24 November 1997

1. Developmental Delay, Obesity
2. Definition of a Pediatrician
3. Introducing Foods to Infants
4. Hand, Foot, & Mouth Disease
5. Masturbation, A Sign of Sexual Abuse?
6. Protein in the Urine
7. Grief on the Death of a Child
8. Sensitivity to Noise, Things in Room Appear to Be Moving
9. Disclaimer

• Read Questions & Answers in Another Column

Developmental Delay, Obesity

A loving cousin in need of answers,

-LF

Dear LF: At 40 inches, C is the appropriate size for a 4 year old. But at 80 pounds, he weighs twice what a 4 year old should weigh. He must be huge. He certainly cannot fit into diapers. But his weight sounds like the least of his problems.

Any child with delayed communication skills deserves a complete evaluation by a speech pathologist. The evaluation must include a hearing evaluation. Sometimes a child may have just enough hearing to be somewhat aware of what's going on and yet not enough to develop language. Another possibility to consider is Asperger's Syndrome - a kind of high functioning pervasive developmental disorder (previously known as autism). These children tend to relate better to things than people. They may be quite bright with regard to numbers and reading and yet have no communication skills. A speech pathologist can help to determine if hearing loss or Asperger's Syndrome is the diagnosis.

If we consider the obesity along with the developmental delays, a diagnosis of Prader-Willi Syndrome should be considered.

Further evaluation by a developmental specialist or a pediatric neurologist should also be considered.

Sincerely,
Dr. Warren

My assignment is to write an essay defining something. I chose to do my definition essay on a pediatrician.

If it wouldn't be too much trouble, I was hoping you could e-mail me your thoughts on what you think makes a pediatrician what he is. Is it the love for kids, the respect, or whatever you think?

Thank you very much for your valuable time.

Yours sincerely,
NP-

Dear NP: A pediatrician is a physician who treats children. The choice to care for children should be based on a love for children and a belief that it is a significant accomplishment to make a difference in a child's life. In the process, a pediatrician discovers that he treats parents because children come to the pediatrician primarily as a result of parental concerns. As a bonus, a pediatrician gets to hold his patients in his arms, to see them grow and change, and years later, to see the adults they have become.

Sincerely,
Dr. Warren

-DJ

Dear DJ: You are in luck. I have written a whole article on infant feeding. It can be found at http://www.mindspring.com/~drwarren/feedbaby.htm.

The American Academy of Pediatrics recommends not introducing any solids until at least 4 months of age. In children who may have allergies, it is preferable to wait longer. Single ingredient foods should be introduced with a few days between each new food to allow observation for reactions.

Table foods can be introduced when a child's swallowing mechanism is mature enough to handle particles without gagging. For some infants this is as early as 7 or 8 months and for others, not before 1 year.

For more details, please read my article, Feeding Your Infant. Please contact me if you have additional questions.

Sincerely,
Dr. Warren

Thank you.

-R

Dear R: Hand, foot, and mouth disease is caused by coxsackie virus. It spreads through secretions like exposure to coughing and sneezing, and it spreads through stool. The most important things you can do to prevent spread of coxsackie virus are to keep the sick child away from healthy children and wash your hands after dealing with the sick child, especially after handling his diapers.

Coxsackie viruses can cause a variety of illnesses. The most common is herpangina. Herpangina is a late spring through summer illness characterized by fever and sore throat. In a typical case of herpangina the doctor will find canker sores in the throat on the palate, and sometimes on the tongue. Hand, foot, and mouth disease is a form of herpangina where the child also has blisters and bumps on the palms and soles, and sometimes on the buttocks. The usual course of the illness is about 5 days. Tylenol or Ibuprofen (Advil, Motrin) are useful for symptomatic relief as are ices and ice pops. Antibiotics are not helpful and should not be used.

Sincerely,
Dr. Warren

(In contrast, our 7 year old daughter has shown no similar behavior as of yet.)

-J & B G

Dear Mr. & Mrs. G: Self exploration and masturbation are normal behaviors for 5 year olds. There is a large degree of variability in the extent to which children engage in these behaviors. Therefore your daughter's apparent lack of interest is also normal. Additionally, the period from 6 or 7 years until adolescence (known in traditional psychiatric texts as the latency period) is characterized by an increased interest in socialization outside the home and a decreased interest in "sexual" behavior.

Most 5 year olds are aware that their genitals are private and choose to masturbate in private. From the point of view of teaching appropriate social behaviors, that is our goal. Teaching children that it is "bad" to touch oneself, if successful, is bound to create psychological conflict later in adolescence and adulthood. Your son probably has an awareness when you question him that there is some implied disapproval just from the circumstances of the question, even if you try to be matter-of-fact about it. What's more, at 5 years of age, he is hardly in a position to fully understand what primal urge he is responding to, no less explain it to you. Therefore, he gives the traditional childhood response to a question he can't handle. He clams up.

Children who have been abused may exhibit a number of sexual behaviors. They may dress and act provocatively toward older children and adults (their abusers). They may apply what they've learned and abuse younger children. At the same time, they may exhibit stress reactions such as nightmares, loss of appetite, sudden behavioral difficulties, sudden fears of certain people or situations.

