2 February 1998

1. Speech Delay
2. Sunscreen for Infants
3. When Do Infants Sleep Through the Night?
4. No Bowel Movement
5. Mineral Oil for Constipation
6. Seeking Advice on Women's Health
7. Insomnia
8. Growth Hormone for Short Adolescents?
9. Disclaimer

• Read Questions & Answers in Another Column

Speech Delay

Is this normal? Should be vocalizing and associating words better? Is there anything we should be doing to improve his talking?

Thank you very much for your input and advice on this matter.

-JA

Dear JA: The norms for language development indicate that a child should be using "mama" or "dada" to mean mom or dad by 12 months, say 1 word by 15 months, 2 words by 16 months, and 3 words by 18 months. When a child's development falls outside the normal range, it does not automatically mean there is something wrong, but it increases the possibility that something is interfering with normal development. Neither of my daughters said a word before 18 months and they speak perfectly well now.

The best stimulation for language development is to read books to children and to speak to them. Young children do well with picture books where you can show a picture and say the word. When your child wants something, say the word as you give it to him. Encourage him to imitate you, but don't frustrate him by demanding speech to get what he wants. Play games where words are important like pointing to body parts and saying the word and getting him to point to his own nose or ears when the words are spoken. The more actions and objects are associated with words, the easier it will be for him to learn the words.

If, over the next few months, a concentrated effort at stimulating speech doesn't yield results, your son should have a hearing and speech evaluation.

Sincerely,
Dr. Warren

-Sincerely,
TK

Dear TK: Sunscreens haven't been approved for infants under 6 months because they haven't been tested on young infants. There is no reason to anticipate any harm to your baby from using the sunscreen at 2 months; however, it is reasonable to suggest that an infant that young shouldn't be exposed to enough direct sunlight to require a sunscreen.

Sincerely,
Dr. Warren

-Anissa

Dear Anissa: Infants may sleep through the night as early as 1 month, but most take until 2 to 3 months to sleep an 8 to 12 hour stretch. If your infant isn't ready to sleep through the night there isn't anything you can do to make it happen faster. Adding cereal to the formula adds more carbohydrate to a protein and carbohydrate food. It provides no nutritional benefit and does not make babies sleep through the night.

At your baby's age it is reasonable for him to wake for a 2 AM feed, but it is not reasonable for him to need to feed again in 1 to 2 hours. If he only takes small amounts at any of these feedings then he is using the feeding to put himself back to sleep and he doesn't need that feeding. Therefore, you should make an effort to get him back to sleep without feeding if he has just been fed.

Sincerely,
Dr. Warren

-Susan

Dear Susan: There is no relationship between coxsackie virus and constipation, but it is likely that your daughter's lack of food intake and decreased fluid intake have contributed to her not having a bowel movement. No matter what the reason is that a child doesn't have a bowel movement, the longer stool sits in the rectum, the harder it gets.

If your daughter hasn't had a BM by the time you receive this e-mail, you should use a glycerin suppository to see if it can induce her to go. If that does not succeed, the next step would be a pediatric fleets enema. If she is old enough to cooperate, make sure you explain the need to her to make a major effort to pass the stool since she may be resisting its passage because it is painful.

Sincerely,
Dr. Warren

He eats a health diet - whole wheat bread, lots of fruit, some vegetables, pastas…. He does love dairy products, but we try to keep that to no more than 3 cups a day. I also try to give him a prune every day, and we mix prune juice with other fruit juice when he's constipated.

Our pediatrician suggested that we give him mineral oil in his milk once a day for several months, to help him get used to having bowel movements that aren't painful. However, the back of the mineral oil bottle has some warnings that are worrisome. Can you please explain why it is okay to give him the oil despite the warnings (see below). (Our pediatrician was unsure why the warnings were there, and the distributor of the oil just told me they were there for liability reasons - that isn't enough to do away with our concern.)

