10 November 1997

1. Tongue Tie
2. Formula Intolerance
3. Night Waking, Night Feedings, Eczema
4. Incubation Period for Chicken Pox
5. Fainting Infant
6. Tantrums
7. Drug Tests and Pot
8. Child Won't Stay in Own Bed
9. Disclaimer

• Read Questions & Answers in Another Column

Tongue Tie

-Gloria

Dear Gloria: Your difficulty in finding an answer regarding tongue tie stems from the fact that it remains a controversial subject. Since your son is now 11 months old I assume that he didn't have any feeding problems as a result of being tongue tied. To the best of my knowledge, no study has ever established that tongue ties cause speech impediments. Certain sounds which are usually made with the tip of the tongue at the upper teeth (such as "s", "d", "l", and "t") have to be made with the tongue at the lower teeth, but they sound the same that way. In my opinion tongue ties can be left alone unless tongue mobility is so impaired that it interferes with sucking.

The final answer as to whether tongue ties cause speech impediments should come not from doctors or dentists, but from someone who treats speech disorders such as a speech pathologist or speech therapist. The questions for them are, "how many of their patients have speech impediments as a result of tongue tie, and how difficult are they to treat?" An equally important observation would be how many children with tongue tie have no problem as a result.

Sincerely,
Dr. Warren

Sincerely,
-CK

Dear CK: If your son has a problem with formula intolerance soy formula may be just as much of a problem as a milk based formula. You may need to try a hypoallergenic formula such as Nutramigen or Alimentum. Another possibility to consider is that bottle feeding is causing your son to swallow air which may cause him gas pains and excess spitting. If this is the case, rather than a change in formula your son may need a change in the bottle or nipple. For that you might want to try the bag bottle arrangement like the Playtex Nurser. These minimize air swallowing since air doesn't have to enter the bottle for the formula to come out.

Sincerely,
Dr. Warren

When the problem first arose(about 6 weeks ago), my pediatrician said not to feed him, because if he slept through at all, he could do it and we would start a bad habit. So we let him cry for 2 weeks.

Then we had his 4 month visit and saw a different doctor in the same practise (there are about 6). This doctor said we were being cruel not to feed him. When I asked about putting him on solids, he said not to before 6 mos. My son has eczema possibly related to dairy - he's now on soy. I was told that starting on solids earlier than 6 mos. might cause further food allergy problems.

As for the eczema, it went away almost overnight when we switched to Soy but is now back again. I was given a prescription for aclovate, but it doesn't seem to help too much. Could he now be reacting to the soy?

I have called my own doctors back, considering the rash keeps changing in intensity I feel stupid calling them every few days.

Do you have any advice or differing opinions?

Thanks,
-Jeremy's Mom

Dear Jeremy's Mom: In general, a 5 month old should not need to be fed in the middle of the night to get him to sleep. The risk in feeding a child to get him to sleep, is that he learns to use feeding as a means to fall asleep and then demands a feeding any time he awakens. This is known as "trained night feeding." If your son uses a bottle to put himself to sleep at night, his demands for feeding at night may represent trained night feeding. On the other hand, if your son goes to sleep at night and nap time without a bottle, and only occasionally demands a bottle to get to sleep, then he may be genuinely hungry. Still, if he gets in the habit, he could become a trained night feeder.

I would not consider it cruel to try to avoid feeding a 5 month old in the middle of the night, but if he needs a midnight feed and then sleeps 6 to 8 hours, or sleeps at least 6 to 8 hours but then needs a feeding by 5 AM, I'd consider that reasonable. If you do try to avoid feeding your son, you should still make periodic visits as you deem necessary to comfort him briefly and make sure he is okay and knows he's not being ignored. Check my article on sleep habits, "Helping Your Child to Sleep Through the Night" at http://www.mindspring.com/~drwarren/sleep.htm.

The American Academy of Pediatrics does not recommend solid feeding before 4 months because prior to that infants don't have adequate head and swallowing control to learn and control spoon feeding. If children have allergies, it is generally advisable to wait until at least 6 month of age before starting solids. Formula and human milk are protein foods and are adequate to meet an infants nutritional needs and fill his belly until at least 6 months.

Soy is as potent an allergen as milk. It is certainly possible that his eczema has flared in response to the soy. If your son has severe allergies or eczema, you should try a hypoallergenic formula like Alimentum or Nutramigen.

Aclovate is a fairly potent cream and should reduce the inflammation of your son's rash, but it is not a cure for eczema, and the eczema may return in which case you may need a milder steroid cream for more regular use. Remember that eczema is a very dry rash so that skin care is just as important in its treatment as an anti-inflammatory cream. You should avoid any drying soap and not bathe your son more than necessary. After bathing, you should apply a moisturizer to his skin. I recommend Eucerin ointment for my eczema patients.

Sincerely,
Dr. Warren

-G

Dear G: Chicken pox becomes contagious about a day before the rash comes out and remains contagious for the whole time there are any blisters, usually about 7 days. During that time the child may not attend school. Another child who is exposed to chicken pox may develop chicken pox within 12 days after exposure until 21 days after exposure. It is not necessary or even reasonable to keep a child out of school during the 12 to 21 day incubation period since there is no way to know if or when the child will get sick.

Sincerely,
Dr. Warren

Sincerely,
-R

Dear R: I was unable to find any information on the Net regarding syncope in infants using several different search engines. I can't say that I have ever treated syncope in infancy with the exception of breath-holding, which I would call "breath-holding" rather than "syncope."

