28 July 1997

1. Ear Infections, Persistent Middle Ear Fluid
2. Ears Turn Red and Hot
3. We've Tried Everything and the Baby is Still Crying!
4. Hand, Foot, and Mouth Disease vs. Chicken Pox
5. Slow Growth
6. Blue Lips During Feeding
7. Poor Weight Gain - Is Tube Feeding the Answer?
8. Sinus Infection, Vomiting, Diarrhea
9. Disclaimer

• Read Questions & Answers in Another Column

• Feature Article: Managing the Difficult Child: Toddlers: There is no simple formula that creates well behaved children, but no matter what approach you choose the key to success is consistency.

Ear Infections, Persistent Middle Ear Fluid

Can you handle more questions about ear problems in infants? In a previous message, I advised that our daughter (almost 8 months) has had two ear infections since March 25, 1997, each infection involving both ears with fluid in both ears too. Both infections cleared up promptly with 10 days of antibiotic treatment. With the first infection, fluid persisted for about two weeks after antibiotic treatment in the right ear and then disappeared totally. A small amount remained in the left ear. With the second infection (diagnosed on April 26), the fluid was gone in both ears by May 5 and so was the infection.

However, as of May 12, she has a lot of fluid again in both ears (but no sign of an ear infection) due to another upper respiratory infection. We were advised to bring her back within 1 week to recheck the fluid and to make sure that no infection had developed. She is not now taking antibiotics because no acute infection was found.

I should add that, during all of her upper respiratory infections, we gave her Pedia-Care or Triaminic and kept a vaporizer on at night to help her to clear the congestion. But, it seems that nothing really speeds the process of clearing the congestion except time itself.

I am becoming increasingly concerned about the length of time that she has had fluid in one or both ears and its effect on her hearing and language development. At her age, what type of sounds should we expect to hear from her? At present, she makes one syllable sounds such as ba-ba, ma-ma, along with various sorts of infant noises. Also, are there any guidelines concerning when middle ear fluid is determined to be persistent enough to warrant further intervention and/or evaluation?

Thank you again for providing such detailed responses.

-TE

Dear TE: It isn't uncommon for children to go in and out of having middle ear fluid, especially when they have colds. Decongestant medicines may relieve the cold symptoms but they do not clear up fluid. It is unlikely that you could prevent the fluid by treating a cold. If a child has persistent fluid for more than 4 to 6 months the it may require surgical treatment, especially if there is demonstrable hearing loss. During that 4 to 6 months, if there are recurrent infections, a long course of low dose antibiotics to try to prevent reinfection might help avoid surgery.

I can understand your concern about language development. If your daughter's hearing is satisfactory in just one ear most of the time that is sufficient for learning speech. Some children may actually say words as early as 6 months, but for most babies babbling syllables is normal at 8 months.

If you have not yet looked at it, check my article Another Ear Infection!?!.

Sincerely,
Dr. Warren

Thank you,

-Concerned Mom

Dear Concerned Mom: The reddening of your son's ears is similar to blushing. It is essentially blushing in the ears instead of the cheeks. The redness and heat both come from increased blood flow to the ears. This can occur spontaneously, especially if the child is over-heated, when a child has fever, or in response to emotional stress. I know of no way to prevent it. Your son should be reassured that it is normal for some people. If other people notice it and he is truly distressed by it, perhaps a change in hair style can help him hide it.

Sincerely,
Dr. Warren

we are very well experienced and well read with respect to infants and children, and our pediatrician doesn't seem to get this, preferring to repeat the same introductory advice we already have (eg "have you tried talking softly to him?"). do you have any suggestions? we have tried: walking, talking, stroller, snugli, frontpack, swing, simethecone (ovol), acetaminophen (tempra), dressing, undressing, changing, feeding, soothers (actually a clean finger on advice of la leche), rattles, dolls, books, pictures, chew toys, face games, hand games, foot games, music, singing, humming, patting, leaving on belly, leaving on back, sitting up, "flying" (ie holding overhead with flying sounds, which he used to like), massage, strokes, warm air, cool air. the only thing we have not yet tried (tonight, we will) that we can think of is putting him in a seat on the dryer, and bathing him.

please help if you can by e-mail response as our web access is limited. you are welcome to post this question, edited or not, on your web site.

