8 December 1997

1. Lyme, Pyloric Stenosis, Feeding Problem
2. Yellow Skin
3. Small Penis
4. Lifting Weights, Dieting
5. Picking Scabs
6. Wants Pull-Ups for BM at 4½
7. Bed Wetting, Soiling Since New Baby
8. OPV vs IPV
9. Disclaimer

• Read Questions & Answers in Another Column

Lyme, Pyloric Stenosis, Feeding Problem

Also, our six-week-old son we think may be experiencing pyloric stenosis. He commonly vomits (which concerned us because our daughter had reflux) but in the last 48-hours it has been projectile vomiting in large volume. His diaper is still very wet, when should we become concerned? Should we ask for a diagnosis?

Do you think this could be pyloric Stenosis? Any other thoughts?He was one month early and was 5lbs. 6ozs. Could this contribute to excessive spitting up?

Finally, our older son has been engaged in a particulary annoying practice we've named "chipmunking." This practice includes stuffing the mouth full of food and chewing and chewing and chewing--but not swallowing. We're pretty sure this is some weird attention-getting tactic, but it concerns us because he is in the lowest percentage weight-wise (he's alomost 3 and only wieghs 27 lbs.).

He eventually must spit out the food. Waiting him out does not seem to be an option (he's real stubborn) neither does discipline.

Any advice?

Kind regards,
-J & S K

Dear Mr. & Mrs K: The drug of choice to treat a child under 8 years of age for Lyme disease is Amoxicillin for 2 to 3 weeks. Early treatment (at the stage the rash develops) almost always prevents development of later stages of Lyme disease. The risks to a young child are no different than for anyone else with Lyme disease. If later stages of Lyme develop the symptoms include arthritis and various neurological symptoms. These require treatment with intravenous ceftriaxone.

If your son suddenly developed projectile vomiting at 6 weeks even if he had been spitter before, the first diagnosis to consider is pyloric stenosis. You could try putting him on Pedialyte for a few feedings to see if he improves, but if he isn't holding down fluids he should be seen by the pediatrician right away if only to get his current weight for a baseline. The decision to do further diagnostic tests can best be made by your pediatrician by following the situation closely.

Your son Michael's feeding problem is a behavioral problem and should be dealt with as such. By that, I don't mean you should threaten, scold, or discipline him, because these approaches do not give you control over the situation. By calling it a behavioral problem I am trying to separate it in your mind from a feeding problem. I understand your concern about his nutrition, but you can't control the situation if you are worried about how much he eats. And face it, giving him a plate full of food to stuff in his mouth isn't getting him to eat it anyway. It is possible that this behavior has developed in response to mealtime stress about his eating.

At this point you must provide him only the smallest portion of food and offer nothing else until he has eaten it. It is wise while trying to retrain his eating pattern to offer foods he eats well and can eat easily. Additional nutrition can be offered by having him drink Pediasure. If he does not eat, his plate should be removed from the table. He must not be cajoled about his eating. When the meal is over, he should be excused from the table along with everyone else. He should not be given extra time for his meal unless he is eating it well. He needs to learn that a meal has a beginning and end whether or not he eats. And he needs to learn that he can only have food to eat, not to stuff his mouth.

Parents of small children who are finicky eaters need to know that good eating habits can not be developed by pushing the children to eat. If parents provide their children with the nutritious foods they like along with the opportunity to try new things without any pressure and don't offer junk food in place of nutritious food, even the most finicky eater should eventually develop good eating habits. For more information on this subject read my article "Nutrition Without Tears" at http://www.mindspring.com/~drwarren/feedkid.htm.

Sincerely,
Dr. Warren

Thanks,
-BA

Dear BA: Yellow skin in the distribution you describe (palms, soles, knees, nose) with the whites of the eyes not yellow is typical of carotenemia. Carotenemia means high blood levels of the pigment carotene which comes from yellow vegetables like carrots, squash, and sweet potatoes. Since these yellow vegetables are favorites of many babies and the main ingredient in jarred dinners, carotenemia is very common in infants. It is absolutely harmless and therefore, no cause for concern.

Sincerely,
Dr. Warren

I would normaly put this off to a typical bully type situation except that his penis and scrotum are rather small in relation to his body and other boys his age.

We first noticed this at birth. We did bring this to the attention of our Family Physician at about 3 years of age but he did not seem alarmed.

My question is, is there a condition in medicine that would inhibit genital development? He is very sensitive about this and I would not take him to a doctor unless there is something to pursue.

Thank you for your help.

-SG

Dear SG: There are a number of conditions that can be associated with small genitalia. Most are congenital syndromes that are associated with other findings besides small genitals. Most congenital syndromes as well as most glandular conditions that could affect the genitals are associated with abnormalities in growth, especially short stature. If your son's growth is normal, it is less likely that he has any such condition.

