15 September 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
-MG
Dear MG: If your 8 month old is gaining and growing adequately you shouldn't be alarmed about what is probably a temporary decrease in her consumption of solids. Her formula still provides complete nutrition. Since you say she got 5 new teeth in the past 3 weeks it may very well be that she doesn't want the spoon in her mouth because of teething. It is also possible that because of decreased growth needs and an interest in the world around her, she may have a decrease in her overall intake. If she seems happy and healthy, the key to determining if there is a cause for concern is what happens to her growth and weight gain.
Sincerely,
Dr. Warren
-LG
Dear LG: In some respects, 1 to 2 year olds are the most difficult to deal with when they develop an unacceptable behavior. They are using that behavior as a means to communicate something, and if it gets attention, it is difficult to change the behavior. They don't have language to communicate, and their response to spoken language is variable. Even the most basic command like "No!" takes it's meaning from the manner in which it's enforced.
One of the biggest mistakes parents make with regard to disciplining young children is that they assume that if they were doing the right thing it would result in immediate improvement in the behavior. When it doesn't, they change their response. As a result, the child doesn't learn to associate the parent's response with the problem behavior. At this pre-verbal stage, associating a parent's response to a specific behavior is a crucial part of the child's understanding that the particular behavior needs to be changed. Only by being consistent in handling a child's behavior can you expect the child to learn what it is you want. That consistency also helps provide the structure that will help a child control his behavior when he has an impulse to do what he usually does, such as bite. But we must remember that toddlers this age have very little self control. It can take a long time to teach a child not to do something, and when the child is particularly stressed, even after a behavior has been extinguished it may occur.
It is best to avoid slapping a child for aggressive behaviors. That sends a mixed message that aggressive behaviors are sometimes acceptable. He may very well substitute slapping for biting. The best approach to biting is to respond immediately with a firm "NO!" and whisk the child away to a time out. It is important to make sure this is done every single time the child bites, and to make sure that the response is immediate. The response should also be brief with the child getting to time out as quickly as possible. Discussing the behavior may be appropriate later, but at the time of the incident you don't want to give the child a lot of attention as part of your response.
It is equally important to avoid the situations that result in biting. That means Mom needs to be alert to her son's needs so that he won't resort to biting as a means of communication. That doesn't mean she should give him whatever he wants. It's important for him to get plenty of attention when he is behaving properly. When Mom is busy and can't supervise him, he should be put safely into a playpen. He shouldn't have the opportunity to come up to Mom and bite her when she is busy.
Sincerely,
Dr. Warren
I don't feel any more at ease than I did before I took her to the doctor this morning. I don't know why this node is swollen and if it is a perfectly normal thing. What if the pain lingers but the node stays the same size? Should I get another opinion or just wait to see if it gets larger?
I look forward to your response!
Thank you--
-KH
Dear KH: Enlarged lymph nodes may occur anywhere on the body in response to virus infections. The most common location for swollen nodes is the neck. The next most common locations are under the arms and in the groin.
If a lymph node is tender, it usually means it is inflamed. An inflamed axillary (underarm) lymph node may occur as a result of a rash or a scrape on the hand or arm. It may be quite small and may sometimes have healed by the time the inflammatory lymph node becomes evident. One very important cause of inflamed lymph nodes is cat scratch disease (which requires exposure to cats to be considered as a diagnosis). Axillary nodes may swell with mononucleosis. Usually there are other symptoms to point toward this diagnosis, but if the lymph node persists your doctor will want to take blood for a mono test and a complete blood count.
I realize your daughter is only twelve, but just in case she is very mature, I have to ask, "Does she shave under her arms?" If she does, that could cause the lymph node.
A small lymph node that is not enlarging can certainly be watched for several months. If it remains tender, it should be reevaluated sooner, probably within a week. You should consider another opinion if you don't trust the examination your doctor did or if you don't feel you are able to get adequate information from her. Otherwise, since your doctor has already seen it, she should do any necessary follow up examination.
Sincerely,
Dr. Warren
-(anonymous)
Dear Parent: When children have colds, the inflamed nasal membrane bleeds more easily. An other factor which can contribute to nose bleeds is dry air. This is especially true during the winter when the humidity is low and the air is dried by heating the house. Keeping a humidifier going can help.
Small nosebleeds that stop themselves are a nuisance, but not a worry. If possible, it helps to stop nosebleeds correctly by pinching the entire fleshy part of the bleeding nostril closed against the middle. This helps to stop the bleeding without a large clot forming. Large clots get knocked free much more easily resulting in recurrent bleeding. It may help to put a very thin layer of Vaseline into the affected nostril to keep it lubricated. As the clot dries out it may bother your son and he may inadvertently pick at it. This could even happen in his sleep.
One other thing to be aware of if your child has nosebleeds in his sleep: If your son swallows a lot of blood he may vomit it up forming a large blood stain on the bedding. It is alarming to see, but not dangerous.
Sincerely,
Dr. Warren
-DD
Dear DD: Shingles is an outbreak of blisters along a nerve caused by Herpes Zoster virus. It is the same virus that causes chicken pox. In order to develop shingles you have to have had chicken pox. Shingles occurs when there is a reactivation of the virus where it is lying dormant in a nerve root. There are live virus particles in the blisters of shingles, but the person who has shingles doesn't shed the virus from his nose and throat like someone with chicken pox, therefore shingles is generally not contagious, especially if the affected area is covered. If someone has decreased immunity, he should be cautious about exposure to shingles. For that reason, a person with shingles should generally not handle a newborn.
If your children are healthy and the person with shingles washes his hands after handling the area and keeps the affected area covered during your visit, there is no need to avoid him.
