr. Warren
-BB
Dear BB: If you daughter had never learned to sleep in her own bed I would explain to you in great detail the need to get tough. And in fact I do think you need to be tough in your resolve that she learn and accept the idea that she had better sleep in her own bed. But it is unusual for a child of 3 (the age I calculate the problem to have started) who has been sleeping in her own bed to suddenly have such anxiety about sleeping in her own bed. Therefore I would have to urge you to think back about what might be going on in your daughter's life that might have upset her because dealing with that is part of the solution. On the other hand, it is possible that whatever happened is long past and your daughter simply hasn't relearned good sleeping habits. One of the impediments to her learning to sleep in her own bed is that even if you refuse to let her sleep with you she has the option of sleeping with big brother. Big brother may not mind, but little sister isn't learning to deal with staying in her own bed. Please understand that if this solution (sleeping in brother's bed) were acceptable to you then it's fine with me, but if your goal is for your daughter to stay in her bed, then brother's bed has to be eliminated as an option. If your goal is simply to keep her out of your bed so you can get a good night's sleep, then you can settle on any alternative arrangement you find satisfactory. If the two children want to be in the same room that may be an acceptable solution; however, since they are not the same sex, separation will become mandatory as they get older. Bottom line: there is no quick solution, but there must be some consistency to what she does night after night, whether it's staying in her own bed or being with her brother.
Sincerely,
Dr. Warren
Kyle went into Childrens Hosp in San Diego from 2/24-3/6. Kyle was given intraventious antibiotics and fluids. No food for 3 of the days. Kyle continued to vomit up about half of what he ate. Kyle was evaluated by Drs at the hospital, his Neuro Dr., Gastro Dr., Gastro Dr., and his Ped Dr. We did xrays of stomach, CAT scans, Stomach motility tests - all negative. Nobody could determine the reason or devise a solution for the vomiting.
All of Kyles tests and history were sent to Dr. D. T. in Los Angeles Chilren's Hospital which Kyle visited on 4/2. Kyle had a breath test for H-Pylori on 4/16 at UCSD which showed that Kyle was cured of the H-Pylori. Currently, the plan is to try a ani-depression drug which has worked in cases of people who can't stop vomiting. Dr. D. T. conferred with Kyle's other Drs. on this.
Kyle switched from a low dose of Dilantin to Tegratol (also low) after a Grand mal seizure on 4/3. The vomiting went down somewhat at first, but he just had another bad day - about 20 times. We also tried accupuncture - no effect.
Overall, this has been a extremely terrible experience for my son and everyone involved. Kyle has attended only a few days of school since Jan - the school dose not want to deal with the situation. My wife has quit work and school. We are desperate to stop the vomiting. Kyle has never had behavioral problems with food and continues to eat well and does not want to vomit - limited verbal and expressions to that effect. I am looking for any advice, clues, clinics/hospitals, doctors, contacts can help us. My wife thinks that John Hopkins may be next place to check out? Our situation is desperate and I would be so grateful for any advice you can provide. Please don't hesitate to forward this meessage to anyone who could help. Sincerely,
-SEB
Dear SEB: After seeing so many doctors including specialists I doubt that I have anything to add regarding your son's management, and yet I feel that I'm missing some basic information. For example: what is happening to your son's weight. While you mention that Kyle is distressed by the vomiting you don't say that he has any abdominal pain, and you do say that he continues to eat with a good appetite. 190 pounds is quite large for a 14 year old. Has he lost weight with the vomiting? Is it possible that he is gorging himself with food and vomiting the excess? His food tolerance may have changed with the H. pylori infection but his eating habits may not have changed accordingly.
Since Kyle has been seen by a Gastroenterologist I have to presume that liver function tests were done, but I mention them just in case they were overlooked in the search for esoteric causes for vomiting. Both Tegretol and Dilantin are liver toxic.
Has your Neurologist ruled out a neurological cause for the vomiting? You've described some of Kyle's GI workup to me, but since vomiting can occur with neurological disorders such as brain tumors and abdominal epilepsy, I figured I'd ask.
Is it safe to assume that metabolic causes of vomiting such as diabetes have been ruled out? I don't like to assume anything and you didn't tell me about Kyle's blood chemistries.
If you wish to send your query to a large number of pediatricians you may subscribe to pedtalk, a pediatric mailing list. To subscribe send an e-mail message to pedtalk-request@pcc.com with the word "subscribe" in the body of the message. They will send you further information once you subscribe.
Johns Hopkins is an excellent institution. I am sure that they would do a thorough evaluation of your son, but it is a very big trip for you to take without a referral. You'd start from ground zero in the emergency room unless you know a doctor to go to. Also there are many excellent hospitals on the west coast. Before you start running around the country seeking answers, why not discuss the possibility of seeking outside help with your physicians. They can help you coordinate a visit elsewhere so you get the most out of it.
Sincerely,
Dr. Warren
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