30 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
My second question is now that I have Colton healthy I need to keep him that way, he has asthma so when he catches anything he can't keep it at a common cold level he always get a lot sicker, I avoid children filled places but I do need to go out into the public once in a while. What can I carry in his diaper bag to use to clean things such as high chair trays in restaurants, that won't harm him. He always seems to get sick after he sits in a high chair in a restaurant or in a shopping cart at the grocery store so I need something that will kill the germs on them but won't harm him, and doesn't need to be rinsed after cleaning?
Thank-you for any help you may be able to give me.
-TG
Dear TG: When children are ill it can severely upset routines that were learned. Add to that a frightening experience such as a hospitalization and it aggravates the separation anxiety most infants and toddlers have. Additionally, hospitals are not great places to sleep. Sick children are awakened frequently for procedures, treatments, and to check their vital signs. Hospitalized children have all kinds of frightening and painful things done to them. Nothing can make them understand that it will benefit them, and nothing can make them understand why we, the parents, permit it. In some sense, this little child's world will never seem quite as safe to him. It takes time to get over such a traumatic event.
So the child comes home with new, undesirable sleeping habits, and new anxieties, and the parents are also anxious and not quite ready or able to return to the old routine. In a very short time, the new routine becomes established. Since children this age cannot be reasoned with, the only way to change their routine is for them to experience the desired change and learn to become comfortable with it.
Sleep is a necessity. But how we go to sleep is a learned behavior. The only way your child will learn to stay in his bed and sleep in his bed is to experience it. For starters, that means he should go into his bed awake. It is much easier to deal with an unhappy child who doesn't want to stay in his bed at 9 or 10 PM than it is at 2 or 3 AM. Make your intervention sufficient to let him know you hear him, that you're there for him, to soothe him when you feel it is necessary, and to assure yourself that everything is okay. Keep your intervention minimal and progressively decrease the amount of time and contact of the interventions. Your goal is for him to fall asleep in his own bed so that he can learn that it is safe to do that.
At first your son will scream for a long time. That will gradually diminish. It may not disappear completely until he is older. Many parents ask how long to let a child scream. The answer is to not set a limit for yourself or you will succeed in teaching your child your limit and he will learn to cry at least that long. Your son's vomiting at this point is probably just a result of being extremely upset. As his screaming decreases this should happen less frequently. If you respond to the vomiting by trying to avoid it or taking your son out of the crib for anything more than the briefest clean up, he will learn to use it to get what he wants. I understand and sympathize with the difficulty you are going through and the mess you will have to clean, but you must set up his room for easy clean up recognizing that he may vomit. If your son were not giving you a hard time or vomiting, you would no doubt already have solved the sleeping problem. Be careful, in your attempts to change your son's sleeping habits, that you don't introduce any new behaviors that you don't wish to continue indefinitely. For example, don't offer a bottle.
Question 2: I am not familiar with the large variety of antiseptic products on the market so you might want to check with your pharmacist about what products they might carry. Probably the simplest thing to use would be alcohol wipes which are available in a pharmacy because people who give themselves injections use them to clean their skin. Alcohol is toxic, but if you dry the surface with a paper towel after cleaning it should be safe. For high chair trays, as an added safety measure, consider bringing along a place mat and clips to hold it in place on the tray.
Sincerely,
Dr. Warren
Thank you very much.
-BD
Dear BD: The testicles are in the abdomen in early development and descend into the scrotum (the external sac) before birth. As they descend they are enveloped in membranes that descend with them. These membranes may sometimes have fluid in them, or if they do not close completely after the descent of the testicles, fluid may leak in. This results in a hydrocoele. Hydrocoeles are not dangerous. They may be associated with a hernia, and large hydrocoele increase the risk of injury to the testicle or torsion (twisting) of the testicle, therefore, hydrocoeles that persist should be surgically repaired.
Sincerely,
Dr. Warren
Is this something I should bring up again at his next visit or should I not worry about it for now?
Thank you for your time,
-SS
Dear SS: From your description, it sounds like your pediatrician may have misunderstood your concerns. It is reasonable for a mother to be concerned about obvious blemishes that might make her child stand out since these can lead to teasing and low self esteem. Your pediatrician should have explained to you just what the mark is and what you can expect to happen to it. And since he has seen the mark, and I have not, you will have to ask him just that.
