20 July 1998

1. Dealing With Hemorrhoids
2. Pinworms - Anal Itching
3. Dealing With a Cough
4. Bullous Myringitis - Mycoplasma
5. Childhood Migraine
6. Sick Children Lose Their Appetites
7. Rectal Bleeding Can Be Serious
8. Steroids and Chicken Pox
9. Disclaimer

• Read Questions & Answers in Another Column

Dealing With Hemorrhoids

My questions are, is this the only solution? Is it a health risk to continue treating them this way indefinitely? Is there a preferred surgical procedure?

I have read the literature that encourages a high fibre diet, and drinking lots of fluids to keep the stool soft. I have tried these approaches and the problem still persists.

Can you help me? Thank you in advance.

-SW

Dear SW: Hemorrhoids are varicose veins in the rectum and anus. Medications used to treat hemorrhoids reduce the inflammation in the hemorrhoids thereby relieving symptoms. Eating the appropriate diet and avoiding constipation can avoid aggravating the hemorrhoids. Neither medication nor diet will cure the hemorrhoids. Hemorrhoids do not pose any significant health risk. They are simply a major nuisance. As long as medication helps and the symptoms are not severe, a surgical approach is not necessary. There are prescription medications used to treat hemorrhoids, so if the over the counter medications are not helping, you might want to talk to your doctor before you consider surgical treatment. Surgical treatment is the only thing that will get rid of the hemorrhoids, so if they continue to be a significant problem, then you will need to consult a surgeon about the different surgical procedures. The best surgical procedure for you may depend on the surgeon's experience as well as your unique circumstances.

Sincerely,
Dr. Warren

If I may, I would like to ask another question regarding my son.

Q 1.       My three-year-old has been complaining about anal itching and wants me to scratch him. Because the itching is internal, I'm not sure what to do. An advice nurse told me to check him for pinworms. I'm not sure what exactly what that is. I let him sleep for 2 hours and when I checked him , I found nothing. However, I'm not sure if I missed something since I wasn't exactly sure what I was looking for. I didn't see anything that resembled any worms. Is there some medication I could get to help him? What about preparation-H?

Q 2.       He complains about an itchy penis. According to him it is internal. I notice that he gets very dry around his testicles. Sometimes he wakes up screaming and wants me to scrath him. I asked his pediatrician about this and she did some UA testing. The results were negative. I have used cortisone cream, lotrimin, bacitracin, vaseline and AD&D ointment to relieve his discomfort. It gives him a temporary relief. I'm getting depressed because I don't know how to help him. Do you have any suggestions?

Thank you,
-Patrice

Dear Patrice: Pinworms look like white threads, 1/8 to 1/4 inch long. They can be seen around the anus and can be noticed to be moving. They migrate out at night to lay eggs which is why the itching is most intense at night. The best way to see them is to check your child's anus with a dim flashlight after he has been sleeping in a dark room. If the itching is not most intense at night, pinworms may not be the cause. If the itching is disturbing your son's sleep, it could be pinworms even if you don't see them. I cannot recommend using any kind of cream without a diagnosis.

Any cause of penile itch should be as much of a problem during the day as the night. The fact that your son's sleep is disturbed leads me to believe he may have pinworms and may be having difficulty localizing the sensation. Pinworms can migrate into the vagina and cause vaginal discomfort and itching in girls. I have never heard of them causing itching of the penis, but there is no cause of penile itch that should disturb sleep, especially in the absence of a rash.

You should discuss with your pediatrician whether or not to test your son for pinworms or just treat him on the basis of clinical suspicion. The treatment is very simple: 1 chewable Vermox tablet now and in a week.

Sincerely,
Dr. Warren

At present he's getting over a runny nose but the coughing is not much better. This is pretty typical. He doesn't cough too much in the day time but he will have cough attacks in his sleep that are almost non stop. No fever, he seems to feel okay otherwise, no wheezing that we can notice.

Is there an OTC medicine that will allow him a good nights sleep? Or is the coughing what his body needs him to be doing? When it starts it seems to last 15-20 min. of constant coughing. I'm wondering if the drainage is working it's way down his throat, and the coughing is bringing it back up only for it to irritate its way back down again.

-JB

Dear JB: The most useful over the counter medication for disturbing coughs is the cough suppressant dextromethorphan which can be found in many cough preparations including Robitussin DM. Knowing what's causing the cough may be important to determine the best treatment. If your son has a post nasal drip, a decongestant would be just as important as a cough suppressant. If he has allergies, an antihistamine would be beneficial. A sinus infection requires antibiotic treatment. Severe and persistent coughing can be a symptom of asthma even if you don't hear wheezing. If the cough persists and doesn't respond to a cough suppressant, you should see your pediatrician.

