31 August 1998

1. Retractile Testis, Bedwetting
2. Paternity, Duration of Pregnancy
3. Pneumonia
4. Gastroesophageal Reflux
5. Four Year Old Masturbates
6. Is This Baby Sick???
7. Vesicoureteral Reflux
8. Potty Training and Stool Withholding
9. Disclaimer

• Read Questions & Answers in Another Column

Retractile Testis, Bedwetting

He is a bedwetter 4 nites a week minimum, but so were his dad and I. What do you think of ADH as a treatment? I suggested that to my sister for her daughter and it worked. Our son's MD didn't go for it.

Thanks from a mom and RN

-RG

Dear RG: A retractile testis should not impact on your son's self image since it should not be obvious to anyone who isn't examining him. If your son is concerned about it, perhaps too much attention is being paid to it. If the testis is high at the inguinal ring and does not come down into the scrotum, it is not retractile, but rather, not fully descended. In that case, it should be brought down into the scrotum surgically.

DDAVP (ADH) is an excellent medication for treating bedwetting. It is extremely safe. The major disadvantage is that it is expensive. Even though many children respond well to DDAVP, it does nothing to train them to wake when they have a bladder spasm. As a result, some children resume wetting when they discontinue the medication. I always prefer to try treating without medication since even safe medications have side effects. My preference is to use an alarm system. If this is not acceptable or is unsuccessful, then DDAVP would be my next choice. Even though Tofranil (imipramine) has been around much longer than DDAVP and has a good track record, Tofranil has a long list of potential side effects.

Sincerely,
Dr. Warren

The delivery date was August 12 97 and the time I had sex with her was the first or second week of Nov. 96. Could she be lying to me?

Please help

-Confused Male

Dear Confused Male: A normal pregnancy lasts about 38 to 40 weeks (266 to 280 days) Based on the dates you gave me, you could certainly be the baby's father. Of course, if the mother had relations with someone else at the time he could be the father as well. Only you can decide how much you trust the mother and whether you need proof of paternity. If you doubt that you are the father, a blood test can help establish paternity. If you are the baby's father you have both a financial and emotional obligation to the baby which I hope you will honor.

Sincerely,
Dr. Warren

Appreciate if you could kindly answer the following questions:

1. How did my son catch the pneumonia -i.e. what were the causes? How could we have avoided it?
2. Now that he has it, how do we care for him?
3. He sounded as though he is full of phlegm and seems to choke on it sometimes - what could we do about it?
4. He has lost his otherwise 'huge' appetite for food -both milk and solids.(This is the 4th day).
5. He sleeps in an airconditoned room - is this advisable?

Thank you and best wishes,

-Lawrence

Dear Lawrence: Some forms of pneumonia are contagious respiratory infections. In order to catch it, one only needs to be exposed to the germ in much the same way one catches a cold. Pneumonia may also develop as a complication of upper respiratory virus infections, especially influenza. Pneumonia may result from a blood borne infection. Finally, it may develop as a result of chronic illness and debilitation. Certain factors may contribute to an increased risk of developing pneumonia such as asthma, emphysema, cystic fibrosis, sickle disease, asplenia, exposure to cigarette smoke, and immune deficiencies. Limiting your son's exposure to sick people and careful handwashing may prevent infection. If your son has any underlying condition such as asthma, treatment which keeps the underlying condition in optimal control will decrease his risk.

If your son is on antibiotics and drinking adequate fluids he needs no additional treatment except those interventions dictated by his symptoms. For example, if he were wheezing, he would need medication to treat the wheezing. If he has fever, Tylenol or ibuprofen would be useful. Treatment of any respiratory symptoms or other worrisome symptoms should be directed by your pediatrician with careful follow up.

If your son has a lot of mucus in his airways your pediatrician may prescribe postural drainage for your son. A cough suppressant medication like dextromethorphan can help to quiet reflex irritative coughing, but it is not desirable to stop all coughing since your son needs to clear out the inflammatory products in his airways. As the infection comes under control the cough will decrease.

Your son's appetite will return when he feels better. Right now it is important for him to drink adequate fluids. He will not develop any significant malnutrition from his decreased intake if he has been previously healthy. It is best to respect his lack of appetite. Pushing food on him could make him vomit.

