27 April 1998

1. Nursemaid's Elbow vs. Fracture
2. Cold vs. Allergy
3. Why Can't I Grow a Beard?
4. The Rash of Lyme Disease
5. Mouth Sores
6. Growing Pains
7. Is It Migraine?
8. Normal Movements or Neurological Problem?
9. Disclaimer

• Read Questions & Answers in Another Column

Nursemaid's Elbow vs. Fracture

- Worried First Time Mother!!!!!

Dear Worried First Time Mother: A Nursemaid's Elbow is a dislocation of the radius, the bone that runs between the wrist and the elbow on the thumb side of the hand. The dislocation actually involves both the elbow or wrist, or both. This dislocation results from the hand or arm being yanked as when swinging a child by his hand, grabbing a child's hand to prevent him from running out into the street, a child falling while his hand is being held, or a child falling and grabbing onto something on the way down to stop his fall. These children typically hold the affected arm hanging down loosely with the palm facing toward the back. The diagnosis is confirmed by rotating the arm and flexing the elbow in such a way as to pop the radius back into place. The treating physician can feel a pop and the treated child will begin to move the arm again in a few minutes. This maneuver is not recommended to be tried by parents since the arm must first be examined to determine if there is possibly a fracture or if a dislocated radial head is the most likely diagnosis. After a prolonged time, the joint tissues in the elbow and wrist may become inflamed making it hard to reduce the dislocation.

A fracture is unlikely in the absence of a history of injury; however, it is possible, if a child falls, to fracture his wrist and not have it noticed until the next morning. Younger children sometimes develop greenstick or buckle fractures of the bone where the cortex of the bone buckles rather than cracking, so that the fracture may not be obvious at the time of the fall. A less likely possibility is that a child in his crib might catch his arm and twist it resulting in a spiral fracture of the arm. Dislocations do not show up on x-ray. Fractures do show up on x-rays. Hairline fractures and fractures through the growth plate may not be visible on the first x-ray, but they become visible on subsequent x-rays after new bone growth begins.

If your son is casted, even if his diagnosis is uncertain, the cast should keep him from moving the painful part. That should prevent him from having a great deal of pain. He may find the cast objectionable. If your son seems to be in pain, you may find ibuprofen more effective than Tylenol to relieve his pain. The dose is 1/2 teaspoon of Children's Motrin or Advil for each 11 pounds of body weight. The dose may be repeated up to 4 times in 24 hours.

There are other things a painful joint with no history of injury could be, but if your doctor did not find anything unusual and your child isn't running any fever, it is unlikely to be either an infection or an arthritis.

Sincerely,
Dr. Warren

I'm curious as to other possible causes. Could this possibly be the result of a food allergy? She has been on the same formula (Simulac w/ iron) for 8 months with no previous symptoms of intolerance. For the past 2 months, she's been getting more table foods (Cheerios, cheese, bananas, bits of cooked ham, crackers). Is it possible to develop an allergy to formula after 8 months? She has no other symptoms (no fever, eats well, good spirits), except for the last 2 days she has had a watery eye discharge.

Someone suggested to me that a sinus infection may be the culprit. We'll see her doctor again today, but I'd appreciate your opinion too.

-TE

Dear TE: Children who are exposed to many upper respiratory infections may have so many colds that they go from one to another with no significant break. The symptoms of each cold can last up to 2 weeks. Sinusitis generally causes fever and a pussy nasal discharge. A severe cold that persists more than three weeks may indicate sinusitis, but I wouldn't consider that diagnosis in a child who has mild symptoms and clear runny nose.

Allergy can develop to something after a long time of exposure. In fact, allergy requires prior exposure to sensitize an individual; however, if your child's only symptom is runny nose and sneezing, food allergy is an unlikely cause. Children with food allergies often have eczema, wheezing, or hives. An allergy that causes only nasal symptoms is more likely to be an inhalant allergy like allergy to dust mites or pollens. Your doctor may be able to distinguish between colds and allergies based on his examination. Allergic children usually have a pale, swollen nasal membrane, while upper respiratory infections generally cause the membrane to be red and inflamed.

Sincerely,
Dr. Warren

I am a Vietnamese young male, currently living in Canada. I have tried to grow a beard and/or a goatee for some time but I can't !. I am wondering why Asian men tend to be less hairy than their European, Black, Middle Eastern counterparts. Is it because of the difference in Hormones, in Genes, or whatever inside the human body that we may need a Ph. D in Biology to fully comprehend or is it because Asian people tend to eat less meat and dairy products than Westeners ? (For example, Shikhs are also Asians but they are really hairy, aren't they)

Do you know why ? I am desperate to grow a goatee but it seems impossible. Here are some info about me which hopefully will shed some light on this matter. I am of Vietnamese origin, 20 years of age, has lived in Canada for the last 3 years. I am fit, 6 feet and 145 pounds and have no medical disease. I am a non-smoker, non-drinker, non-drug-user, do lift a lot of weight but rarely play sports. I usually. I usually eat Vietnamese foods-rice and vermicelli-but I do drink a lot of milk and eat a lot of bread, rarely eat cheese and ice-cream though. As far as I know, my hair grows faster than normal, there are also quite a lot of hair under the arms (armpits) but there are very little (if not nothing) hair on my chest, my arms, my thighs, and my legs, and most importantly, on my face (Try to grow sideburns too, but to no avail !). Just for the record, my father (60 years old) and my two older brothers don't seem to have any goatee/beard either though they aren't bald.

