5 January 1998

1. Refuses Dairy. What About Calcium?
2. Two Doctors, Two Opinions
3. Sudden Weight Gain
4. Swaddling
5. Head Size
6. Very Sick Child
7. Taking Medication While Breast Feeding
8. Grieving Parent Asks MDs for Honest Answers
9. Disclaimer

• Read Questions & Answers in Another Column

Refuses Dairy. What About Calcium?

-AP

Dear AP: Lactose intolerance causes gas, bloating, and diarrhea after a meal containing lactose. It is possible your child is lactose intolerant, but if he never had these symptoms, it would be hard to say. He could have developed a dislike for lactose containing foods if they gave him gas pains, but he would have had to have pains pretty quickly after a milk meal to have learned to avoid it. Therefore, it's possible your son simply doesn't like milk.

I'm curious regarding what formula he was on. If he was on a milk based formula like Enfamil, Similac, Gerber, or Carnation, he would have had trouble with the formula if he were lactose intolerant.

The nurse's suggestion to give you child Tums is a good one since Tums is Calcium. Even though Mylanta is not made from calcium, the new Children's Mylanta is calcium based and may be easier to give to an infant.

Sincerely,
Dr. Warren

My (now) 5 1/2 month old has reflux (as you may recall..) and is currently on 1.7 cc's of Propulsid 4 times a day and 20 MG of Prilosec twice a day. (He weighs 15 lbs.) For the past 12 days he has had VERY frequent bm's (5-7 a day~his normal amt is 1-2, if that). Our Gastro initially upped the Propulsid (from 1.5 to the 1.7 amt), thinking the acid building up again was causing the problem. This lowered the frequency from 7 to 4-5 a day. Since it didn't go down anymore, he cut the Prilosec dosage in half, which was a big mistake because his reflux symptoms got worse again and the bm amts. did not change. Then on Friday; as a last resort, took all of his fruits away saying if this didn't work he would do testing for infection. It's been three days now and nothing has changed. Sometimes the stools are watery and other times just soft and mushy. I called our reg pedi for a second opinion, and he says not to worry about dehydration (he's not throwing up) and it's probably just an intestinal virus and we need to wait it out and feed him a regular diet. I am concerned because this is a child that barely drinks 20 oz of formula a day, but since he is acting okay, just a little fussy...maybe teething? I don't know for sure, but he has all the signs of teething. I think the two things that worry me the most about this is his weight gain, because he has such problems, gaining no more than 15 oz a month and always growing at least 1" -1 1/2" a month and they dehydration factor. So, I was supposed to call the Gastro yesterday afternoon and talk about the testing which now our pedi thinks is uneccesary....Any advice? Should I pursue the testing and conflict with what our reg pedi suggests and if so how do I go about approaching him for a referral?

Also, what do you do in the case that your child's two pediatricians don't seem to agree on ANYTHING, nor do they discuss the treatments/approaches with eachother? (We are talking everything: Pedi says solids and juice at 4 mos, Gastro says he prefers nothing until at least 6 mos, Pedi says what ever amount of formula he will drink in a day is fine, Gastro says at least 21 oz a day, Pedi isn't big on the reflux meds, Gastro insists that they need to be comfortable and wholeheartedly endorses the use of meds for children w/reflux.....on....and..on....)

Thanks in advance!

-Susan

Dear Susan : There is a reason that managed care plans require referrals from primary care providers before you see a specialist. Part of that reason involves expense, which is the insurance company's interest, but what they really want to limit is unnecessary expense by limiting unnecessary procedures.

Since the gastroenterologist sees children with diarrhea who have chronic or severe problems he is very ready to do a major workup. He doesn't treat healthy kids and his focus is on finding answers to every gastrointestinal problem that comes his way. But diarrhea is such a common childhood problem that every baby deals with it at some point, even those with other gastrointestinal problems. The main risk to diarrhea is dehydration. If the baby isn't vomiting and has 4 to 5 stools per day ranging from watery to mushy, and drinks adequate fluids, there is no real risk of dehydration. Even if the baby has something more than a gastrointestinal virus (gastroenteritis) which often runs 3 to 5 days, it won't hurt to wait a little longer before embarking on a medical workup.

The other side of the coin here is that your child does have a chronic gastrointestinal problem, and your pediatrician cannot afford to dismiss all the advice of the specialist. What's more, he can't put you in the middle. The specialist and the pediatrician must communicate with each other and agree on a care plan. If your pediatrician disagrees with the gastroenterologist's approach, he should refer you to another gastroenterologist for a second opinion. If you have any doubts about your pediatrician's point of view and can't get him to work in a way that helps you, you should consider seeing another pediatrician. It is simply unprofessional for the doctors to stick you in the middle. One of them has to make the first move to start communicating so that you will have a care program agreed on by both of them.

When I send a patient to a specialist I am expecting an opinion from someone who knows more about the treatment or diagnosis of a particular problem than I do. If I disagree with the information I get, I have an obligation to talk to the specialist in order to understand his point of view. If we then can't agree, in order to provide my patient care, I'm obliged to send my patient for another opinion. If the parents have taken the specialist's advice and feel their child has benefited, then regardless of what my original opinion of the treatment was, I should support the parents in the management of their child's symptoms unless there are risks to the treatment. If there are significant risks to the specialist's advice, then it is up to me to help the parents explore these risks. In the end, treatment decisions must be up to the parents, even though the doctors are the ones who provide the information that the decision is based on.