There is a considerable range of normal for genital size just like there is for height. Unfortunately, when it comes to height and genital size, most people, kids included, tend to feel that bigger is better. For a 6 year old the normal range for penile length is approximately 1.6 inches to 2.5 inches, but this is a stretched measurement from the pubic bone to the tip of the penis. The visible portion of the penis unstretched is considerably smaller and I don't believe there are any standards for appearance.

Sometimes the penis appears small when, in fact, it is normal. That is why the standard is based on a stretched length measured from the pubic bone (ruler pressed into the pubic fat pad). If a child has a large pubic fat pad, which can occur even if the child isn't fat, the shaft of the penis will be partially or even completely buried in the fat pad, but if you put your fingers around the base of the penis and press into the fat pad you will be able to appreciate the full length of the shaft. The scrotum often appears small if the testes are retractile and don't spend most of the time in the scrotum or if they are undescended.

Even if your doctor isn't "alarmed" about the size of your child's penis you need more reassurance that everything is normal. For your child to be the subject of ridicule by his peers, even if his genitals are normal, the appearance is obviously small to others besides yourselves. The possibilities are too many and too complex for me to suggest a list of conditions that could cause small genitals. You should start by having an answer to the question "Are my son's genitals abnormally small for his age?" The only person who can answer that is an examining physician. At your son's age, he should be having regular physical examinations to assess his health, growth, and development. Regardless of whether your son is sensitive about the subject every complete physical (not illness visits) should include a genital exam. There is no better way for you to know his status without focusing attention on your son's genitals.

Sincerely,
Dr. Warren

Thanks,
-Josh

Dear Josh: I also didn't find a lot of information on the Web about weight training. You might try the news group misc.fitness.weights and see if you can find any useful information there. One caution: I cannot vouch for the safety of any program that aims at producing the most muscle bulk in the shortest amount of time. As a pediatrician, I tend to think about what's safe rather than what will give you the most fantastic results. Your best source of information might be a coach or gym teacher in high school.

If I were designing a program I would aim at exercising all muscle groups. That means curls for the biceps, overhead presses (I don't know if that's the correct name since I'm not a weight lifter) for the triceps, a small weight lifted out to the side for the deltoids, bench presses for the chest, and squats for the legs. This should be done with a heavy enough weight to require effort but not heavy enough to injure yourself. As your tolerance increases, increase the weight.

Adding muscle bulk will help you lose weight because muscles burn more calories than fat, but to burn those calories you should do aerobic exercise as well such as jogging, bicycling, swimming laps, cross country ski machine, etc.

The only diet that's safe for a teenager is a sensible, low fat diet, that doesn't aim at producing rapid weight loss. If you do weight training and aerobic exercises you will probably have to eat at least 2500 calories per day even if you want to lose weight. You can cut down on calories by drinking only water and sugar-free soda or tea. If you drink milk for protein drink skim milk. Avoid fried foods. Limit added fats such as dressings, butter, margarine, sour cream, and mayonnaise. Limit foods naturally high in fat such as cold cuts and cheese. Use only skim milk dairy products. Eat healthy portions at meals but don't take seconds. Get in the habit of eating salad and vegetables to help fill your belly. Limit the frequency and quantity of between meal snacks and choose snacks without fat such as fruit. Substitute pretzels or air popped popcorn (no added butter) for chips, ice milk for ice cream.

See if these suggestions help and get back to me if you have any specific questions about dieting.

Sincerely,
Dr. Warren

After these bites have been picked daily for a couple of months, you can't call them bites any longer.

I have just started trying to get her involved more in the healing. Following a bath, we put Caladryl on some, Neosporin on others. Then she puts a total of 25 small circular bandaids on the worst ones. She currently has about 25-30 visible on each leg.

I ask her not to remove them until the next bath, and started putting pants on her (in the Texas summer!), to try and give them a chance to start healing.

What to do?

-Ms. B

Dear Ms. B: The steps you have taken to involve your daughter in a positive way in the process of controlling her habit are excellent.

The picking may represent some degree of compulsive behavior, but it may also be done without your daughter even being conscious that she is doing it. When you see your daughter picking on something, try reminding her that she is doing it, but don't make your reminder stressful. The purpose of the reminder is to help avoid the picking if it is occurring without her being aware she is doing it. Avoid any battles or demands that she stop when you mention it.

Since getting your daughter involved in controlling the behavior seems to help, you might work with her to see if she can find some acceptable substitute behaviors for the picking. For example, she could hold an ice cube on the scab or rub some ointment into the scab to see if the urge to pick can be diminished.

The other thing you can do is to try to minimize the number of things she has to pick at. When she gets a mosquito bite try to treat the itching vigorously so that she won't get a scab to pick at. Show her how to rub an itch instead of scratching it. Rub 1% hydrocortisone or a local anesthetic anti-itch cream into mosquito bites. Consider giving her an antihistamine like Benadryl for itching, but one caution: Antihistamines can make kids drowsy, and if she is picking without itching, drowsiness could aggravate the symptom. Make sure her skin is in good shape. You might want to consult a dermatologist to be sure that her skin is not excessively dry or that she doesn't have a skin condition that makes her prone to scratch since scratching leads to scabs which can then be picked.