Anyway, I am just curious to know if there are certain type of foods (or medicine) out there that could help me grow a goatee/beard. (I mean should I go out and eat a lot of Shikh or Lebanese food). or it is just natural to have or not to have a goatee ? If you think you can help me with this not-so-trivial matter !, you are more than welcome to drop me a few lines. I also try to do a little research at the library and on the Net, but it is like finding a needle in the haystack so if you know where I can also contact for more info, please, please tell me. Thank you very much in advance for your assistance. Hope to hear from you soon.

-NH

Dear NH: The fact that Asian men have less facial and body hair than other races is purely genetic. It is not hormonal at all. I can't tell you why the genetic distribution of body hair is as it is in Asian men. In Caucasians there is considerably more variability which makes it easier to see that there is a large genetic component to body hair distribution. Those men who have hairy ancestors are more likely to be hairy, while those with smooth ancestors will likely be smooth. If you're not convinced, let me give you a personal example. As a teen, my identical twin brother discovered he had one long white hair on his abdomen in the midst of the rest of his body hair. When he found it, I looked to see if I had the same thing, and there it was - one long white hair on my belly in the exact same place as my twin's.

I know of nothing dietary or medical that can increase your facial hair, but since you are only 20, you should be aware that your beard potential may not have reached it's peak. Many of the men I went to college with had smooth faces at 20, but later grew beards. On the other hand, I don't wish to hold out false hope to you. If your father and brother can't grow beards, your genetic potential is likely to follow theirs unless your mother has some hairy relatives. I realize that this is not a trivial matter to you, but I have to suggest that you not focus too much energy on it since there is little you can do about it.

Sincerely,
Dr. Warren

I am concerned about this whole incident for a number of reasons. First and foremost, I am concerned about the proper diagnosis and treatment for my daughter. Second, I am concerned about the lack of awareness and information the doctors in this area have about the possibility, occurrance, and treatment of lyme disease. For example, no one told me that the rash may appear between 3 and 32 days after being bitten - I found that information out on my own. So when doctors asked me if she had been anywhere where she could have had contact with a tick I said no, thinking back only to the past couple of days. Also, the doctors assured me that if it had been a tick bite, only the site of the bite would have the rash. I also found out that that is a fallacy and that the INITIAL site is usually the first and biggest ring to appear, but that as the disease progresses, so does the rash. The ring on her wrist (and one on her leg) were by far the biggest. Even the doctor that is treating her with the antibiotic did not write her diagnosis as lyme. He wrote it as EM, which from all accounts, seems to be very vague. So if it is lyme disease, there is still no "documented" case of it in this state, if that is in fact even true. AND, without a definitive blood or other test, how can anyone, even me - her mother - be sure of what it is. In my reading I have also read that ticks carrying the disease have now been found in 49 states (I doubt that SC is the one left out!) I have also read that 1/4 - 1/2 of all people bitten by lyme-infected ticks don't even develop a rash. With that in mind and in light of my daughter's rash and possible infection, should my son and I be tested as well, since we were together when blueberry picking and are usually doing things all together?

What can you advise me to do at this point and how can I be sure she is receiving proper medical care and treatment, especially if it is lyme disease? Could it be a coincidence that the rash is subsiding with the introduction of antibiotics and what type and course of antibiotics should I request or insist on? Should I insist on a blood test and if so, at what point?

I appreciate any advice or information you can give me, especially since I seem to remember you being in the northeast where the incidence of this has been more prevalent.

-JG

Dear JG: The rash of Erythema Multiforme is so named because it can appear many different ways. Neither crusting nor blistering are hallmarks of Erythema Multiforme. The characteristic lesion of Erythema Multiforme are target lesions, concentric rings. In general, these target lesions are significantly smaller than the rash of Lyme. A patient with Erythema Multiforme may have many target lesions, but most will be less than an inch in diameter.