-Mr. & Mrs. R

Dear Mr. & Mrs. R: It sounds like you have done everything reasonable to try to calm your infant. To come up with something different would be difficult. It is possible though, that it isn't what you are doing, but how you are doing it that may be a problem. At this point your stress level may translate into your efforts to calm your son. You need to make a plan so that you don't feel overwhelmed.

Divide the care of your son into specific shifts. Get others besides yourselves (his parents) involved in the effort. Include in that plan some time out of the house for both of you together. Take notes to see if you can find what is causing your son's distress. See if there are any common factors such as feedings, time of day, outside stimuli or any associated symptoms such as vomiting, diarrhea, or fever. Carefully touch different parts of his body gently to see if anything causes pain since pain in handling him could interfere with your efforts to soothe him. Make a conscious effort to remain calm when your son is not. Dividing his care into shifts and getting refreshed yourself will be essential to do that. Sometimes when babies become overwrought their caretakers become overwrought in their efforts to calm the babies. They shift too quickly form one method to another in an effort to find something that works without allowing the baby to adapt and respond to their efforts. Or they may over-stimulate the infant in an effort to bring their calming activities to their infant's attention, for example, they may rock too vigorously or pat their infant too hard.

If none of these suggestions improve your son's situation it is time for a very thorough evaluation to find out what is causing his distress. There is no question that some children are just more high strung than others, but 4 month of age is generally when things begin to get better and the infant becomes more responsive and involved in what's going on around him. If your son is becoming more irritable and interactions he used to enjoy no longer please him something is causing a problem. The problem doesn't have to be with him since infants can respond to stress in their environment. If there are no environmental factors and your physician finds nothing physical, I would suggest a complete neurological evaluation since neurological symptoms may include irritability.

Sincerely,
Dr. Warren

-CM

Dear CM: It is possible to confuse hand foot and mouth disease with chicken pox, but an experienced pediatrician should be able to tell them apart. While chicken pox may sometimes cause cankers in the mouth this occurs with severe cases of chicken pox where there are many pox on the body. Cankers in the throat are an essential part of hand foot and mouth disease. The spots of hand foot and mouth disease occur primarily on the palms and soles and sometimes extend up the extremities and involve the buttocks. These spots don't crust or scab and the blisters don't have the characteristic umbilicated dew drop shape of chicken pox. Chicken pox may occur on the palms and soles, but that occurs primarily in severe cases since most of the blisters come out on the body. Chicken pox blisters start as a red oval bump which forms a water blister, then crusts, and then scabs. Since they don't all come out at once chicken pox can be seen in all stages on the body at the same time. Itching is generally significant with chicken pox, not with hand foot and mouth disease.

Sincerely,
Dr. Warren

He has probably gained about 5 pounds in the last 2 years. He is growing slowly, but is it too slowly? Last year we had a blood test and an xray and they determined that at 3 years, his bone mass was that of a 2 year old.

This week we are going to an endocrinologist (I hope I spelled that right!) What is that specialist going to do?

How do you know when your child is just going to be small or has a growth hormone problem? I think I might be more concerned about this because my son does not eat. He is happy to eat one meal a day.

Do you have some thoughts or give me some direction for some literature to read?

Thanks

-CR

Dear CR: At 28 pounds your son's weight is just below the 3rd percentile for a 4 year old. His height, 37­3/4 inches, is in the 10th percentile. His height is in the low normal range. If his height has been increasing steadily along this percentile curve that is normal growth. Your pediatrician can review your son's growth chart with you to tell you if his growth has been steady or if his percentiles have been decreasing. Your son's weight is low for his height, but if he has maintained his weight percentile over the years that is not necessarily a problem.

An endocrinologist can determine if there is any hormonal problem causing your son to be small. Even though short stature is not always caused by hormone deficiencies endocrinologists are experts at evaluating short stature. The most important hormone to check is thyroid hormone. If your child's rate of growth is inadequate the endocrinologist can arrange growth hormone testing.

Small children often don't eat much because they have smaller caloric requirements for growth. It is rare for healthy children with good food available to be short because of inadequate nutrition. A child can satisfy his nutritional requirements with one good meal a day. Please read my article, Nutrition Without Tears.