Sincerely,
Dr. Warren
- Sincerely,
SD
Dear SD: The first illness that comes to mind is Lupus. Lupus is an autoimmune disease where the body's immune system attacks various organs in the body. Actually, one can live quite a long time with Lupus, but some patients have a rapidly progressive course and do poorly. At first their various complaints may be thought to be hypochondria. Some may be diagnosed with chronic fatigue syndrome. They may only be diagnosed if they develop some specific symptoms that are hard to explain. If a typical Lupus rash develops over the cheeks and nose, the doctor may do some tests. Blood found in the urine on microscopic analysis (not visible to the naked eye) may lead to further evaluation. Or the diagnosis may not be made until the patient has catastrophic symptoms. I had one patient who was admitted to the hospital for evaluation of a swollen joint and prolonged fever. Shortly after the diagnosis was made he had a stroke and had seizures. Then his kidneys shut down and he developed congestive heart failure from fluid overload. He recovered from each of his crises and is on tons of medication and in the care of many specialists, but it is easy to imagine that he could not have survived one of his crises. The diagnosis is made from a variety of tests, but the most helpful initial tests (which are blood tests) would be a positive ANA (antinuclear antibody) and an elevated ESR (sedimentation rate). If you wish to use this illness, I'm sure you can find more information on the Web.
The other illness that comes to mind, of course, is Leukemia. Many patients do well with Leukemia, but sometimes it can be aggressive, and sometimes the treatments can kill the patient. Leukemia cannot always be diagnosed by a blood test. The diagnosis is made by finding abnormal cells in the bone marrow, but sometimes the blood can be loaded with leukemic cells and the diagnosis is obvious.
Sincerely,
Dr. Warren
It seems as if she has had a runny nose since she has been 6 months old. She often has violent coughing fits when she is laying down. At times the cough is accompanied by a fever. She has been to the doctor many times. Some of those times he has said she just has a cold, SEVERAL times she has been diagnosed with an upper respiratory infection and treated with antibiotics. The doctor doesn't seem to concerned with the severity of the cough (the daycare workers tell us they have never heard a cough so violent) or the frequency of the infections. Could there be a bigger problem or a reason why she is so susceptible?
Before she had these problems she was a health & very happy child. When she doesn't feel good, she just isn't herself.
Thanks for your help.
-MH
Dear MH: I have found that the significance of a child's cough cannot be gauged by how harsh it is. I've had patients who get terrible honking coughs every year as a result of seasonal allergies. Their teachers always think that something horrible is going on and being neglected, which is not the case.
The fact that the day care center is clean and well run is great, but that alone can't eliminate the risk of exposure to infectious disease which is inherent in any setting that has a lot of children. If the day care workers wash their hands between handling each and every child that will decrease the exposure, but the risk of exposure to infectious illnesses still increases in proportion to the number of children present.
Since runny nose seems to be a major part of the picture, it is possible that your daughter has just had many colds because of exposure to cold viruses; however, since you describe her as having a runny nose since six months of age, it is also possible that she has allergies. Food allergy is certainly a possible contributor in a child around 6 months of age. At this point in her life, it might be difficult to try an elimination diet, but if you wish to try it, the first thing I would try is a milk free diet.
Let's not forget to consider environmental issues. If your child is regularly exposed to cigarette smoke, that has been shown to increase the frequency and severity of colds and to aggravate asthma and other respiratory conditions.
If we take our focus off your daughter's runny nose and focus on her cough, asthma is very important cause of chronic cough. It tends to be aggravated by colds. If your daughter has had several bouts of bronchitis, she may very well have asthma. If a child doesn't wheeze severely, asthma may be hard to diagnose in an infant. First, the physician absolutely must do a good chest exam. This requires that the child not cry. For children this age, that can best be accomplished by holding the stethoscope in the same place for a long time so that the child gets used to it and at the same time, have the mother talk softly to the child about something of interest to the child in order to distract him. The exam should be done in Mom's arms. Since children this age cannot cooperate with the exam, in order to not miss a faint wheeze, the pediatrician should gently squeeze on the chest as the child is breathing out to force more air out. If the diagnosis cannot be made on clinical grounds and there is a real suspicion of asthma, a chest x-ray may be helpful if it shows hyperexpansion of the chest. If all else fails, if there is a big enough suspicion of asthma, the pediatrician could try treating with a bronchodilator to see what clinical response there is to medication.
For an overview of upper respiratory infections check my article Upper Respiratory Infections (URIs).
Sincerely,
Dr. Warren
-SL
Dear SL: Your daughter has a slight variation on the problem of children who don't sleep through the night or won't sleep in their own beds. You might like to read my article, Helping Your Child to Sleep Through the Night. In order for your daughter to feel comfortable staying in her own room or bed for the night, she has to experience it and get used to it. That means she has to repeatedly experience staying in her own bed. She has 9 years of not staying in her own bed. It's more than just a habit to come into your room. She will experience separation anxiety staying in her own room, but with out this experience, there is no potential for her to grow beyond her separation anxiety. Can you depend on maturation to get her past this? Maybe. But most 7 year olds are well past bedtime separation anxiety, and if she continues to sleep on your floor, there's no guarantee she won't still feel the need to sleep in your room when she is older.
Since she comes into your room without waking you, you could simply take the attitude that she's not hurting anyone and let things be. But since she doesn't wake you, you also have no opportunity to exercise control over the situation. Therefore, the only way to change the situation is to lock her out of your room. Of course she will make a fuss. Eventually she will get used to the change. Neither inconvenient hours nor lack of sleep should prevent parents from enforcing what they feel is right when a child fusses. Your role at that point is to help her get back to sleep in her own bed. With repeated success, her awakenings and need to join you will decrease.
Sincerely,
Dr. Warren
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