7 December 1998

1. Rash Under Arms
2. A Persistent Virus
3. My Daughter Was Toilet Trained!
4. Repeat Circumcision?
5. Persistent Sore Throat
6. Swollen Lymph Nodes
7. The Genital Exam is Important
8. Stool Withholding & Constipation
9. Disclaimer

• Read Questions & Answers in Another Column

Rash Under Arms

Sincerely,
-Melissa

Dear Melissa: If your rash is caused by moisture or a fungus infection you could try an antifungal powder like Tinactin. Although I have no reason to believe your rash is serious, proper treatment requires proper diagnosis which can only be obtained by seeing a physician. The rash could be a contact dermatitis which would respond well to a Hydrocortisone cream, but a Hydrocortisone cream would aggravate a fungal rash if you don't treat with an antifungal as well.

Sincerely,
Dr. Warren

Having gone through 3 months of waiting to see a paediatrician, about 20 blood tests, urine tests, and stool tests - our paediatrician has told us that she doesn't have Celiacs disease (coeliac), which we thought initially would explain all the symptoms. What we have been told is that the last blood test showed a virus called Anadone (or something that sounded like that on the phone).

My question is what is this virus and how long can a virus stay in the body before it is seen off by the immune system?

Thanks for any advice you may be able to give.

-TM

Dear TM: The closest I can come to a "virus called Anadone" is adenovirus. Adenovirus may cause a variety of symptoms and be prolonged, but it doesn't cause all of your daughter's symptoms and does not last 8 or 9 months. With the exception of a controversial area like the association between Epstein-Barr Virus and chronic fatigue syndrome, there are no viruses I can think of which cause ongoing symptoms for 8 to 9 months. Even bacterial infections rarely cause ongoing symptoms for many months, but parasites may cause chronic and recurrent intestinal symptoms and anemia. Your daughter should be checked for parasites.

I'm not sure that all of your daughter's symptoms fit into one unifying diagnosis. There is no obvious relationship between asthma, nosebleeds, or intestinal symptoms. There are some possible associations. For example, if your daughter had severe allergies including food allergies, the allergies could cause both asthma and intestinal symptoms and possibly anemia through blood loss in the stool. The unifying thread could be gastrointestinal since gastroesophageal reflux may contribute to asthma symptoms. I would suggest that your daughter be evaluated by a pediatric allergist and a pediatric gastroenterologist. Even if all your daughter's symptoms cannot be put together into one package, these specialist should be able to help you deal with your daughter's persistent symptoms.

Sincerely,
Dr. Warren

She is now 3 years and 5 months old and is having frequent (3 or more a day) accidents in her underwear. She still wears a pull-up at night and is not expected to go through the night without wetting the bed. She has no explanation for these accidents and we do not shame her, yell or punish her when they occur. They occur at all different times of the day; during a meal, while playing on the computer, at school, or while playing. There doesn't seem to be a consistant factor when they occur.

We recently (2 months ago), moved from Arizona to Texas. She seems to have adjusted well, is doing well in school and has made friends. I have yet to find a Dr. and I am not sure how to handle the situation. Should I just ignore it? Could it be a sign of a physical problem or should I be looking for some other explanation? I should tell you she has both parents present and there have been no other changes in her life other than the move. She has some nervous habits such as chronic nail biting and I am fearful that there may be something I am overlooking. Should I put her in a pull-up during the day? She has never worn pull-ups during the day, she went straight from the diaper to underwear.

I just want to make sure I handle this situation in the best possible manner. Thank you for your help.

Sincerely,
-SH

Dear SH: If your daughter's wetting began shortly after your move, the possibility that it is a reaction to the move cannot be overlooked. Even though a child may adjust to a change, the loss of the known and familiar surroundings can cause stress symptoms which the child is unable to express resulting in physical rather than emotional symptoms. Sometimes, these symptoms may become habitual and persist beyond the stress.

Wetting could be a symptoms of a urinary tract infection or even diabetes, therefore, a child who was previously dry who starts to have accidents should have a urine culture and a urinalysis as a minimal evaluation.