Sincerely,
Dr. Warren

-SD

Dear SD: Children certainly can develop thyroid problems, but while hypothyroid children tend to be overweight for their height their main problem is growth failure which results in their being short. Your doctor may be able to determine from your daughter's growth curve if there is a reason to think of thyroid gland dysfunction, but if there is any doubt, he can be sure by doing a blood test to check her thyroid hormone levels.

While 6 months is a relatively short time to gain a lot of weight, a small change in your daughter's eating habits or exercise habits could gradually result in a lot of weight gain. Just consuming 100 more calories per day than your body burns for 6 months can result in a 5 pound weight gain above the normal weight gain associated with growth. For more details on this point and on the management of weight gain in children look for my article on Childhood Obesity.

Some children do gain excess weight prior to a growth spurt and then slim down as they grow. This can be especially true for girls starting puberty.

You are right that a 9 year old should not obsess about weight gain, but if she has a realistic concern, even though she might like to know that she is always beautiful to you, she will find it more helpful to discuss her concerns with you if acknowledge that her concerns are real. Then she can plan with you to solve her problem. She needs to choose realistic and safe goals with your support and to understand that there are no quick fixes or miracle cures for weight gain. If she gets on a program that she has faith in, the sense of empowerment from knowing she is in control should sustain her until she reaches her goal. Concerns about weight and realistic, safe dieting do not lead to anorexia nervosa.

Sincerely,
Dr. Warren

-(unsigned)

Dear Parents: After a baby spends 9 months in a womb fully surrounded by the uterine wall and cushioned by amniotic fluid, you can understand why swaddling would make him more calm. The restriction of his movement also helps to decrease the startle reflex which can sometimes be self stimulated and self perpetuating. While swaddling makes sense in early infancy, as the infant gets more used to interacting with the outside world, it makes sense to swaddle the infant less. After all, if you've spent your whole life swaddled, there isn't any age at which it would just come naturally to not want to be swaddled. It stands to reason that the severe restriction of movement associated with tight swaddling can interfere with motor development. But it also is likely that not too much of that development happens during sleep. Therefore, the first step to wean your child off swaddling is to only swaddle him when you put him down to sleep. During the day when you hold him, feed him, or play with him, keep him unwrapped and help him get used to his own movement. After he has had an opportunity to adjust to daytime without swaddling, decrease the nighttime swaddling. First, let him get used to having his hands out if he is being swaddled with his hands held against him. Then swaddle him with the blankets wrapped progressively more loosely until eventually he is no longer swaddled.

Sincerely,
Dr. Warren

-Sincerely,
TK

Dear TK: A head circumference in the 75th percentile on a child whose other measurements are in the 50th percentile is entirely normal. To be further reassured, review your child's head growth curve with your pediatrician. When head size is in the normal range, even when its percentile is significantly larger than the other measurements, the first indication of a potential problem like hydrocephalus would be a rapidly increasing head size which would result in the head circumference percentile increasing. Even if a child has a large head there is less cause for concern if the percentile remains the same over a long period of growth.

Sincerely,
Dr. Warren

-SN

Dear SN: Seek urgent medical attention for your 6 year old at once. While it is possible he may have nothing more than a virus and may respond to efforts to get him to retain small amounts of clear fluids, you describe a child with high fever and lethargy for three days who is now vomiting. By your description the child is pretty sick and getting sicker. He could have something serious like meningitis, in which case, you don't have time to wait for medical evaluation. Head for your nearest emergency room now!

Sincerely,
Dr. Warren

Thank you for your help.

-Sincerely,
MD

Dear MD: The simple answer to your question is that you don't have to wean to be on an antidepressant; however, the choice of medication and the timing of administration should take into account that you are nursing, and you must assess whether the risks associated with taking medications while nursing outweigh the benefits of continuing to nurse. Most medications that enter the breast milk don't achieve high enough levels to significantly medicate the nursing infant, but if you are on a medication long term, it increases the potential risk to the infant.

To help you decide check the article Breastfeeding and Lactation: Medications for Depression. You can also check other articles by the Parents' Place Lactation Consultant about specific medications. Another web resource you can check is ParentTime - The Safety of Drugs During Breastfeeding.

Sincerely,
Dr. Warren

Dear Dr. Warren: Thank you for your kind words. There appears to be little else anyone can do, except perhaps as a medical person you may like to try and explain why, in such tragic circumstances, doctors wish to lie and cover up for their failings. These are time when plain talking and truth is needed. Many, many thanks for your interest.

-Sincerely,
David

Dear David: I don't know why some doctors lie, but I suspect some of them may be in denial. It is a fact that before you can tell the truth to others, you must first admit the truth to yourself. Denial is one of the most primitive ego defense mechanisms, but it can work very well if you never have to face the truth, especially if you begin to believe your own lies. For a physician, the worst thing that can happen is to lose a patient, especially if the physician fears that he may somehow have been responsible.

A physician's responsibility is to deal honestly with the bereaved family. His own pain does not excuse him. But many physicians have great difficulty dealing with death, no less, a death to which their treatment may have contributed. At some point, there may be a conscious cover up by the physicians, but it usually begins with psychological denial, an inability to face the truth themselves, an inability to deal with the family's pain when it adds to their own pain.

Is that what happened with your doctors? I don't know. Does this understanding make it any easier for you? I'm sure it does not.

Again, my condolences on your loss.

Sincerely,
Dr. Warren

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

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