21 December 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
-TE
Dear TE: Cystic fibrosis is a genetic defect that results in abnormal mucus production by glands all over the body. Mucus is produced by all membranes as a protective lining. The thickened mucus produced in a variety of organs can have various effects so that the main symptoms are not the same for all children with cystic fibrosis. The main organs affected are the lungs, pancreas, and intestinal tract. As a result of abnormal mucus in the bronchial tree, most CF patients have chronic lung disease with wheezing and recurrent pneumonia. Pancreatic failure effects the part of the pancreas that produces digestive enzymes, so that many CF patients have abnormal stools and fat malabsorption. Some CF patients develop cirrhosis of the liver and complications associated with cirrhosis such as esophageal varices (enlarged veins in the esophagus which can result is serious bleeding).
The simplest test for diagnosis CF is a sweat test. The defect which results in abnormal mucus is related to transport of sodium across cell membranes. The concentration of sodium is abnormally high in secretions including sweat. The sweat is collected in a small cup which is attached to the skin surface. Sweating is induced from that portion of the skin by a small and painless electrical current. Then the concentration of sodium in the collected sweat is measured. Since the different genetic markers for different types of CF have been identified, the diagnosis can be further refined with genetic testing.
Sincerely,
Dr. Warren
My question is what exactly is a right sided accessory connection, what does this mean? and of course other than freezing the hair does the freezer part help. If you could direct me to an internet source regarding this information I would greatly appreciatte it.
Thank you!
-WA
Dear WA: I imagine the right sided accessory connection you are talking about is an aberrant electrical pathway which is conducting an electrical impulse that results in the tachycardia. Treatment of the tachycardia may be accomplished with medication, but the medication would have to be taken to prevent the tachycardia which means taking medication all the time. If the episodes are infrequent, that may be undesirable. Sticking the head in the freezer, splashing cold water on the face, applying pressure to the eyeballs, etc., are methods of stimulating the vagus nerve which is part of the parasympathetic (inhibitory) nervous system. Successful stimulation of the vagus nerve will cause a drop in the heart rate and blood pressure and may break the episode of tachycardia.
Sincerely,
Dr. Warren
THANK YOU,
-ADAM
Dear Adam: The answers to your questions are as follows:
1. The bulk of major motor milestones are accomplished by a child's second birthday. These include rolling over, sitting, crawling, standing, and walking. Over the following years until adolescence children refine those skills and develop the fine motor skills necessary for writing, crafts, and various athletics.
2. Children may experience delays in achieving any of the motor milestones. Physical abnormalities of limbs, abnormalities of the nervous system, or acute illness may interfere with achieving certain skills.
3. Healthy children achieve their motor milestones without parental help as long as they are provided the opportunity to roll, crawl, and walk. If a child is kept in his crib all day long he cannot develop his motor skills. Children must have stimulation and normal social interaction to develop properly. Children who are deprived of these things have not only delayed language and social skills, but also delayed motor milestones and physical growth.
Children who have physical or neurological problems such as cerebral palsy may require specific interventions by their parents and/or physical and occupational therapists to achieve their motor milestones.
4. Milestones like crawling and walking are not taught and require no special intervention. Swimming, riding a bicycle, and skills associated with crafts and sports generally require some teaching (not necessarily by the parents). These skills are not really considered motor milestones since they don't occur at a specific age and some people may never learn them. Milestones are essentially skills that are generally accomplished by all normal children by certain ages without training.
5. See answers 3 and 4. The usual motor milestones should be accomplished without parental involvement, but the parents' interactions with their child play a pivotal role in everything the infant does. A child becomes physically capable of walking when his nervous system is ready, but he often takes his first step at the encouragement of his parents. Very often the first steps lead directly into Mommy's or Daddy's arms.
6. Growth requires nurturing in the form of feeding and love. Social, emotional, intellectual, and language development all come from interactions with other people, at first primarily the parents and then the rest of the world. See #10 below.
7. The primitive reflexes of infancy such as the startle reflex, stepping reflex, grasp, and tonic neck reflex generally disappear by 6 to 9 months.
8. When primitive reflexes persist beyond the normal age, they may interfere with motor development. Their persistence usually indicates a neurological problem.