If there is any potential that your children could be sexually abused (time spent in the care of others in your absence) you should talk to your children calmly about the subject. You should tell them that their genitals are private. Nobody should touch their genitals except for parents and caretakers (explain who they are) when bathing, doctors when examining (generally with the parents present), and themselves. Most important, you should teach them that they can tell you anything, that you will love them no matter what. Make sure they understand that anyone who tells them to keep something secret from you is doing something bad and that they should tell you. If there are threats, it is even more important to tell you. Assure them that no one has the power to hurt you and that you won't let anybody hurt them, but the best way for you to protect them is for them to tell you everything.

Sincerely,
Dr. Warren

-CF

Dear CF: Protein may be present in the urine of perfectly healthy people. In the process of filtering the blood healthy kidneys generally allow only small amounts of protein to pass out into the urine. This usually results in a urinalysis negative for protein. Sometimes if the urine is concentrated the protein concentration may be high but the total amount of protein passed into the urine in 24 hours remains negligible.

Orthostatic proteinuria is increased protein in the urine related to activity. The total protein spilled over the course of 24 hours is generally not significant with orthostatic proteinuria. The best way to check for orthostatic proteinuria is to check a first morning specimen obtained immediately on arising, before any activity, after a night of sleep. If this first morning specimen is negative for protein no further evaluation is necessary. Orthostatic proteinuria is perfectly normal.

If a first morning specimen shows elevated protein then the urine can be checked to see if the kidneys are spilling too much protein by measuring the total amount of protein in a 24 hour collection or by measuring the protein/creatinine ratio in a random specimen.

Transient episodes of proteinuria may be associated with exercise, cold exposure, stress, and dehydration. Persistent proteinuria may be a sign of kidney disease, some of which may be genetic and some related to infections such as strep throat. Many of the kidney disorders associated with protein in the urine never progress to the point of requiring treatment. Often, a definitive diagnosis can only be made with a kidney biopsy. This is generally done only if there are other signs of kidney disease. After evaluation, the nephrologist will fill you in on the possibilities if there is any reason to consider kidney disease.

Sincerely,
Dr. Warren

Please do not think that these are the rantings of an irrational grieving and hurt parent. They are not. I have now fully regained my composure and I intend to approach this situation with all my experience and maturity gained with the benefit of three university degrees, 52 years of maturing, the privilege of working within the high levels of environmental protection consultancy, and of course the joy of being a mature father to a very special little girl.

Through contacting a number of physicians and nurses and based on my own empirical observations, it has become increasing plain to see that had more attention been give to my child she would have been here today. If you wish to have a more detailed presentation of the circumstances, I will gladly send you details. The bottom line is that I have been lied to by the doctors concerned, certain records have been mislaid, and a general closing of ranks has been ordered by the hospital administration. A number of prominent paediatricians here in the UK are somewhat concerned over matters and have freely consented to attend and give evidence at the coroner's inquest in due course. I in turn have run and am running a number of adverts requesting information and parents' opinions on paediatric care here in West Glamorgan. As a professional you would be astounded at what I have learned to date. Although the information I have gathered is without support, it is information from genuinely concerned parents who feel that all is not as well as it could be.

What I need to know is this. Are you aware of any organisation of parents, in the USA, who are together because they have suffered a loss of a child through negligence and have had the further indignation of facing a cover up of the true facts which led to the death? If so I would welcome your support.

A child's life is so precious, the innocences and love in the eyes that look up to you as a dad is truly God's gift to the most hardened of souls which we as men become. My little girl was everything to me and my devoted wife, and our hearts which were once so filled with the joy of life are now burdened. We will be strong, for each other, and more importantly for our other three children. But the web of deceit which hangs over our beloved little scout must and will be blown away to preserve her sacred memory. And not wishing to sound vengeful, for that is God's privilege, those who should have done more and failed must not be allowed to hide and commit the same folly again.--Thank you for you time--Sincerely

-DG

Dear DG: My condolences on your terrible loss. As time goes by your life will go on, but even without experiencing the horror of a loss of one of my sweet children I know that no parent ever recovers from the loss of a child.

I am not aware of a support group specifically aimed at parents who have lost a child through medical malpractice; however, one of the most excellent parents' groups on the Web is Parents' Soup. They do have a discussion group for grief* at Parents' Soup. The members talk about grief of losing parents, losing children, children losing parents. If you cannot find the support you need there, perhaps one of the members has experienced the kind of loss you have suffered and can direct you to a support group more appropriate for your needs. You do not have to join Parents' Soup to read the messages, but joining is free, so you might as well join if it meets your needs.

If you feel I can help you by answering specific questions of yours I would be happy to.

Sincerely,
Dr. Warren

The last attack really scared us. It went on for about 30 minutes. My wife finally calmed her down with some milk and lying quietly on the sofa.

Can you help me narrow in on what this might be so that I might be more accurate in seeking medical help for her?

Thank you very much for your help.

Sincerely,
-FW

Dear FW: Without any other symptoms to go by, three basic causes come to mind as to why a child might have a sensation that things in the room are moving and noises are too loud.

1. A psychological or stress reaction
2. A migraine equivalent
3. A seizure equivalent

If the movement of things moving in the room really means that your child feels like the room is moving, she is describing vertigo. Vertigo can be caused by neurological conditions, but it can also be caused by middle ear conditions.

If she were an older child I would feel obliged to mention the possibility of drug use. Even in a younger child we have to consider the possibility of medication side effects for both prescribed and OTC medicines.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

ask Dr. Warren a question?!?