The rash of Lyme Disease, known as Erythema Chronicum Migrans (ECM) or Erythema Migrans forms large rings or plaques which expand over days to weeks to more than 2 inches in size, an average size being 6 inches. The initial rash forms around the tick bite, but in disseminated disease multiple lesions may appear. Approximately 60% of patients with Lyme Disease develop ECM, which means that 40% don't develop the characteristic rash. Since the rash is an early finding, the blood test may be negative at the time of it's appearance. Patients who are treated at this stage may never develop a positive blood test. The rash has a characteristic appearance which is distinct from any other rash making Lyme a clinical diagnosis in patients who present with ECM. Since the blood test is likely to be negative at this stage patients should be treated solely on the basis of the characteristic rash rather than waiting for a positive blood test.

The recommended treatment depends on the age of your child. Since it sounds like your daughter has early disseminated disease the drug of choice is doxycycline if she is over 8 years of age. Amoxicillin is an acceptable alternative for all ages in patients who are not allergic to penicillin. The recommended duration of treatment for early disseminated disease is 21 days. Your pediatrician can find all this information in the current Red Book which is updated and published annually by the American Academy of Pediatrics.

Blood tests on you and your son may be negative at this point. Even though 40% of patients with Lyme do not develop ECM I can't recommend that you be tested on the basis of your daughter's experience if you are not symptomatic. By way of explanation let me quote a paragraph from the Red Book.

"The widespread practice of ordering serologic tests in patients with nonspecific symptoms (such as fatigue or arthralgia) who have a low probability of having Lyme disease is a major problem. Nearly all positive serologic test results in these patients are false-positive. Patients with acute Lyme disease almost always have objective signs of infection (eg, erythema migrans, facial nerve palsy, and/or arthritis). Nonspecific symptoms commonly accompany these specific signs, often in persons with neurologic manifestations of chronic Lyme disease, but are almost never the only evidence of Lyme disease."

Sincerely,
Dr. Warren

-MM

Dear MM: There are several things that can cause blisters in a child's mouth. Herpes virus causes inflammation of the gums and sores in the mouth and on the outside of the mouth. Anyone who has had a herpes infection can have recurrences in the form of fever blisters, but these are generally not inside the mouth. Coxsackie virus causes canker sores in the throat and sometimes in the cheeks and on the tongue. It is not a recurrent illness but there are multiple strains so that some children may have it more than once in a summer. Thrush is a yeast infection that causes white patches in the mouth that look like cottage cheese. It is generally not painful. Some children are prone to canker sores, but since they are not contagious, it would be a little unusual for both grandchildren to have them at the same time. Since I don't have enough information to know what your grandchildren have, I would suggest that when they have the next recurrence they see their pediatrician.

Sincerely,
Dr. Warren

-CA

Dear CA: Night time leg pains in children who have no daytime pain and are able to run and play without pain or limp are commonly referred to as "Growing Pains." These are muscular pains that are related to the day's activities. I am not aware of any treatments that prevent the pains. You might try warms baths with massage of the calves and hamstrings (muscles on the back of the thigh) before bed. Also, be sure that the bed covers are not tucked in tight against the bed as this would make a person who sleeps flat on his belly point his feet straight down, increasing the risk of calf muscle spasm.

I am not aware of vitamin deficiencies being related to night time leg cramps, but if there is any question about your daughter's nutrition, you might ask her pediatrician about a vitamin supplement.

Sincerely,
Dr. Warren

Thank you.

-DF

Dear DF: If your son gets pounding headaches that result in nausea, vomiting, and the need to sleep, they could be migraines. If they respond adequately to pain medication such as Tylenol or ibuprofen, that would be sufficient treatment; however, if the nausea or the pain is difficult to control, you should see your pediatrician or a pediatric neurologist for evaluation and treatment.

One simple thing you could do is to take note of whether any foods provoke your son's headaches. Chocolate can cause migraines and eliminating chocolate from the diet can sometimes cure or improve the headaches. Less commonly, hard cheeses like cheddar can contribute to migraines.

Sincerely,
Dr. Warren

My 6-month-old son has suddenly started shaking his head right to left (as if signaling "NO") for several minutes at a time. It looks and seems rather odd, but don;t know if it is a behavior that should cause alarm.

Additionally, he sometimes stares into space and is unresponsive for a few moments, typically right before he falls asleep. It is as if he is "asleep with his eyes open."

He just had his 6 month pediatrician's visit, appears healthy by that check, and is in the 70% for height, weight and head circumference. He seems like a happy, active, normal child other than these 2 odd habits. Any cause for concern?

This is a FABULOUS service you provide and it is much appreicated by parents everywhere!

Thanks in advance for your response.

-JM

Dear JM: If your son only stares into space and is unresponsive as he is falling asleep, it is simply part of falling asleep. This is true even if he wakes up right away or startles awake as this is happening. If he has spells as you described that have nothing to do with drifting off to sleep, he needs a neurological evaluation.

The head movement you described is perfectly normal if it is a voluntary movement. If he is playing with shaking his head it is of no significance. On the other hand, if this head movement seems to be associated with other automatic movements or a change in his responsiveness to the outside world, this also would require neurological evaluation.

Sincerely,
Dr. Warren

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