9. Immunizations prevent diseases. Since severe illness can interfere with normal growth and development, immunizations aid development by preventing disease; however, immunizations have no direct effect on physical development.
10. A child's relationship with the world starts with his inborn personality and his interaction with his parents. An infant is totally dependent on his parents. His parents are his whole world. His parents meet his needs, provide him comfort, and define the values he will learn. A child's early efforts at becoming civilized and learning rules are all a result of trying to please his parents. Later, when these rules and values become internalized, they become the child's conscience, his sense of right and wrong.
Children enter the world with their own personalities, but their early interactions with their parents play a large role in their emotional well being. Children whose parents are warm and loving and respond to their children's needs teach their children to trust and love. Parents who are consistent in their discipline of their children provide stability that allows children to learn to follow rules and get along with others. But before we give all the responsibility to the parents, keep in mind that the parents' interactions with their child will be affected by his response to them as much as he will be affected by their response to him. Some children are simply more difficult by nature and their parents become stressed out in dealing with them.
Children continue to seek the approval of their parents, sometimes into adulthood. Much of the emotional baggage that adults deal with revolves around their interactions with their parents, or at least their perceptions of what happened during their childhood. Even the adolescent who is in constant conflict with his parents would like the approval and trust of his parents and to feel that he will continue to be loved no matter what.
11. Children enjoy a unique relationship with their parents, but getting along in the real world and finding out who you are and what your values are, requires dealing with people who aren't your parents. School provides the major opportunity for children to learn social interaction with people outside the family and to develop emotional independence from their parents. Interactions with peers provide the major training for future interaction with the world. By adolescence peer interactions provide the main source of emotional support and experimentation with ideas and values. Ideally this should all occur with a backdrop of parental love and support, but the goal of childhood, and especially adolescence is to develop emotional and social independence from one's parents and emerge with one's own set of values and beliefs (which generally reflect to a large extent the values and beliefs of the parents).
12. Children who don't have active parental involvement are more likely to do poorly in school, to have behavioral problems, and to have low self esteem. Older children without parental involvement are more likely to take risks, experiment with drugs, seek inappropriate relationships including sex in an effort to feel loved, and get into trouble with the law.
13. The number of parents in a household is not as important as the relationship between the children and the parents. Some children suffer significant emotional distress from the death of a parent or the effects of divorce, especially if they get caught in the middle between fighting parents, but a two parent household can be just as devastating or even more devastating when there is physical or emotional abuse by one of the parents toward the other parent or the children.
14. Teachers need the support of parents to do their jobs. Parents need to know what's going on with their kids. Communication is essential.
15. Peers play a major role in emotional and social development, especially during adolescence. Children who are not accepted by their peers or get teased, picked on, or bullied, suffer emotional distress which parents cannot eliminate. If it persists it can lead to low self esteem and even depression.
Teens who get into a "bad crowd" are more likely to reject a greater number of their parents values and to seek the support and approval of their peers for their actions and decisions. This carries a greater risk of drug and alcohol use and a great likelihood of parent/child conflict. The conflict may result in the teen's turning increasingly to his peers for approval resulting in escalating parent/child conflict in a vicious cycle. The key to avoiding this vicious cycle is to keep the lines of communication open and for the parents to maintain a loving relationship with their teen even when they don't approve of what he is doing.
Teens who have good peer relationships and rewarding interactions in activities that support positive social goals and values, benefit with high self esteem, a sense of accomplishment, and development of a good attitude toward goal oriented behavior which is the cornerstone of success.
Sincerely,
Dr. Warren
Sincerely,
-CG
Dear CG: If a child needs growth hormone to grow, he will need it for his entire period of growth, but not for the rest of his life. The only true medical indication for giving growth hormone is to treat growth hormone deficiency; however, we do recognize that there are some relative degrees of growth hormone deficiency which benefit from treatment.
The treatment of short stature unrelated to growth hormone deficiency remains controversial. While there is evidence that growth hormone can accelerate the growth of children who are not growth hormone deficient, it is not yet known whether or not their treatment with growth hormone has any effect on their final height. Growth hormone hadn't been plentiful enough to treat anyone but those proven to be growth hormone deficient until it was produced by recombinant DNA technology. Since this is a recent development, no children started on treatment early in childhood have reached their final adult height yet.