Air conditioning does not affect pneumonia. The temperature of the room should be kept reasonable, not chilled or overheated. Even when he is healthy it is preferable that he not be in the direct draft of the air conditioner.

Sincerely,
Dr. Warren

AG

Dear AG: Gastroesophageal reflux, also known just as reflux or GER, refers to stomach contents coming up into the esophagus. When adults have reflux they may develop heartburn, an acid taste in the mouth, or even painful esophageal spasms. Most infants have some degree of reflux because the angle of rotation of the stomach at its attachment to the esophagus makes the valve between the stomach and the esophagus incompetent. As a result, most babies spit up. When babies stand upright as they grow, the rotation of the stomach changes and the valve becomes more competent. As a result, most toddlers don't spit up. I don't think I've ever seen a child who walks still spitting up.

Since some degree of reflux in infants is normal, the question is whether or not your son has a problem. Generally, we consider reflux in infants a problem when it causes symptoms such as poor weight gain, irritability, wheezing, or pneumonia. If a child is thriving and well, the amount of spitting is not necessarily an indication of a problem. If there is a diagnostic question your pediatrician can refer you to a pediatric gastroenterologist for evaluation.

Reflux can be treated with medication, but since all medications have side effects, one wouldn't prescribe medication in a child who is doing well simply because of excessive spitting, especially considering that the spitting is likely to resolve by the time the infant becomes a toddler. If your son is eating solids well, you might increase his solids slightly and decrease his formula intake accordingly; however, you should not decrease his formula below 16 to 20 ounces per day. Alternatively, you could try thickening his formula by adding cereal to see if it will decrease the spitting.

Sincerely,
Dr. Warren

We have tried ignoring it, a strategy that we used especially when he was younger since we understand that it is normal for young children to explore their bodies and what they do. We have tried getting him interested in something else--playing, reading a book to him, watching a video, etc. We have tried disciplining him in various ways. We have tried asking him why he does it and have, now that he is older, tried discussing with him our conviction (based on our religious belief) that it is not a acceptable thing to do.

Do you have any suggestions about how we can curb this behavior or about why he might be so interested? I baby sit quite a lot and have never seen a boy who was so determined about this.

Thank you.

RL-

Dear RL: The interest in masturbation or any form of sexual stimulation varies significantly from child to child. It is a primal urge which is essentially inborn. In order to reproduce, man, just like the animals, must be a sexual being. Why some children discover sexual stimulation as a source of pleasure and others don't is as much a mystery as why some children bite or hit when they get angry while others cry or sulk. Asking a 4 year old to explain a primal urge is pointless. Not only doesn't he understand it, but he is incapable of logical thinking. Even if he were able to handle abstract thought, it is doubtful that he could provide an explanation that you would find satisfactory, and in some sense, he knows that.

My usual approach to childhood masturbation is to help children learn that, just like other bodily functions, it is a private act and shouldn't be carried out in public. If your belief is that masturbation is plain wrong under any circumstance, then this may be a difficult thing to teach your son. Given the strength of his urge, you can only expect to stop him from doing it by making it a disciplinary matter and disciplining him immediately and consistently for each occasion you catch him doing it. The method of discipline is not as important as being consistent. Whether you choose to have him stand in a corner, take away a privilege, or some other punishment, it must be done every time and as swiftly as possible.

A better, and more realistic approach, but not necessarily consistent with your convictions, is to treat his masturbation as a habit such as thumb sucking. When you see him doing it, gently stop him and redirect his activities. Like any habit, his masturbation may increase when he is under stress because it may relieve his tension when he masturbates. Therefore, his habit should be gently broken since stress surrounding the habit may increase it. Recognizing that it is a habit, you must be realistic and expect that it will recur. Avoiding making the situation confrontational does not prevent you from calmly stating your religious convictions each time you redirect his activity. Repetition is a great teacher. With time and maturity, at the very least, he will come to desire privacy since he will understand that it is not publicly acceptable. He may even fully come to understand that you feel it is wrong, but that may not stop him. Rather, he may hide it and feel guilt for it. Since any man with a conscience must sometimes feel guilt, it is not necessarily our goal to raise children without guilt. Therefore, you must decide how important it is for your son to believe that masturbation is wrong.