Many significantly red marks on infants are vascular birth marks such as hemangiomas (also known as strawberries). These may not be present at birth and may enlarge during the first two years of life, but then shrink and sometimes fade completely. Since these marks often disappear, they should not be treated early on because treatment may sometimes result in scarring and the final appearance may be quite acceptable without treatment.
Vascular marks that persist are being treated these days quite successfully by laser. Many dermatologists are treating these conditions.
I don't think you need to worry, but perhaps if you could prevail upon your pediatrician to explain to you what the red bump is, you would feel less worried. Answering your questions is part of his job, and he should do it without making any assumptions about your reasons for asking the questions.
Sincerely,
Dr. Warren
My friend told me that the new antibiotic :"Zebra" is very safe for children. It needs only 5 days to complete the course instead of 10 days like: Amoxicillin, .... If the children use this product "Zebra". children will not lose weight like the other. Is that true?. Thank you for your help.
Best regards,
-MT
Dear MT: Colds don't last 2 months, and allergies don't cause green mucus. The most likely explanation is that your child has had several colds in this 2 month period. Since colds don't respond to treatment with antibiotics, it is not surprising that the medicine didn't make any difference. Colds don't get better with any medicine. Cold medicines provide symptomatic relief, but they don't cure colds.
If your child improved on antibiotics but then got worse as soon as the antibiotics were stopped, he could have a chronic sinus infection. In that case it may require 3 or more weeks of antibiotic treatment to clear the condition. If there was no response at all to antibiotics, your child most likely had several colds as stated above.
Recurrent colds occur primarily as a result of exposure to colds. This happens most frequently to children in day care or infants with school age siblings at home. Frequent hand washing by those who handle the baby may decrease the spread of these colds.
If cough is the most prominent symptom, you pediatrician must check the lungs carefully for wheezing. Sometimes a mild wheeze can only be heard if the examining physician squeezes gently on the chest while the infant is breathing out. This requires that the infant be calmed or distracted during the exam. Sometimes considerable patience is necessary since wheezing will be obscured by crying. If wheezing is present then treatment with asthma medications should be helpful.
For a complete discussion of upper respiratory infections take a look at my 26 March 1997 feature article.
The "zebra" antibiotic is Zithromax. Their logo is a zebra. It is an excellent antibiotic, but not necessarily the first choice for treating an infection. Most other antibiotics do not cause weight loss. All antibiotics can upset the stomach or cause diarrhea. Zithromax is not an exception. It is convenient because it is dosed only once per day for 5 days, but other antibiotics may be more appropriate for treating certain infections.
Sincerely,
Dr. Warren
Sign me....
-Worried GA Mom
Dear Worried Mom: It's hard not to be worried when a child is sick for longer than most usual childhood illnesses. Your pediatrician has probably concluded that your son's illness is viral because his white blood cell count and differential is typical of what is seen with virus infections. Virus infections don't respond to antibiotics, which was your experience with your son. Most virus infections don't last more than 5 to 7 days which is why your doctor checked for mononucleosis. Sometimes the mono test may come out negative in children with mono. If your pediatrician still suspects mononucleosis he can check Epstein-Barr virus titers. He might also check for illnesses that sometimes mimic mononucleosis such as CMV.
If your son remains ill, your pediatrician may want to repeat the blood count since the results may change after he is off antibiotics for a while. If your son has extreme difficulty swallowing he should be checked to be sure he doesn't have a peritonsillar abscess. This may sometimes require intravenous antibiotics or surgical drainage to resolve. On examination the palate will appear swollen on one side. The children have so much difficulty swallowing they may even drool. It may even be painful to open their mouths.
Of course, the longer an illness drags on, and the sicker a child looks, the more vigorously a physician must search for unusual problems. Your pediatrician may not be concerned if your son doesn't look too sick. If he seems sicker in any regard you must contact your pediatrician right away.
Sincerely,
Dr. Warren
-JK
Dear Aunt JK: We certainly do see severe belly aches from constipation, but your daughter's situation sounds a bit extreme for constipation. We see children who withhold stool to the extent that they are constantly soiling themselves and their intestines are full of stool, and these children don't lose weight, become weak, or get dehydrated. In any event, if your doctors believe that her problem is constipation, then her pain should be solved by cleaning her out with enemas. If getting her well cleaned out does not improve her status then she clearly needs further evaluation.