At the very least, your nephew should have a complete evaluation by an endocrinologist before embarking on treatment with growth hormone. If he is not growth hormone deficient, the pros and cons of treatment must be discussed along with considerations of normal familial growth patterns. If your nephew's growth rate is normal, even if he is short there is a high likelihood that he will achieve a normal adult height without intervention. On the other hand, there is no question that some children suffer significant loss of self esteem from being short.
There were some concerns about potential disease being carried by growth hormone when the only source was cadavers. There were some cases of Jacob-Kreutzfeld Disease associated with cadaver growth hormone. The growth hormone produced by recombinant DNA technology is pure and has so far been shown to be safe. Treatment is quite expensive and must be administered daily by injection, which generally means the parents must learn how to give the injections.
Sincerely,
Dr. Warren
Are my concerns legitimate or am I being overparanoid? Your feedback will be most appreciated.
Sincerely
-NP
Dear NP: I don't think exposure to a Pittsburgh winter is an issue for the health of a 3 month old since I assume she will be dressed appropriately for the weather and will not be kept outdoors any longer than necessary. I can assure you that the babies born in Pittsburgh don't suffer any ill effects from the winter there.
Exposure to germs becomes an issue as soon as children are exposed to crowds, but that has to happen sooner or later, and while one wouldn't want his young infant to become ill, one also wouldn't want to live life around avoiding all potential exposures. Whether it's an airplane or the church where your baby is baptized, your baby will be exposed to germs. The largest part of the exposure will come from family and friends who are actually handling the baby rather than from being in an airplane. The best way to minimize exposure is to insist that anyone who is ill keep their distance and to make sure that everyone washes his hands before handling the baby.
Sincerely,
Dr. Warren
Thanks and regards
-Sonia
Dear Sonia: I have no reason to believe that your brother's symptoms are psychological since I haven't been told of any psychological risk factors or stress. On the other hand, you and your brother believe that he has a fever when his temperature is normal and none of the doctors involved in his care have reassuredd him that he has nothing serious. As long as your brother believes that he has a fever and chronic pharyngitis (which I have never heard of), he has every reason to interpret his symptoms as significant and worry about them.
Since I haven't examined your brother, I'm not able to tell you if there is anything wrong with him, but I can tell you that a temperature of 99.2 is not a fever, and is not a sign of illness. I can also tell you that throwing antibiotics at him with a negative throat culture and a normal white blood count will be of no benefit to him. If your doctor believes your brother has a persisting illness or your brother has persisting symptoms (not referring to his temperature which is normal) then he needs a thorough evaluation to find the cause.
A slight increase in the eosinophil count may be of no significance, but it could also be seen with allergies which could cause chronic symptoms. Eosinophilia may also be seen with parasites.
Sincerely,
Dr. Warren
-KM
Dear KM: What you describe is typical separation anxiety. If your daughter is happy in daycare when she doesn't see you, and happy with you when you're at home, don't worry about it. Some children have more difficulty with separation anxiety than others. I've seen children cry when their parents left them on the first day of kindergarten. The fact that she is separated form you at daycare may contribute to her being more demanding of you when she is with you and more fussy about separation, and yet at the same time, her good experience at daycare will eventually help her to cope with the separation.
Sincerely,
Dr. Warren
My son's diet consists of Isomil with iron (approximately 32 ounces a day) plus two solid meals, iron fortified cereal and a fruit or vegetable. I have been preparing his fruits and vegetables at home. I currently do not offer additional fluids and question the importance of this as our water is fluoride fortified.
I am interested in your opinion on this topic. Thank you for your time.
Sincerely,
-ML
Dear ML: Since the formula contains the full day's supply of vitamins and iron, I don't prescribe vitamins or iron for children on iron fortified formula. Once children come off formula, hopefully they are eating a large enough variety of foods to meet their vitamin and mineral needs. The key is variety of foods and not quantity. If a child consumes a diet of only one or two foods, a vitamin and mineral supplement may be necessary.
Too much fluoride is as bad for the teeth as not getting fluoride. If your son is drinking fluoridated water or you use the water for cooking or making formula or juice from concentrate, you should not give him additional fluoride. I should also mention that the recommendations for fluoride supplementation were changed a few years ago and it is not recommended to start supplementation until 6 months of age.
Sincerely,
Dr. Warren
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