You didn't describe the circumstances under which your child passes out or any associated symptoms, so I can't speak specifically about your child, but by far, the largest cause for healthy infants to lose consciousness recurrently is breath-holding. Breath-holding is generally provoked by pain or fright which results in severe crying. Often the infant will be crying progressively more hysterically until the breath-holding spell begins, but just as often, the infant may start out to cry and immediately hold his breath. This results in an infant who looks like he is going to scream with his mouth wide open and no sound coming out. As the infant continues to hold his breath he begins to turn blue and eventually becomes limp and unconscious. Sometimes there may even be a few beats of seizure activity before the child becomes limp. Breath-holding can be distinguished from a seizure in that the breath-holding spell is provoked by a cry or an attempt to cry, cyanosis (turning blue) with a seizure occurs during the seizure rather than before it, and breath-holders regain consciousness quickly without disorientation whereas after a seizure a child remains unresponsive for several minutes or more and may be disoriented on "awakening." Breath-holding spells are frightening but not dangerous and disappear as children get older.

The pediatric neurologist, who has dealt with more syncope cases than a general pediatrician, will review the history of these syncopal episodes with you as well as reviewing the tests. After that he may offer an opinion and recommendations or suggest further evaluation. Since the bulk of the neurological workup has already been done you should not anticipate a great deal more testing. The pediatric neurologist will review the EEG himself since infant EEGs are often not interpreted correctly by those who don't have experience with infant EEGs. If he feels there is no neurological cause for the syncope, he may recommend seeing another specialist.

The other specialist to see is a pediatric cardiologist. While a normal EKG is good, your child may need to be on a Holter Monitor (a long-term, portable cardiac monitor which can be worn at home) in order to pick up an abnormal rhythm causing the syncope. The cardiologist might review respiratory symptoms and a history of certain activities or movements which provoke the fainting spells to determine if there is a need for further cardiac or vascular evaluation.

Your pediatrician might also consider teaching you how to check your infant's blood sugar at home since syncope can be caused by hypoglycemia, but finding hypoglycemia as a cause of syncope, just like finding an abnormal heart rhythm as a cause of syncope, may require testing the baby during the syncopal episode.

Please let me know what your doctors do and what they find. Unless your baby turns out to be a breath-holder, it is a most unusual case.

Sincerely,
Dr. Warren

-SC

Dear SC: There is no quick and easy way to end tantrums. As a result, many parents make the mistake of assuming that their approach doesn't work and they keep trying different approaches. All children, but especially young children, require consistency. In order to learn what you expect from them, they need to learn what to expect from you.

Thank your lucky stars that your 4 year old son is easy and charming. Then forget it when dealing with your daughter. She isn't the same person. In time you will discover her most endearing traits, but any comparisons to her brother sound like she will fall short right now.

Part of what's going on is that your daughter is frustrated and unable to express her feelings. This comes out as tantrums. Your first reaction then, should be to see if you can calm her and defuse the situation. This does not mean give her her way. But it does mean that you need to ignore your own natural reaction to yet another tantrum and try to calmly control the situation. If this does not work then your daughter should be removed from the situation for a time out to calm down. If she is hitting prior to the time out you should hold her hands firmly with your arms wrapped tightly around her to control her. This and time out should be done consistently every time. It will not make your daughter easy to deal with. But it will give you a calm sense of control over the situation and in time your daughter will learn to be calmer and express herself calmly.

In the meanwhile, it sounds like she needs her social situations to be smaller so that she does not become overwhelmed. She is telling you from her response that she can't handle the stimulation and the crowds in certain social situations. She needs an opportunity to learn how to deal with people outside the main family unit, but she needs it in smaller doses with lots of support from you. And don't forget to let her know when you are pleased with what she is doing.

Sincerely,
Dr. Warren

-Lowkoweed

Dear Lowkoweed: I'm not aware of any medicines or tricks that will clean pot out of your system, but since pot is not a legal drug, it shouldn't surprise you that the information you seek has not been researched or published in any medical journals. If there is such a thing, the first people to know would be pot-heads, and the next would be law enforcement. Be careful about trying any home remedies suggested by friends or other pot smokers. Most likely they won't work, and they could be dangerous.

Sincerely,
Dr. Warren

-PH

Dear PH: It is unusual for a 2 year old who has never had a problem going to bed to suddenly have a problem being in bed. Even if the bedtime routine hasn't changed look for some possible source of tension or upset that might have caused some separation anxiety. This could even be something that you think has nothing to do with her. You'd be surprised how sensitive children can sometimes be to what's going on in their family's life.

On the other hand, children can develop bad habits very quickly. Your daughter may have simply discovered that she could get out of her crib and from that time forward, decided that she wanted to be part of what was going on outside her room. Had you asked me at the outset, I would have told you, "If you don't want your daughter in your bed or bedroom, no matter how desperate you get, don't let her be there."

If you want her to sleep in her own bed, you must put her to sleep in her own bed every single night, and make it clear to her that that is what you expect. Stay with her after you put her into bed (in her room, but preferably not lying with her). Gradually decrease the amount of time you spend with her. At first you might stay until she's asleep, but eventually you should leave when she is relaxed and drowsy, but awake. Then decrease your intervention from there. If she gets out of bed, repeat the procedure. If getting out of bed is a serious problem, you will have to decide whether you want to make it difficult for her to get out of her room rather than repeatedly taking her back.

Please read my article on Teaching Good Sleep Habits at http://www.mindspring.com/~drwarren/sleep.htm.

Sincerely,
Dr. Warren

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