The warnings are as follows:
• Do not give to children under 6 unless directed by a physician. (Our pediatrician said this was because it is possible to aspirate the oil into the lungs if forced to take it incorrectly.)
• Do not take with meals (the pediatrician suggested mixing it with milk or juice).
• Do not take if failure to have a bowel movement after use (in the past when I have given it to my son, he has not always had a BM that same day; sometimes it still takes an additional day or two).
• Avoid use longer than one week (the pediatrician suggested use for three months on a daily basis).
• In case of overdose, call a physician or Poison Control Center immediately.

-S & A B

Dear Mr. & Mrs. B: Most over the counter medications have warnings to limit use without the direction of a physician. This is aimed at limiting their liability in case the patient uses the medication inappropriately.

Children under 6 are a special category for all medications. Even though any cutoff is artificial by nature, children below the age of 6 are much less able than older children to express clearly what is bothering them. Because of this, there is a greater risk of misinterpreting their symptoms and treating them inappropriately. No pharmaceutical company wants to be liable for that, so they protect themselves by indicating on the label that young children should only be treated with their product if directed by a physician. Aspiration would pose a risk in any patient who is being forced to take mineral oil, but since children under six are less influenced by logic, they may not be convinced as easily to cooperate. On the other hand, an 8 or 10 year old who has made up his mind not to take the oil is just as much at risk for aspiration as a younger child if he is forced.

If consumed with food, especially a whole meal, the oil will sit in the stomach longer. This may increase the risk of aspiration if a child vomits. Also, the oil may interfere with the absorption of some nutrients. But this does not mean that the oil can't be mixed with a small quantity of food to make it easier to give. If you mix it with a drink like milk, it may float to the top. Usually, I recommend giving it chilled. This makes it less oily, and it is flavorless to begin with.

The warning not to take mineral oil if it doesn't result in a bowel movement and not to continue beyond a week goes back to the pharmaceutical company's concerns about liability. They don't want to be responsible for someone treating himself with their product when he has a condition that requires medical attention. It would be inappropriate for someone with a bowel obstruction to take mineral oil. But there is no problem with someone using mineral oil long term after an appropriate diagnosis is made and his physician advises mineral oil. Also no problem if the patient doesn't have a BM every day as long as the physician deems treatment with mineral oil to be appropriate.

Mineral oil is inert. It is not absorbed, so it is hard to imagine an overdose. But a large volume of mineral oil in the stomach could result in vomiting and aspiration. If not vomited, it will most likely cause oily diarrhea. Large amounts taken chronically can result in malabsorption of fat soluble vitamins.

Sincerely,
Dr. Warren

-Thank you,
A.K.

Dear AK: Check the drkoop.com Women's Health Center for topics related to women's health. The list of links at http://www.museum.state.il.us/isas/oblink.html may lead you to the information you are looking for.

Sincerely,
Dr. Warren

Thank you

-CF

Dear CF: As a general rule I recommend avoiding sleep aids. For occasional use they may help a person through a sleepless night and for a person in pain, a pain medication and a sleeping pill may be the only means of getting sleep, but over the long haul, people don't get the best of sleep when they use medication. To be honest, as a pediatrician, I'm opposed to using sleep aids in kids, and I have no experience treating adults.

You didn't state your age or give me any information about your life, but as people age, they sometimes need less sleep. Their sleep pattern may be further disturbed by sleeping during the day and going to sleep early at night. On the other hand, young to middle aged adults, as well as seniors, may be kept awake by stress and worry. These things must be dealt with before you can get a good night's sleep.

Three things I would suggest.
1. Keep active during the day including both physical and mental activity.
2. Establish a bedtime routine. Try to go to sleep at a regular time with perhaps a specific relaxing activity.
3. Look into self hypnosis tapes or meditation techniques to help you relax.

Sincerely,
Dr. Warren

Thanks for any help you can give.

-Sue

Dear Sue: If your daughter has already been menstruating for a year and has not grown since, chances are the growth centers in her bones are fused and no more growth is possible; however, before you give up completely, you might have a bone age x-ray done, or an x-ray of her long bones to see if her growth centers are fused. Even if she still has a little potential left for growth, children near the end of their growth cycle do not respond very well to growth hormone, but a consultation with an endocrinologist may help you determine if anything more can be done.

Sincerely,
Dr. Warren

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