16 February 1998
Dear Readers: Sincerely,
Dr. Warren hopes to help all who ask his advice and to enlighten all who read Ask Dr. Warren. For your own well being please keep in mind that
advice you read here may not apply exactly to your own situation, and that if you are sick, no information on the web can take the place of a hands on examination by your physician who knows you and cares about you.
Dr. Warren
My son weighs 70 pounds and is 4ft.9". What do you recommend for treating it?? Should I take him to his doctor??
Thanks!
-EEM
Dear EEM: Poison ivy is a contact dermatitis, a rash which develops when something irritating or something to which a person is sensitive touches the skin. The rash is self limiting. It breaks out over a period of 3 to 4 days with the rash starting and being most intense in the areas that got the most plant resin on them. The areas that got less resin on them break out later. This creates an impression of spread, but in reality the rash does not spread. It only breaks out in the areas that came in contact with plant resin. The resin is water soluble, so once it is washed off the clothes and body, there is nothing to cause the rash to spread. The blisters have tissue fluid in them, just like a sunburn. There is nothing contagious in the poison ivy rash. When children get the resin on their hands, their hands don't generally develop a rash, but the other areas they touch before they wash their hands develop a rash. For this reason, it is very common for boys to develop poison ivy around the genitals since they handle themselves when they use the toilet and generally don't wash their hands before handling their genitals.
In extreme cases where there is an extensive amount of rash, especially facial rash, a short course of steroids may be prescribed by a doctor to reduce the inflammation; however, generally the rash must simply run its course and treatment is aimed at symptomatic relief. Benadryl can be taken by mouth to relieve the itching, but it may cause drowsiness. 1% hydrocortisone cream rubbed into the rash may relieve the itching. Calamine is helpful to soothe and dry the rash. Caladryl is similar to Calamine, but has some ingredients to relieve itching.
If your son is uncomfortable in spite of symptomatic relief, shows any signs of secondary infection, or seems ill, you should see your doctor.
Sincerely,
Dr. Warren
Your advice is greatly appreciated,
-EM
Dear EM: Seizures with fever are frightening, but almost never dangerous. Even though a child who has had a seizure with fever has a higher risk than the general population of having another, most children who have had a seizure with fever never have a second one.
You can decrease your child's risk of having a seizure with fever by treating fever vigorously. That means making sure you child drinks adequate fluids, making sure she is not dressed too warmly, and giving ibuprofen (Motrin or Advil) for fever. For fevers that persist over 104 an hour after giving medication immerse your daughter into a room temperature tub to bring down the fever but do not keep her in if she has chills since chills drive the fever up.
If your child has more seizures with fever then you will want to consult a pediatric neurologist about anticonvulsant treatment.
Sincerely,
Dr. Warren
-Sincerly,
CT
Dear CT: If you feel that your pediatrician may not be treating your child appropriately it is time to ask him for a referral to a specialist. Given your son's symptoms, a gastroenterologist or infectious disease specialist would be appropriate.
Antibiotics are generally not used for treating Salmonella gastroenteritis because they have little effect on the course of the illness and may prolong the period of bacterial carriage. If the infection has a focus outside the intestinal tract; however, antibiotics are necessary, in which case, intravenous antibiotics may be required to eradicate the infection. The choice of antibiotics should be based on culture results showing the organism's antibiotic sensitivity since not all strains of Salmonella are sensitive to the same antibiotics.
Since your son has been persistently ill for so long I won't even try to guess what is affecting his breathing and heart rate. He should be seen at a university hospital by pediatric specialists who can work together to figure out what should be done to help your son.
Sincerely,
Dr. Warren
That said, there is a history of sexual abuse in my family. I am worried that something may be wrong with my husband and daughter. However, I am also concerned I may be over-reacting to a stage that toddlers go through. My daughter has been examined by her doctor briefly during regular check-ups and they never say anything about abuse. I am also afraid now that my daughter may be getting "bad vibes" from me about him - although the behavior did start before I ever considered this issue.
What should I do? My husband also likes to take my daughter for walks while I relax or clean the house and I frankly don't trust him at this point. Do I try to catch him doing something? Do I confront him? Thank you for any help you can provide.
-Between a Rock and a Hard Place
Dear Between: When you say there is a history of sexual abuse in your family, you don't indicate that your husband was involved. I think it's important for mothers to protect their children by at least being aware that sexual abuse can occur with fathers and even young children. Maternal denial or complicity plays a large role in continuing abuse. But you may be overly sensitized to the possibility.
