15 February 1999
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
I've always gone in and uncovered his head after he's fallen asleep. I'd like to leave him be if it's safe.
Sincerely,
-Meg
Dear Meg: If the quilt is made of cloth and your son isn't wrapping it tightly around his face, he should have no trouble getting enough oxygen or getting rid of carbon dioxide. If the quilt has any kind of plastic lining inside or outside that would not allow free air flow (I can't imagine that any quilt would), it should be removed and replaced.
For your own peace of mind, you can continue to remove the blankets from his head after he's fallen asleep.
Sincerely,
Dr. Warren
Thank you,
-Not a Pushover Anymore
Dear Not a Pushover: Thank you for sharing your experience with ear infections. Children who have decreased hearing during a significant portion of the first two years of life are at great risk of having speech and language difficulties secondary to their hearing loss. A child who has persistent middle ear fluid for 4 or more months, recurrent ear infections which cannot be controlled with prophylactic antibiotics, or demonstrable hearing loss, may be a candidate for tubes.
Many of the parents of my patients who have had tubes have been very pleased with the results, and some had wished they'd done it earlier. But tubes are not a panacea. Some children continue to have chronic ear infections even with the tubes in place and some children's tubes get rejected after only a short time. Since the placement of tubes requires general anesthesia and doesn't carry a 100% guarantee of success, not all parents are anxious to rush to tubes and consider it a last resort.
I would agree that any child with recurrent ear infections requires careful monitoring to determine the optimal time for additional intervention, but many of my patients have had two ear infections within two months or an ear infection that didn't clear for two to three courses of treatment, and then gone on to long term resolution without surgical intervention. It is well known that children may develop middle ear fluid with colds which then resolves on it's own and that ears may cycle in and out of having middle ear fluid. I have also had patients with middle ear fluid who passed their hearing tests while others whose ears looked the same did poorly on their hearing tests. The decision to place tubes requires weighing all the factors such as frequency and severity of ear infections, the amount of time the ears are free of fluid and the amount of time the fluid persists, and any evidence of hearing loss. When in doubt, an ENT should be consulted for evaluation of the middle ear.
Sincerely,
Dr. Warren
-Sandy
Dear Sandy: Conjunctivitis may be viral or bacterial, or it may be from non infectious causes like allergy. Generally, very red conjunctivae with copious green or yellow pus is bacterial. If it responds to the antibiotic drop, there is no need for a culture or a change in antibiotics. It may be necessary to continue the drops longer in order to avoid a relapse.
Seasonal allergies may contribute to conjunctivitis because they may cause the conjunctivae to be inflamed and more susceptible to infection. Eye rubbing may increase the risk of contamination, especially if the hands have been near the nose.
Since your son has had such a frequent problem with recurrent conjunctivitis, perhaps you should consult an ophthalmologist to be sure that your son doesn't have any eye condition predisposing him to have recurrent conjunctivitis.
Sincerely,
Dr. Warren
-rgds
Dear rgds: Animals that hibernate have metabolic changes that occur during hibernation. Their metabolic rate goes down allowing their bodies to function on less energy. Hibernation is built into their seasonal clocks just like our normal sleep patterns are built into our daily rhythms. There is no equivalent to hibernation in a human being since it is not just a long sleep, and it requires metabolic changes which are not under voluntary control.
Sincerely,
Dr. Warren
We drove up to the camp, and found her sitting with the counselor, and the spasms were still occurring. She appeared to be having something like hiccups, but without the characteristic sound. The spasms were occurring about 2 times a second, with her shoulders going up, her head tilting or nodding a little, and her eyes closing momentarily, all in unison. Her expression was otherwise relaxed, and she could talk and tell us that she felt o.k. The spasms seemed to involve her entire upper torso, something like hiccups do, but again without the hiccup sound. We drove home, and the spasms seemed to go away shortly after we left the camp. We decided it must have been the stress of being away from home, in a strange place, etc. We had plans to visit family that evening, and decided we could go, and our daughter said she would like to go.
After dinner at our relations' house, the spasms began again, and became quite strong and obvious. We could not reach our HMO advice number, so we called 911 and Jan was taken to a hospital emergency room. The spasms went away about when they arrived there. Naturally all vital signs were normal, and the behavior/symptom did not occur again that night. The next morning at home they developed again while she was eating breakfast. I drove Jan to the pediatrics department of our local hospital, and the spasms were still occurring when a pediatrician began examining her. As he was examining her, asking her to move her arms, push against his hands, touch her nose, etc. the spasms went away. He suggested I do similar exercises if this should occur again, or get Jan to do something that required concentration, such as playing a board game or computer game. The spasms did not occur again that day, in particular not at all after lunch or dinner. Today they did not occur after breakfast, but an episode did occur in school today, about 45 minutes after lunch. The teacher had been informed that this might happen, and tried to distract Jan with an activity, but the spasms continued. The school called my wife, and she took Jan to the hospital again. However, the spasms had ceased before they arrived at the hospital, about an hour after they had first commenced.