Sincerely,
Dr. Warren

Is this something we should be concerned with? Can this problem have any relation to SIDS?

Thanks for your time.

-MZ

Dear MZ: Your child's lips appearing blue during feeding may be nothing more than immaturity and not taking a breath during intense sucking; however, if exertion such as feeding makes her lips turn blue, it could also be indicative of a heart problem. You should have your pediatrician observe your daughter's feeding and if he sees significant cyanosis (turning blue), he will arrange for a cardiac evaluation.

It is unlikely that what you are describing has anything to do with SIDS. Don't forget to put your baby to sleep on her back to decrease her risk of SIDS.

Sincerely,
Dr. Warren

She takes 5 ounces of milk four times a day by mouth plus cereal plus soup. she was born with 6.12lbs wt. Now at 9 month she is 12.20lbs. except her weight, she is doing well, starts crawling on fore hands last week. Very active responsive.

I guess my question is in what condition tube is neccesary, and what's is side effects?

If you know any WEB SITE or E MAIL address please let me know. We have CAT, Barium Sallow test last week every thing is OK, We are doing for MRI as per our doctor. I do not favor it. Because of X Ray Radiation. Let me know the side effects of Radiation due to X Ray?

Look forward to hear from you.

Thanks

-M

Dear M: Tube feeding is appropriate when a patient is unable to take adequate calories by mouth. Tube feeding can be done by nasogastric tube which is a tube passed through the nose down through the throat an into the stomach. The tube can be left in place for some period of time and may be replaced when necessary; however there is some risk of aspiration (breathing stomach contents or food into the lungs) with prolonged use of nasogastric feeding. If the feeding disorder is determined to be chronic and prolonged tube feeding is required, a gastrostomy, which is a surgical opening directly through the abdomen into the stomach, is appropriate.

The main risk to placing the gastrostomy is the risk of anesthesia. A button is put in place to act as a valve through which the feeding tube is passed. Once in place there is a small risk of infection or bleeding around the button. Naturally some care must be taken not to injure the area.

It is difficult for me to make any comment as to whether your child requires tube feeding since I don't know her height or what kind of evaluation she has had for poor growth besides evaluation of her upper intestinal tract. Her weight is far below the 3rd percentile for her age. If she is small for some reason unrelated to feeding such as heart disease or a hormonal disorder such as thyroid disease or growth hormone deficiency, or malabsorption, pushing more calories into her will not make her grow. If she has had a thorough evaluation of all systems and your pediatrician is certain that insufficient calories is the cause of her problem, then it becomes essential to find a way to get more calories into her; however, before I accepted a surgical solution to the problem, I would want a diagnosis as to why this child doesn't eat. Except for children with neurological disorders or chronically ill infants who were unable to establish oral feedings early, it is unusual to require tube feeding. And since your infant consumes 20 ounces of formula per day, she has demonstrated that she is capable of eating.

Radiation over a lifetime is cumulative, so unnecessary x-rays should not be done, but the amount of radiation in these procedures is so small that they don't carry any risk and will not have any side effects. An MRI is done with magnets and doesn't involve any radiation at all. The only risk to the test is the need for sedation in a 9 month old.

Sincerely,
Dr. Warren

-CL

Dear CL: Sometimes when children have sinus infections the infection may spread into the tissue around the eye causing a periorbital or preseptal cellulitis. This generally results in an angry red, tender swelling under the eye and fever. It does not cause eye discharge like conjunctivitis (pink eye), but it may cause some build up of mucus in the eye if the eye is swollen shut. Because of the location of the sinuses close to the brain, preseptal cellulitis is a potentially serious infection, the main risk being meningitis.

Vomiting may be seen as part of many illnesses because sick kids vomit, but diarrhea is generally not part of the picture with sinus infections or cellulitis. If the diarrhea developed after starting antibiotics it could be a complication of antibiotic therapy.

If your child is vomiting over a long period of time or not retaining fluids, he needs reevaluation by his doctor regardless of whether it is related to the sinus infection, the antibiotics, or an intestinal virus. If his fever persists, your pediatrician must recheck your son to determine if his response to antibiotics is adequate.

By the time you get this email, if your son is not significantly better, you should contact your pediatrician.

Sincerely,
Dr. Warren

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