It is not unusual for infants who are extremely attached to their mothers to refuse to be alone with their fathers. It's a little unusual for it to happen at 20 months, but given the separation problems your daughter has experienced, it's not unreasonable. And if your daughter were abused elsewhere, such as daycare, she could react with separation anxiety even though the abuse doesn't involve her father since her primary attachment is to you.
I would suggest you try to build your daughter's relationship with your husband by spending time with them in such a way as to encourage their interaction in your presence. If you continue to distrust your husband, it will poison your marriage. Spying on him isn't the answer, because if you never catch him, that won't relieve your anxiety, and he's bound to begin to sense that something's wrong. Therefore, if your suspicions continue to gnaw at you, I would suggest joint counseling. Even if he is perfectly innocent, he needs to learn to deal with your past experience and you need to learn how to deal with it regarding your husband in order for you to have a successful life together.
Sincerely,
Dr. Warren
-Thank you,
MP
Dear MP: The rule in evaluating any treatment is to weigh the benefits against the risks. When it comes to migraines, the first thing to remember is that treatment is aimed at the symptoms and not the diagnosis. If pain is the main symptom the treatment is different from the situation where nausea is the main symptom. Frequency, duration, intensity (degree of symptoms or disability), and response to symptomatic relief medication must all be considered in deciding whether or not to embark on preventive or maintenance treatment.
If there were a medicine that would alter the course of your son's future experience with migraines now, it would be foolish to pass up the opportunity, but I think you can decide based on what's happening here and now. If your son's headaches can be managed with Ibuprofen (Motrin or Advil) given early in the course of the headache (the longer you wait the harder it is to get relief), even if the frequency is twice a week that may be sufficient treatment. If your son's response to treatment is inadequate, than even at only twice a week preventive management is worth a try. If he experiences too many side effects, the management can be changed. You don't have to make a lifetime commitment.
Your neurologist will be more knowledgeable than I am regarding the choices of medications. If you believe your child deserves a trial on preventive medication you should ask him to discuss the different options including side effects.
Sorry, I'm not familiar with Feverfew or any herbs to treat migraines.
By the way, how did your doctor make a diagnosis of migraine at 13 months? Since he was apparently correct, I'm impressed.
Sincerely,
Dr. Warren
Dear Dr. Warren: Thank you for responding to my e-mail. You asked how he was diagnosed at thirteen months with migraines. He started at about 6 months of age, he would get pale, ashen coloring, clammy, and have pinpoint pupils. He then would vomit and pass out, he would continue to vomit. This would last for anywhere from 30 min. to 1 hour. Of course this was very upsetting, and I would have him seen each time. However, usually by the time he was seen he would be acting normal and the doctors would look at me like I was some neurotic mother. At the age of thirteen months he had one that lasted longer and his pediatrician saw him during it. He gave him a shot of Phenegran and watched him for about 1 hr. He continued to vomit and was unresponsive, so he had him admitted to the hospital. Because of the lack of responsivness to pain during the I.V. procedure, they put him in intensive care and called in several specialists. They wanted to rule out brain tumors, and seizures. They did an EEG, an MRI and a CAT scan. The main thing they said that would make migraine most likely was the fact that I noticed that his eyes would always pinpoint.
You stated that treatment is aimed at the symptoms and not the diagnosis. He has both pain and nausea. Since he is older, he is able to tell me when one is starting which helps tremendously because I can give Motrin at the start. He also does not pass out, but to get relief he has to lie down in a dark, quiet room and he usually goes into a deep sleep. This usually will control the pain. If not I have given him Tylenol with codeine.
He is not under the care of a neurologist. However, I believe I shall look into this. I hated the thought of putting him through all of the test and have the diagnosis be migraines, especially if the medications has side effects that were more traumatic than the migraines. Perhaps they have more to offer now than 4 years ago. The migraines are affecting his life more and more. Heat sometimes brings them on, smells, certain foods and even lack of sleep. I hate for him to always wonder if what he is doing, or eating is going to cause one.
-Thank you again,
MP
Our three and a half year old son is hyper-active, we think. He seems to have a very short attention span and he is very physical. He will not sit at the dining table for more than a couple of minutes. He is very lovable, friendly and outgoing little boy. We fear that he many not be eating enough.
Can you please help?
-DK
Dear DK: Many parents fear that their children are not eating enough. Most healthy children eat a lot less than what parents think they should. The only way for you to know if your child is eating enough is to review his growth with his pediatrician. If you wish to contact me with his height and weight I can tell you if it is good for his age.