Sincerely,
Dr. Warren

When he needs to go, he goes and puts his pull-ups on or comes to me to put them on. I then try to talk him into using the potty but he refuses (sometimes he will skip the BM).. He used to go into a private place to have his BM, but now will do it in front of us. He does not have regular BMs everyday...he will usually go 3-4 days in between BMs. He then complains of stomach pains when he has to go. I have tried everything from punishment, incentives and ignoring this, but nothing has changed. Do you have any ideas??? He will urinate in the potty fine.

Thank you,

-K

Dear K: Constipation adds significantly to the difficulty in bowel training, and stool withholding (holding it in and refusing to have a bowel movement) adds significantly to constipation. The best approach to your son's problem is a two pronged approach.

1. Keep the stool soft. This may be accomplished by increasing the fiber and fruit juice in your son's diet. This may require the addition of bran, prunes, and prune juice. It may be necessary to give your son a stool softener such as malt supex, colace, or metamucil, or even a mild laxative/softener such as senokot. He may need to take mineral oil to act as a lubricant. You should consult your pediatrician before offering any medication. In addition, avoid constipating foods like white rice and bananas. In your efforts to avoid constipation it may be necessary to continue letting your son use a pull-up for his BM's even as you encourage him to use the toilet.
2. Acclimate your son to sitting on the toilet. The first step to having bowel movements on the toilet is sitting on a toilet. Bring him in after each meal and encourage him to sit. Keep it pressure free. Praise his cooperation. Make no demands. At first, he may need to sit with the lid down and his pants up. To encourage long sitting he may need some diversion. Since he wants to have his bowel movements in his pull-up, he might be able to get used to doing it in the sitting position by sitting on the toilet with his pull-up on. Eventually, he needs to sit on an open toilet with no pants on. Once he does this regularly he should be encouraged to push. If the stool is soft enough he should have the success he needs to build on.

Sincerely,
Dr. Warren

-DL

Dear DL: Wetting the bed generally occurs during sleep. As children mature many will stop wetting. There are treatments that can help. I suggest you read my article on bed wetting at http://www.mindspring.com/~drwarren/enuresis.htm.

It is absolutely not an accident that your son has started to have daytime bowel and bladder accidents since the arrival of a new baby. He is apparently having some difficulty dealing with not being the baby anymore and is regressing in response. He will need lots of attention and reassurance to realize that the new baby will not take his place.

Most children who have accidents claim that they don't feel it. They believe they can't feel it. This is an ego defense known as denial. As long as a person can deny (to himself) that something is happening, he doesn't have to deal with it. Even adults sometimes resort to denial since it occurs subconsciously rather than consciously.

The best approach is to schedule his time in the bathroom. He must sit on the toilet after every meal and attempt to have a bowel movement, and he must use the toilet before going outside or getting involved in any long activities. He should be praised for cooperating and making the effort even if it doesn't result in immediate success at staying clean and dry.

Most children who soil their pants are stool withholders. That means that they hold the bowel movement in as long as possible resulting in a rectum full of hard stool. In other words they become severely constipated. The soiling results from small amounts of soft stool leaking out around the large hard stool in the rectum. Essentially, they only let out what they can't hold in and end up with their intestines full of stool. Treatment requires not only scheduled sitting on the toilet, but also medication to keep the stool soft. Treatment of stool withholding can be a complex matter and generally requires the involvement of a patient pediatrician. If you think your child is a stool withholder you might like to read my article about Fecal Soiling at http://www.mindspring.com/~drwarren/encopres.htm.

Sincerely,
Dr. Warren

-AB

Dear AB: The inactivated polio vaccine is very effective at preventing polio. Even if your son started with the live vaccine he can switch to the inactivated vaccine and get good protection. The risks of the live vaccine are very small, but they are very real. The incidence of polio in the USA is so low that the 6 to 8 cases of polio reported each year are now vaccine related. As a result, the recommendations for polio vaccination have changed. Since January 1, 1997, the recommended immunization schedule for polio is to give the first two doses (2 and 4 months) with the inactivated vaccine. It is recommended that the boosters (18 months and 5 years) be given with the live vaccine to provide the additional benefit of intestinal immunity. The reasoning is that the first two doses of inactivated vaccine will provide some protection against a paralytic reaction to the live vaccine. Since some parents may wish to avoid injections and others may consider the risks of the live vaccine too high even for the boosters, and since any combination of the vaccines will give a child immunity, it is recommended that the risks and benefits be explained to parents and that they may be given a choice.

Sincerely,
Dr. Warren

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