If your niece's situation is as extreme as you describe it she should be hospitalized for treatment and complete evaluation. This could include many tests since there are so many causes for abdominal pain. A complete blood count and blood chemistries including amylase, kidney functions, and liver functions would be a good place to start. Although this would be an unusual presentation for diabetes, diabetic ketoacidosis can cause abdominal pain, weakness, weight loss, and dehydration; however, I trust her blood sugar and electrolytes were checked before she was treated with IV fluids the last time.
After these initial tests further evaluation could include a barium enema and/or upper GI series depending on the location of the pain. If she has fever and an elevated white blood cell count the possibility of a ruptured appendix has to be considered. This and other possibilities can be evaluated with an abdominal CT scan.
At this point she needs her case managed by a Pediatric Gastroenterologist. He should be directing the evaluation and helping you to understand what is going on.
Sincerely,
Dr. Warren
Dr. Warren: Just thought I'd let you know for your info, that my niece was diagnosed with a rare spinal tumour. She is in critical state right now. Just goes on to show that pediatricians should sometimes look beyond the obvious. Thanks for your response.
-JK
1. How many years of schooling did you attend?Thank you in advance for your help!!
2. What degrees do you have?
3. Where did you attend school?
4. What is a typical day for you?
5. Are there any disadvantages to your job? And if so what are they?
-AF
Dear AF: 1. I attended 4 years of college, 4 years of medical school, and did 3 years of residency which is on the job training.
2. I have a B.S. in biology, and an M.D. degree.
3. I attended Rensselaer Polytechnic Institute for my undergraduate work. I went to S.U.N.Y. Downstate Medical College for my M.D.
4. Schedule for a typical day:
8:30-9 AM: Answer telephone to answer parents questions and make appointments to see sick children.5. Night call and weekend call could certainly be considered a disadvantage. I have a partner, but that still means I have to work half the weekends, and that sometimes means I have to miss some family events and special occasions. Aside from getting awakened during the night for emergencies, sometimes I have to stop what I'm doing in the evening to take care of a patient. When there's a lot of illness in the community I have a lot of interruptions in my personal life.
9 AM- noon: See patients. Do exams. Give immunizations (shots). Fill out school forms, referral forms, insurance forms. Write notes in charts. Call pharmacies with prescriptions. Answer emergency calls from parents. Give inhalation treatments for asthma. occasionally suture lacerations.
noon - 2 PM: Hospital rounds. Lunch if there's time.
2 PM - 6 PM: same as 9 - noon
7:30 PM - 9 PM (Monday night only) same as 9- noon
Evenings: Home but on call. Give advice by telephone. Return to the office to see emergencies as needed.
Being a pediatrician is an awesome responsibility. When a patient of mine is very sick, I worry about the patient. I have to be very careful not to make mistakes because a wrong diagnosis or an error in treatment could have grave consequences. As much as I love being a pediatrician, that makes my job very stressful.
Sincerely,
Dr. Warren
Thank-you very much for taking the time to read my letter. If you could offer any advice I'd be very grateful.
-BB
Dear BB: It is not unusual for young children to have imaginary friends. Often very bright children have very vivid imaginations. If these children don't fit in with other children they may depend on imaginary friends because those friends always accept them and do things their way. The older a child gets, the less likely and appropriate imaginary friends become; however, even children in the upper grades of grade school may still engage in considerable imaginative play and make believe.
Some children will adamantly insist that their imaginary friends are real, but even at 7 years of age one would expect that they know their friends are imaginary. If a child's approach to the world seems to be based in reality, imaginary friends can provide both solace and entertainment for a lonely child. But if a child's imaginary friends prevent her from dealing with the real world, even at 7 there may be a problem.
Sometimes parents can find the imaginary friends a nuisance since they may have to make accommodations for the imaginary friends, and if the friends come out in public, it may be embarrassing. Still, if a child needs imaginary friends, it's best not to insist that she give them up. If any aspect of dealing with the imaginary friends presents a problem, just make sure your daughter knows that she is responsible for her imaginary friends.
To improve your daughter's social life and social skills and hopefully ease her away from her imaginary friends, focus on finding activities that would be of interest to her rather than trying to get her to do things with children her own age. If she is extremely bright she may make friends with older children. Additionally, if her activities are chosen based on her interests rather than the standard fare for children her age, she may find some other bright children around her age in those activities.
Sincerely,
Dr. Warren
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