21 July 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
-CT
Dear CT: All the studies I've read about the ear thermometers suggest that they are the most accurate way to measure the core (central) temperature of the body. The main problem they find is that, if the ear thermometer is not aimed correctly at the ear drum, it may result in a falsely low reading including, possibly, a normal temperature even when the patient has a fever.
My personal experience has varied somewhat from those studies. Most of the highest readings I've seen are from infrared ear thermometers. There are several possible explanations such as: the core temperature is actually higher than the rectal temperature, or parents are more willing to take the temperature with the ear thermometer so we get more temperature readings and many of them are high.
If the ear or the probe is obstructed by wax that may lower the reading. I haven't read any study indicating what happens to the reading when there is an ear infection.
Some of my patients have found the readings vary by as much as one degree, while others say the readings are reproducible and even match the rectal temperature readings.
The ear thermometer should not be used in newborns. It is quick and convenient, and expensive. It shouldn't be the only thermometer in the house. Any reading that's questionable should be confirmed with a rectal glass/mercury thermometer.
Sincerely,
Dr. Warren
THANK YOU AND PLEASE ANSWER
-MIV
Dear MIV: For more information about Kawasaki Syndrome you might like to look at the first letter ever sent to "Ask Dr. Warren." Please note the information about NORD as a source of additional information for you. You can find the article in the first Ask Dr. Warren column.
The diagnosis of Kawasaki is made clinically since there is no specific test to make the diagnosis. To make the diagnosis certain clinical criteria have to be met. These include a minimum of 5 days of fever, conjunctivitis, rash, strawberry tongue, swollen glands, peeling of hands and feet usually after edema of hands and feet. Not all signs need to be present to make the diagnosis. There are probably patients who have mild cases of Kawasaki who will not be diagnosed since the diagnosis requires meeting certain criteria.
Kawasaki is not known to be contagious.
Thrombocytosis (high platelet count) is a nonspecific finding which follows many illnesses as a part of the inflammatory response. Since the thrombocytosis associated with Kawasaki is generally significant finding thrombocytosis helps corroborate the diagnosis.
The main risks of Kawasaki are related to coronary artery aneurysms. Prevention or at least amelioration of these aneurysms can be accomplished by treatment with intravenous gamma globulin. This should be started as soon as possible after the diagnosis of Kawasaki is made. After that he should be kept on aspirin. Your nephew should see a cardiologist (preferably a pediatric cardiologist) and be followed with echocardiograms.
Sincerely,
Dr. Warren
We've tried every thing from switching formulas to spacing out meals to 4 and five hours. Our son never cries that he's hungry. He only cries when we try to give him his bottle. He has also had bad constipation since his second month. Often, we have to help his movements with a thermometer and Vaseline. Our son didn't gain any weight between the 3 and 4th month. I should also tell you that he is the happiest little boy and when he's not smiling he's laughing!!!!
Here's the question---our pediatrician does not seem alarmed. We are besides ourselves. We keep thinking reflux or partial obstruction. Although our pediatrician is not ready to make the referral, we want to take him to a gastroenterologist.Should we do so?? Is there such a thing as a pediatric nutritionalist so we can figure out how to get him the calories he needs? Is there anything else we should try.Thank you for your assistance.
-Mr. & Mrs. H
Dear Mr. & Mrs. H: It is a puzzle why a perfectly healthy and happy baby wouldn't want to eat. Occasionally I see babies who consume less than expected who do well, but the lack of weight gain for one month is a concern. Is your pediatrician unconcerned because your son's weight is in a satisfactory spot on his growth curve?
I can understand your concern when you keep thinking there might be something wrong with your child, but the two conditions you are concerned about really don't fit. A partial obstruction should cause intermittent vomiting and cramping rather than a happy child. Reflux might cause vomiting, coughing, and poor weight gain in the presence of adequate intake.
If your son's intake remains poor and his weight gain unsatisfactory you might look into getting a 24 calorie per ounce or 27 calorie per ounce formula as a temporary measure, but further evaluation will be needed to find out why your son won't eat. His problem may not be gastrointestinal, but it's not a bad place to start. Most pediatric gastroenterologists work with nutritionists.
If your pediatrician does not feel a referral is appropriate at this time, perhaps you can prevail upon him to explain his plan of action for the next month or two so that you don't feel completely up in the air about your son's condition.
Sincerely,
Dr. Warren
-JB
Dear JB: Mineral oil is tasteless, but has an oily consistency. It is less oily if it is well chilled. It can't be mixed in liquid because it floats, but it can be mixed in semi-solids like ice cream or applesauce.
You might also try giving your son a bulk forming laxative to keep his stool softer. Senokot may be helpful. Also, have him drink lots of fruit juice, especially prune juice.
It would be unusual for a child to be harmed by stool impaction. Occasionally a child may develop obstructive symptoms with a bloated belly and vomiting, but for most, the intestines accommodate to the progressively increasing amount of stool. This, of course assumes at some point, even if an enema is necessary, that the child will have a bowel movement. I'm sure there are limits to what the intestines can accommodate.
Sincerely,
Dr. Warren
-AM
Dear AM: I am not familiar with Dr. Meldenson's book. He is, of course, entitled to his opinion, but if he recommends not immunizing children, I disagree with him completely. In fact, I think his advice is irresponsible.