If the urinalysis is normal and the culture is negative, you should embark on a program of retraining your daughter. Many children who have mastered using the toilet to stay dry strive for even greater control, often denying their urges until the very last minute. They can't be bothered interrupting their activities to use the toilet and want to hold their urine, but discover when their bladders are full that they cannot make it to the toilet in time. To avoid this problem, the best thing is to build regular trips to the toilet into the daily schedule at times when there would normally be a break in the activities. Avoid power struggles or pressure to urinate. Praise your daughter if she uses the toilet when you bring her there, and make little or no comment when she doesn't urinate, other than to praise her cooperation for coming to the bathroom and indicating that you would have liked her to use the toilet.

Sincerely,
Dr. Warren

My problem and question is:
The problem...my ped. says that the circ that grew back will actually tear as he grows... My dr says he can recirc..but that it would just grow back because of that extra stuff...He vaguely mentioned some surgery to get rid of the fat tissue...but i don't think it was actually thought about..

Question: What should I do for my son? Is this going to cause problems for my son if I don't get anything done?

-JAR

Dear JAR: Don't do anything to your son. Especially, don't have him recircumcised at this time.

The foreskin that is removed during the circumcision cannot grow back. If any additional skin is removed, it would be skin that is covering the shaft of the penis. Shortening the skin of the shaft of the penis may lead to penile deformity or painful erections later on. If the skin which has been pushed over the shaft of the penis by the fat pad has become adherent to the tip of the penis, the adhesions can be lysed and the circumcision revised at a later date only if it is necessary.

There is no need to do anything about the fat pad in which your son's penis is buried. This fat pad will decrease as your child gets older unless he is obese. When your son enters puberty, his penis will grow well beyond the pubic fat pad. If you press into the pubic fat pad with a finger on either side of the shaft of the penis, you should find that the penis is normal and that the skin and fat covering the penis easily retracts to allow cleaning of the head of the penis. If this is done with every bath your son should not have any problems with his circumcision.

Sincerely,
Dr. Warren

-Sonia

Dear Sonia: Eighteen days would be a long time to run a fever, but a temperature between 99 and 99.4 is perfectly normal and is not a fever. If your brother's throat culture is negative for strep and his CBC (blood count) is normal, as you have stated, antibiotics are not indicated. If the ENT and pediatrician have not found anything on examination of your brother's throat, the occasional symptoms he has had may represent allergy, several upper respiratory virus infections (colds) in a short period of time, or a response to environmental irritants such as dry air or smoke. Unless there is more to this story or your brother feels ill, I think there is nothing more that needs to be done.

Sincerely,
Dr. Warren

1. My baby (13 months) has swollen lymph nodes at the back of her head - sort of behind the ears but lower, just above where the neck ends and the head begins. They've been swollen for about 10 days now but this past weekend got larger. She had a high fever (101 - 103) from Thursday morning until Sunday afternoon. It's now down to about 99. Her nose is extremely stuffy (white to green mucous) and she has a slight periodic cough. The last time her lymph nodes were swollen was when she had cradle cap as an infant. It seems that her doctor at the time gave her something to lessen the swelling. Do you know what that might have been? Also, how worried should I be about this? She's had a cold before, but it never caused this. And, this time, she is listless, fatigued, sad, fussy and not playful (not like herself at all). Ususally, even when sick, she is still happy and playful. I associate swollen lymph nodes with serious illnesses. I'm scared to death!

2. When her fever was 103 on Friday, we took her to the emergency room. They told us it was a viral infection (I don't know how they could tell since they didn't run any tests) and that there was no need to give antibiotics because they only work for bacterial infections. Then Saturday, her pediatrician prescribed Amoxil. Now, I'm not only confused but a little bit angry. Did he prescribe something just to shut me up or can this stuff help her in this situation.

I'm very worried because as you might remember, my baby is small for her age and may not have the ability to bounce back like bigger babies. Also, as a result of being sick, she is eating less.

Thanks so much doctor. This is a wonderful service!

-KM

Dear KM: There is no medication that specifically relieves the swelling of lymph nodes. If lymph nodes swell in response to a local condition such as seborrhea of the scalp, treating the seborrhea will allow the swelling of the lymph nodes to subside. Lymph nodes in the neck may swell with strep throat and treatment with antibiotics will improve all the symptoms of step throat including the swollen glands.