Sincerely,
Dr. Warren

Should I change doctors and is there anything you know of that could cause this?

Thank you.

-CM

Dear CM: If you child has had a significant change in his behavior and is running a persistent rectal temperature over 100, follow your maternal instinct and have him reevaluated, if necessary, by another pediatrician. The symptoms you describe are too nonspecific for me to hazard a guess as to what may be causing them, but if your son's symptoms are a significant departure from his usual behavior, they are somewhat worrisome. Children at 8 months may develop separation anxiety, but even with separation anxiety infants should play happily in the presence of their mothers.

Sincerely,
Dr. Warren

She had four infections by the age of fifteen months. At that point we were referred for an ultrasound that showed mild dilation of her kidneys and ureters and was prescribed maintenance antibiotics. She later had an IVP to rule out any renal scarring and a cystogram to rule out reflux. The VCUG showed that she has Grade III to IV reflux bilateral with normal bladder and urethra. The IVP showed the kidneys were normal and the function was prompt. These two tests were done last December.

She was recently hospitalized when she had a breakthrough infection which could only be treated through IV antibiotics. The latest reports showed:

"Both kidneys have grown in size in the interval. The right kidney is 6.6 CMS in length and the left 5.9 CMS. There is mild parenchymal thinning in the lower pole region. The right Pelvicalyceal system is changing in caliber suggesting the presence of Vesico-ureteral reflux."

Can you tell me what the odds are that she will out grow this and how many years that could take? In your opinion, with the information I have provided, should she undergo surgery to correct this?

Thank you very much for your help,

-GL

Dear GL: The greater the degree of reflux, the greater likelihood that it will not resolve without surgery. If infection is controlled, conservative medical management should be considered the best treatment for up to a year, but if infection is not controlled on appropriate antibiotics or there is evidence of increasing renal scarring, surgery should be considered. Recent studies suggest that a renal scan is a much more sensitive gauge of renal scarring than an IVP. Your daughter's management, including decisions about the optimal timing for surgery, should be done in consultation with a pediatric urologist.

Sincerely,
Dr. Warren

Last Friday she was on her seventh day without going...I had called the doctor and of course they were very concerned. My husband and I had to give her a children's supository when we got home from work -- that was extremely tramautic for her (and me!) -- she was in terrible pain that evening. We also had to give her a liquid laxative. On Saturday morning we had to give her another supository (adult - cut in half) and finally after alot of crying around noon she went. For the rest of the weekend she had very wet stools and cried everytime -- I think it was burning her.

Anyway, we have been advised to give her a little mineral oil everyday to keep her stools soft. By the way, Amy is a very good eater - she eats lots of fruits and veggies but I do have to admit she is not a big drinker...we are trying to get her to drink lots of water -- she is not a big juice fan.

It is now Thursday and she has not gone since Monday. My sister takes care of her and her little brother and she does a fantastic job...between my sister and me we are always asking if she needs to poops on the potty...but all she needs to do is pee.

Should we not emphasize on this so much? Should I really be concerned? Is it normal?

Thank you for your time.

-TH

Dear TH: Your daughter is withholding stool. She does not want to have a bowel movement because she is afraid to or has pain. When she says she doesn't have to go, she is denying the urge. She responds to every urge to go by doing her best to hold it in. Unfortunately, the more she holds it in, the more constipated she gets, and the more painful her bowel movements will become. It is a vicious cycle which a 3 year old is not capable of understanding. No effort at toilet training her for bowel movements can succeed unless her stool is kept soft.

Your daughter is not in any danger, but stool withholders do not become easier to treat when they get older. Therefore, I would suggest that you and her pediatrician treat her aggressively to clear up her constipation. The dose of mineral oil will need to be increased periodically in order to keep her stool soft and make it difficult for her to hold it in. She may also need a stool softener such as Senokot. This should all be done with close management by her pediatrician or a pediatric gastroenterologist. Avoid getting into any battles with her about having bowel movements, but take her to the bathroom regularly and ask her to try rather than asking her if she has to. Praise her for any effort she makes to cooperate. Although you do not complain that your daughter is soiling, her stool withholding may eventually lead to soiling. Please read my article Fecal Soiling for a discussion of stool withholding.

Sincerely,
Dr. Warren

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