Hyperactivity is generally not diagnosed until school age unless a child is unusually hyperactive. Most 3½ year olds don't have a great attention span. Some children need to be more physically active than others. The questions you need to ask yourself are, "Is there anything that holds your child's interest so that he will sit still for a while.?" "Does he play a game or play with a toy for a while, or does he flit from one thing to another?"
Certain activities require that you set some rules. You can't make a child eat. In fact forcing children to eat usually results in poor eating habits. But you can't let a child just leave the table after a few minutes. Children do need to learn to sit still for certain activities. If you never demand it of them, they won't learn. Since he is already 3½ and hasn't learned to sit at the table, you can't suddenly demand that he sit for 20 minutes; however, you should try to create a pleasant family experience for him and gradually increase the length of time that he sits at the table. Praise him for sitting and be sure there aren't things that would distract him such as a TV on or some other activity nearby.
If your son is truly unable to pay attention to anything for more than a brief period of time, you might consider having him evaluated by a pediatric neurologist. There is less reason for concern if your child has appropriate language development.
Sincerely,
Dr. Warren
Hope to receive your advice soon.
-ET
Dear ET: It sounds like your daughter has a narrow or blocked tear duct. This is not dangerous and will not affect her vision. If she gets a lot of discharge you will need to see her pediatrician to be sure she doesn't have conjunctivitis. As children get older the tear duct sometimes opens up. You can help by massaging the tear duct from the inner corner of her eye down to the nose. If the condition does not resolve, you should consult an ophthalmologist about having the tear duct probed.
Sincerely,
Dr. Warren
Returned to emergency and they did more blood work, a UA, and x-rays. All normal. They said he was probably constipated and gave him an enema and to give him milk of magnesia. Throughout the week he had several attacks of mild pain that lasted from 10 to 15 minutes.
Sunday, July 13, within a half hour of eating dinner, he had another severe attack of pain. After about an 1 ½ hr. he vomited and then felt fine.
Monday, July 14, he ate approx. 1/4 of an apple and had another severe attack. Returned to emergency and they did more blood work, another UA, and more x-rays. Blood work and x-rays were normal, 3 to 5 blood cells in the urine. He had no vomiting until they gave him medication to relieve the pain which he immediately vomited. They waited a ½ hr and gave him straight Mylanta with he also vomited. Then they decided to give him a suppository of Phenergan which caused a bowel movement. Then they gave him an IV with medication for the pain and nausea. Then they sent him to Primary Children's Hospital
Primary Children's Hospital gave him 500 ml lactated ringers IV and observed him. They said to return the next day for an IVP. IVP was normal. Now they have recommended him to a regular Doctor (not a Pediatrician) to discuss the problem.
Do you have any ideas as to the cause or recommendations that the parents can take with them to their visit with the Doctor on Wednesday, July 23rd.
On behalf of his parents, thank you for your help.
-TR
Dear TR: When a child is having severe and worrisome symptoms, most parents consider it reasonable to run to an emergency room, but when the symptoms are recurrent, even though the emergency room visits may suffice to deal with the acute situation and to rule out any emergent conditions, these emergency room visits don't bring the patient any closer to a diagnosis. Each emergency room visit means seeing another doctor who must start from the beginning. The emergency physician's responsibility is to determine if a symptom is urgent. Complete diagnostic workups for chronic and recurrent symptoms are rarely orchestrated from an emergency room. This is why, unless a symptom seems potentially life threatening, instead of running to an emergency room, you should call your doctor. This is why the hospital has finally recommended that he see a doctor. I am somewhat surprised that a Children's Hospital would not send a child to a pediatrician. If the child has his own pediatrician (which he should) his mother should call his pediatrician.
There are very many possible causes of recurrent abdominal pain. I don't have enough information to judge what the most likely cause is, but since there are so many possibilities, his doctor will have to review the story, examine the child, and decide what tests need to be run. There are too many tests to just do everything, so the doctor will order a few tests and gather the results before deciding what's next. If the pains appear to be intestinal, he may recommend that the child see a gastroenterologist. Tests the doctor could consider running include urine culture, stool culture, stool for ova and parasites, serum amylase, gallbladder ultrasound, upper GI series, barium enema, renal ultra sound, abdominal CT scan. The most important thing here is that one doctor must take responsibility to follow this situation until it is resolved or a diagnosis has been made which leads to appropriate treatment.
Sincerely,
Dr. Warren
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