Swollen lymph nodes may be seen with some serious illnesses such as leukemia, but the most common cause of swollen lymph nodes in children is infectious disease, especially virus infections. If a child has upper respiratory symptoms, fever, and swollen glands, especially swollen glands in the head and neck, the most likely cause is an upper respiratory virus. One doesn't consider more serious illnesses unless the swollen glands are all over the body, especially in unusual locations, or are abnormally large and enlarging, and persist several weeks or more associated with persistent or recurrent fever. Even then, in the absence of other findings suggesting leukemia such as pallor from anemia or petechiae, bruising, or bleeding, the first diagnosis to consider would be mononucleosis. Given your daughter's symptoms, if she remains ill, a complete blood count and a test for mononucleosis would be appropriate.

It is not necessary to do blood tests on every child with a fever to determine if the infection is viral or bacterial. A virus infection should not be diagnosed just because of the absence of other findings, but if a child has findings typical of a virus infection the diagnosis can be made on clinical grounds. Your child had upper respiratory symptoms and swollen glands running down the back of her head and neck which is typical of upper respiratory viruses.

I won't second guess your pediatrician's intentions since he examined your daughter and I didn't. We are all concerned about the effects of overuse of antibiotics so I hope my colleagues out there are all trying to be rigorous about the indications for using antibiotics rather than giving them "just in case", for convenience, or to satisfy the demands of patients. To this end, it would help if doctors would explain to their patients, exactly what they are treating or, if they are not treating, why treatment is not indicated. Since your daughter has been sick for a while and has thickened, discolored mucus, your pediatrician may have agreed that she has an upper respiratory virus, but may have felt she has developed a secondary bacterial complication such as sinusitis. If your daughter has any secondary complications, antibiotic treatment will help, but it will not cure the cold and will not affect the swollen lymph nodes.

If your daughter is not improving and her lymph nodes are still swollen, it does not mean your pediatrician was wrong to give antibiotics, but it would be time to do the blood count and mononucleosis test.

Sincerely,
Dr. Warren

Is this appropriate and if so what could he have been looking for?

-Mr. B

Dear Mr. B: I'm not sure what you mean by a chest exam. The chest includes the lungs and heart. If your 11 year old has breast development and the doctor felt her breasts he was doing a routine exam for lumps. While these are rare in children, it is appropriate to check. If breast development is not evident, he could have been feeling to see if there were breast buds which is the first sign of puberty. Assessment and documentation of pubertal development is as important a part of the exam as determining if physical growth (weight and height) are appropriate for age.

Inspection of your daughter's vagina may also be a part of assessing pubertal development. He could also be checking for vaginitis (vaginal inflammation); however, it is not necessary for the doctor to be looking for something in particular wrong in order to look at something to see if it is normal.

When the doctor examines the eyes, ears, heart, or lungs, you assume he is checking to be sure everything is okay without his necessarily having a specific reason to look. That is the purpose of a physical - to check and make sure things are normal. Since the genitals are a private area not routinely seen by others including parents as children get older, it becomes even more necessary that a routine exam include a genital exam since children may not recognize problems if they have no bothersome symptoms. The examination becomes even more necessary just before and during puberty since the children and even their parents may not understand or know what is normal during the bodily changes in puberty. Many teens worry about whether their genital changes are normal but are too embarrassed to ask.

The issue is not whether a genital exam is appropriate, because it is an important part of the exam; but whether the genital exam is done in an appropriate manner. Recognizing that there are privacy issues, societal taboos, and that most children have received some information about sexual abuse and appropriate and inappropriate touching, the doctor must explain what he is doing and accomplish the exam in a manner that respects the child's dignity and need for privacy. If there is anything unusual about the exam that will make it take longer or involve a greater degree of touching than usual the doctor should explain why. A pelvic (internal exam) is not routine in a healthy child.

Sincerely,
Dr. Warren

-DS

Dear DS: Your son is trying to hold in his bowel movements. The more he holds them in, the harder they get. The harder the bowel movements become, the more they hurt coming out. The more discomfort your son has with bowel movements, the more his 4-1/2 year old mind thinks the best thing to do is not have the bowel movements. Adult logic will not work on him. You need to get your son's stool soft by giving him a stool softener and giving him a lubricant like mineral oil to make it easier for him to go and harder for him to hold it in. If your son has been severely constipated for a while, you may need to empty him out with a glycerin suppository or even an enema.

Read my article, Fecal Soiling. Even though your son's problem isn't soiling, the article explains stool withholding and its management.

Sincerely,
Dr. Warren

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