A different pediatrician was seen. Jan was given something to eat and something cold to drink, but nothing developed. A neurologist consult is being arranged. No spasms occurred after dinner this evening.
Jan has always been a very healthy child. She is tall for her age, about 90% percentile on height. She has no allergies that we are aware of, and is not taking any medications. I asked her several times on Saturday if she had swallowed anything at the camp, and she said no. During the spasm episodes, her skin temperature felt normal, her pupils were responding normally to light, and both were the same size. I don't think it's an act - when I hugged her, I could feel the spasms, and they did not feel like voluntary actions. Neither my wife or I know of anyone in our relations or family history that had anything similar, nor any nervous system disorders of any kind. Thanks for any comments or suggestions you can provide.
-AM
Dear AM: If the movements look and feel like hiccups, even in the absence of a sound, they may indeed be hiccups. Hiccups can occur after an upper respiratory infection and last 1 to 7 days. Less commonly, they can result from a subphrenic abscess.
These complex movements could be a motor tic. Most, but not all tics, are stress related. Evaluation for tics is generally done by a neurologist since they may be seen as part of some neurological conditions and must be differentiated from other neurological conditions. Any repetitive movement could conceivably be a seizure. Patients can be conscious and communicative during focal (localized rather than generalized) seizures.
Your next step is the neurological consult which you have arranged.
Sincerely,
Dr. Warren
-MZ
Dear MZ: The following information about discontinuing Effexor is quoted from the PDR:
"When discontinuing Effexor after more than 1 week of therapy, it is generally recommended that the dose be tapered to minimize the risk of discontinuation symptoms. Patients who have received Effexor for 6 weeks or more should have their dose tapered gradually over a 2-week period."I am happy to provide this information for you, but I am concerned that your asking me implies that you have decided to discontinue the medication without the advice of the physician who prescribed it. If your daughter is having a problem with the medication or does not feel it is helping her, you or she should be discussing the problem with her doctor. Even if the medication could be stopped without side effects, discontinuation of the medication could risk return of the symptoms being treated by the medication. Assuming that there was a good reason for your daughter to be on Effexor, it should not be discontinued without discussing it with her doctor.
Sincerely,
Dr. Warren
-Perplexed
Dear Perplexed: Three weeks is a long time for a virus to cause a stomach ache. A bland diet does not hasten the resolution of an intestinal virus. Dietary treatment of intestinal viruses is aimed at preventing dehydration and avoiding foods which aggravate the symptoms. Viruses rarely last longer than 1 week, but sometimes the inflammation caused by the virus can last longer resulting in persisting symptoms; however, by three weeks it's time to be looking for other causes of abdominal pain.
It is possible that your daughter has more than one cause of abdominal pain since she had the pain for a while before she developed diarrhea, vomiting and fever. The diarrhea, vomiting and fever are intestinal virus symptoms, and have resolved as expected for a virus. Even your daughter's appetite has returned. Only the abdominal pain remains. Perhaps she is over a virus, and back to where she started.
So what are the causes we should consider for the original and current pain? Is your daughter constipated? Constipation is a common cause of chronic abdominal pains in kids. Stress can also contribute significantly to abdominal pain. In assessing the possibility of stress, keep in mind that a child doesn't have to be unhappy to be stressed. A bright child who always wants to achieve may do well and be happy about it, but have considerable stress about keeping up his accomplishments. Children may sometimes become stressed about things that excite them like an upcoming party or special event. Also keep in mind in searching for possible stresses, that things which cause children stress may seem like minor matters to adults who have already resolved these childhood issues.
If the test for parasites is negative and neither stress nor constipation appear to be playing a role, 3 weeks of persisting pain is long enough to go further in evaluation.
Sincerely,
Dr. Warren
What bothers me most is that I feel she is "over reacting" when it comes to the warmth of our children. We have a son (7) and daughter (6) - right now the weather is great, but she insists on a sweatshirt like jacket on them if the outside temperature is below 79 degrees.
My Question: Is it possible that our children's tolerance to cold be effected by this. In other words, by always keeping them covered up, will they be kind of "wimpy" to the cold?
Please e-mail your answer to: art
Thank you.
-Art
Dear Art: A temperature between 68 and 75 degrees Fahrenheit is comfortable for most people. There is no health benefit from keeping it warmer. In fact, it is likely that a child playing outdoors in 79 degree temperature who is overdressed will become overheated.
I wouldn't say that the children will become "wimpy" to cold, but they may have become used to being warm. I for one can't understand how they could even be comfortable playing in 79 degree weather with anything but light clothes on.
Sincerely,
Dr. Warren
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