Of course there are risks to taking vaccines. And people don't like to do anything to their children that risks hurting them. But there is also a risk to doing nothing. Most people today in the US and Europe, have no idea what epidemics of whooping cough and diphtheria are like. The vaccines have been very effective in preventing epidemics and few people in developed countries have experienced these diseases. The reasons that vaccines were developed for these diseases is that many children died or became permanently harmed by the diseases. When I was a child, every summer parents were frightened by polio. There were wards full of paralyzed children in iron lungs. The survivors usually had permanent disabilities. Today, polio is almost eradicated from the world. Smallpox was a terrible killer. Vaccination was so successful at eliminating smallpox from the world that we no longer consider the small risk associated with the vaccine necessary or justified. As a result, smallpox vaccination was discontinued in the US in 1970. Newer vaccines like HIB vaccine have decreased Haemophilus influenzae b meningitis and epiglottitis. Rubella vaccine has gone a long way toward eliminating horrible birth defects caused by rubella.
I'm not so sure that so many people oppose vaccinating their children. I know some do, but my patients willingly immunize their children to protect them against these diseases.
The American Academy of Pediatrics and the Center for Disease Control in Atlanta recommend that all children be fully immunized against diphtheria, whooping cough, tetanus, polio, measles, mumps, rubella, Haemophilus meningitis, hepatitis B, and chicken pox.. For more information about these diseases and the risks associated with these vaccines check the CDC's Web site.
Sincerely,
Dr. Warren
Also, sometimes he wakes up with a red splotchy rash on his face. It may come and go three times a day.
I can't figure out what could be irritating him. He is on Prosobee formula, so I don't think it could be a reaction to milk.....
Can you help?
Thanks!
-R
Dear R: It sounds like you are describing eczema. Eczema is a dry rash which responds to moisturizers. When it is inflamed hydrocortisone helps. It is a chronic condition which is relieved, but not cured, by treatment, so it will keep coming back. Eczema may be caused by allergy, but often the allergies are environmental (things in the environment). Sometimes food may cause eczema. Using a soy formula like Prosobee can avoid problems with milk allergy, but soy is also a potent allergen. If a child has severe allergy problems a hypoallergenic formula like Alimentum or Nutramigen should be used rather than a soy.
When your child wakes up with a red splotchy rash on his face which then disappears, most likely his face is red because the side he is laying on traps heat and the circulation to the skin increases. Drooling may also contribute since he will be lying in moisture. If the rash disappears without intervention you should just leave it alone.
Sincerely,
Dr. Warren
-AKR
Dear AKR: I believe pediatricians average between $75,000 and $150,000 per year depending on the area of the country they work in and how many hours they work. I couldn't tell you what pediatricians earn working in hospitals as opposed to office practice.
A number of things can happen when a physician makes a mistake. It depends how serious the mistake is. If a physician makes a minor mistake it can still damage his patient's trust and faith in him. Trust and faith are an important part of the therapeutic relationship between physician and patient. If the patient can't regain his trust he may need to find another physician. Doctors have an awesome responsibility. We are all human, and humans can make mistakes, but a physician's mistake can have grave consequences resulting in serious and irreparable injury or death for his patient. I don't know if I could continue to be a physician if I made a serious mistake. I would lose faith in my own ability to be a pediatrician and I would find the guilt overwhelming. Physicians' mistakes can also lead to malpractice lawsuits.
Fortunately I haven't had to deal with too many of my patients dying. The first patient I ever had die was during medical school. I remember talking to him about his upcoming surgery. He was a pleasant, vibrant man. I never even thought about the possibility that he could die, and I just couldn't believe it when I came back the next day and he was gone. The next patient was during my residency. I took care of an eight year old boy with rheumatoid arthritis. I had a clinic where I followed a few patients so he was like my own patient. I got along very well with him and his parents. One morning they called me at home because the boy was very sick. Even though I wasn't working in the clinic I made arrangements for him to be seen. He had leukemia and got sicker very fast. Even though I tried to stay involved with his care, he was in the care of specialists and I was still in training. There was really very little I could do and I felt useless. I've only had one other death since going into practice. He also was a boy with leukemia. I made the diagnosis on the first time I had ever seen him so I hadn't had a chance to develop a relationship with his family. Over a period of time until he died the family became more involved with my office. When he died we all went to the funeral. Children shouldn't die. It is never easy for a pediatrician when any patient dies.
Sincerely,
Dr. Warren
-AP
Dear AP: Protein is filtered through the kidneys along with all the other constituents in the blood. Healthy kidneys allow only a small amount of protein to escape into the urine each day. When the urine is tested for protein, the concentration of protein is measured, but this doesn't really tell you the total amount of protein spilled into the urine each day. If a urine specimen is very concentrated, the protein concentration may be high as well. Healthy children sometimes have protein in the urine after physical activity. That's called orthostatic proteinuria, and is perfectly normal. By collecting a first morning specimen your doctor is checking for orthostatic proteinuria. If the first morning specimen is negative for protein there is no need for further concern. If the protein concentration is significant, additional testing must be done to see if the total daily protein spillage is significant. This can be done by collecting a 24 hour specimen, or, the easier and more accurate way is to measure the protein/creatinine ratio in the specimen. If that ratio is less than 0.2 it is normal. If it is greater than 2.0 it represents heavy proteinuria and should be evaluated.
If a patient has proteinuria and is otherwise asymptomatic meaning no edema (tissue swelling from fluid in hands, feet, over eyes), no blood in the urine, and a normal blood pressure, his physician may observe the situation for a year after checking blood levels of C3 and C4 (components of complement), ANA, BUN, and Creatinine, and obtaining a renal ultrasound study. Proteinuria that persists more than a year should be evaluated by a kidney specialist even if all the above tests are normal. Any abnormals should, of course, be evaluated.
Your son most likely has orthostatic proteinuria and his morning specimen will be normal. The purpose of testing urine protein is to screen for kidney disease, but the finding of protein does not mean that there is a kidney problem. Only by checking further can it be determined if there is even a reason to look further at the kidneys.
Sincerely,
Dr. Warren
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