Sincerely,
Dr. Warren

-PL

Dear PL: Mycoplasma is a germ that is similar to bacteria that cause ear infections but it has some features that make it different from bacteria. It spreads through the respiratory tract just like colds do. When it causes ear infections it usually causes bulging bullae (blisters) which can be quite painful. The bullae sometimes rupture and bleed. Mycoplasma does not respond to penicillins like many bacteria do, but it can be treated with erythromycins.

Sincerely,
Dr. Warren

-JB

Dear JB: In attempting to answer your questions I searched the Web for useful articles and found surprisingly little information about childhood migraine. You might look at the article at http://www.vh.org/Patients/IHB/Neuro/Migraine.html from the Virtual Hospital. It is about adult migraine so some information may not apply, especially information regarding medication; however, you might find the explanations and the information about diet useful.

The symptoms of migraine are caused by constriction of blood vessels going to the head followed by dilation of these blood vessels. The cause of this constriction and dilation is unknown. The treatment is aimed primarily at prevention and treatment of specific symptoms. The treatment varies depending on the symptoms. Those patients who experience significant nausea require treatments aimed at controlling nausea while those having headache as their main symptom require pain medication. Some medications specifically attach the vascular component of migraine. Many children who have atypical migraine will develop headaches when they are older.

Since migraines can be quite debilitating, prevention is certainly desirable when possible. Periactin can be given in an attempt to prevent the headaches. Avoiding triggers such as dietary triggers or environmental conditions can be helpful. Even though migraines have specific features that distinguish them from other headaches, they can be provoked by many of the things that cause ordinary headaches such as stress, fatigue, illness. The seasonal variation of your child's migraine suggests that an environmental trigger such as the weather or an allergy may play a role. Finding and avoiding the trigger could be helpful.

The medical specialists who have the most experience treating and evaluating migraines are neurologists. If you're not seeing a pediatric neurologist you might want to consult one to see if he can provide any new treatments that help your child. Migraine is a chronic problem for which there is no cure, but patients can learn to cope with them. There are many nonmedical specialists who offer treatments for migraine including Chiropractors, Herbalists, Naturopaths, and Acupuncturists. Techniques for treating migraine include biofeedback, hypnosis, and stress reduction/relaxation techniques. Chiropractic, acupuncture, biofeedback, and relaxation techniques have demonstrated efficacy for some patients. I am not familiar enough with other alternative treatments to comment on their validity.

Sincerely,
Dr. Warren

-Frustrated Parent

Dear Frustrated Parent: Forcing a sick child to eat is futile and foolish. Sick children lose their appetites. The loss of calories for a few days is not harmful. It is not surprising that your son vomits when forced to eat when he is sick. You would be wise to respect his appetite. He is only listening to what his body tells him.

Thirst is a powerful drive. If you don't push your child to eat, he should be able to tolerate clear fluids without vomiting. If his intake is poor, offer electrolyte solution like Pedialyte to prevent dehydration. You may also offer Pedialyte ice pops or any ice pop or ices as well as water and clear juice.

Sincerely,
Dr. Warren

Thank you.

-KP

Dear KP: If you told me that sometimes you see bright red blood on the toilet paper and sometimes in the toilet bowl but that your stool was normal, meaning the blood was not mixed into the stool, I would tell you that you may have hemorrhoids or an anal fissure. However, if the blood is mixed into the stool and you sometimes pass frankly bloody stools there are a number of other possibilities ranging from inflammatory bowel disease to cancer. The most likely possibilities depend on your age and other associated symptoms. When you consider the medical expenses you may have down the road if you leave either of those conditions untreated, it seems foolhardy to risk your life because of lack of medical coverage. See a doctor.

Sincerely,
Dr. Warren

-AP

Dear AP: Flonase is a steroid. Steroids work by reducing inflammation. Inflammation is an important part of the body's mechanism for stopping the spread of infection; however, when inflammation causes significant symptoms in situations where there is no infection, the use of anti-inflammatory medications is the best way to control or eliminate symptoms. Several years ago, there was a published report of an asthmatic boy who died from an overwhelming case of chicken pox while taking systemic steroids to control his asthma. Systemic means medication taken by mouth, injection, or intravenously to produce high enough blood levels to get the medication to the part of the body where the medication is needed. Inhaled sprays are not systemic medications. The medication is essentially being applied locally (in your case it's being applied to the nasal membrane) and the dose is not sufficient to cause significant systemic absorption. There have never been any reports of chicken pox or measles fatalities associated with inhaled steroids, however, theoretically the virus's entry into the respiratory tract could be enhanced by reducing the inflammatory response and there is at least a concern that some patients may have significant systemic levels of medication from inhalation. As a result, since the chicken pox death associated with steroids, inhaled steroids have carried that warning. It is part of the general medical principle that the benefits of any treatment should always significantly outweigh the risks.

Sincerely,
Dr. Warren

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