1 March 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
This young boy is now 7 years 9 months. His illness is as yet unknown but the characteristic of his condition include:
* Being unable to understand simple instructions sometimes and a limited
speaking ability.
* He did not begin speaking until he was 7 years 2 months old.
It is suspected that he may have an autism or some problems with hearing ability. As this disease is rare and strange in China, doctors can not give a definite conclusion. Furthermore, some special medical equipments for diagnosing are not available in China. His parents are axious about his illness and they have to look after him on a full time basis.
Your kind assistance would be highly appreciated.
-YYF
Dear YYF: There are many reasons a child might have delayed language. The most important one is hearing loss, because it is treatable, and because deaf children who have normal intelligence can learn as much as hearing children. If the child's hearing hasn't been tested, it is essential that this be done. A trained audiologist will know how to do this by testing in a sound field and using play techniques to condition a response to sound.
A child with general delays resulting from a variety of neurological conditions can have delayed language. It would be best if the child could be evaluated by a pediatric neurologist.
Autism has some very distinctive features besides delayed language which can help to make the diagnosis. Autistic children do not relate normally to people. They do not make eye contact. They don't respond well to affection or cuddling. They do not play appropriately with toys. An autistic child with a toy car might focus on the wheel of the car and just spin it for hours. Or he might spend his time rocking and twirling a string. In spite of the severe delays that autistic children have in all areas, some of them may be brilliant in one specific area such as math, or knowledge of the calendar.
Since I have so little information, it is hard to make recommendations. A neurological evaluation might discover some metabolic diseases or seizures that can be treated, but, with the exception of providing hearing aids to deaf children, the primary treatment of all delays is educational rather than medical. With intensive speech therapy, occupational therapy, physical therapy, and appropriate academic stimulation, the child's outlook may improve.
Sincerely,
Dr. Warren
-JG
Dear JG: It is likely that the diagnosis of ADHD includes a varied group of children having attention problems with multiple different causes. As a result, not all respond as well to the same medications. ADHD would be the primary diagnosis in a child who has attention difficulties with no other neurological problem, but many children with other neurological conditions such as developmental delay, speech/language delay, cerebral palsy, mental retardation, seizure disorder, brain injury, and autism, have attention deficits as part of their condition.
Tic disorders have a high association with ADHD, and some tic disorders may be aggravated by Ritalin. Since most pediatric neurologists treat both tic disorders and ADHD, you would be wise to consult the pediatric neurologist about the management of your son's ADHD. He may need adjustment of his Ritalin dose or he may do better on an entirely different medication. Since it is likely that your son will also need counseling, and so will the family, since medication cannot eradicate the effects his behavior has already had on the family or the maladaptive coping mechanisms your son has already developed, the neurologist and the mental health facility need to coordinate their care by communicating with each other.
It is possible for the diagnosis of autism to be missed in a child who hasn't had significant language delays, but the main features that would suggest autism are delayed language development associated with poor social skills. The poor social skills associated with autism are unique and do not refer simply to difficulty getting along with others. Autistic children do not make eye contact. As infants they don't respond to affection. They relate more to objects than people. They seem to be unaware of their lack of social skills, and what's more, until other children begin to give them a hard time, they don't care that they don't fit in.
There may be a point when the doctors have nothing new to offer your son, but until a child's life is perfect, there is never a point when a mother stops searching for answers. It has nothing to do with paranoia. If you don't express concerns, the treating doctor will conclude, erroneously, that everything is going well, and no attempt will be made to improve the situation.
Sincerely,
Dr. Warren
I would like to know a couple of things from you. Firstly, If
there is no internal infection, why do Pus cells show up in a Stool test?
Secondly, How long do you think does it take, for us, to be able to give
regular milk and milk based products to the baby?
Looking forward to your precious comments on the condition of my baby.
Regards,
-SB
Dear SB: It is not clear to me how much of a problem your baby has with diarrhea since you didn't mention how frequent the bowel movements were and you described them as loose rather than watery. Two to four loose (but not watery) bowel movements per day in a healthy infant who is gaining weight well, eating well, and not having abdominal pain, can be perfectly normal. A greenish color is not of any special significance, especially if the baby is on a formula with iron, since iron may make the stool dark and green.
The presence of sheets of pus cells in stool is suggestive of intestinal inflammation, but it is not diagnostic of infection. It can be seen with ulcerative colitis and Crohn's disease as well as with infections caused by various bacteria. The presence of 10 to 11 pus cells per high power field really isn't diagnostic of anything. There may be small amounts of pus cells in normal stool.
I do not like to criticize the treatment of other physicians, especially when they have seen the patient and I have not, but many physicians are too quick to give antibiotics, and that has resulted in a serious problem with drug resistant bacteria world wide. Since antibiotics can aggravate intestinal problems and the choice of antibiotics is highly dependent on which organism is causing an infection, I would never treat diarrhea with antibiotics without a stool culture showing an organism which requires antibiotic treatment. Even when a bacterial infection is present antibiotics are not always indicated. Treatment of Salmonella enteritis with antibiotics can cause a patient to become a chronic carrier. There are times we have to start antibiotics without having all the answers such as when a child is seriously ill with a potentially life threatening infection, but by your description, that was not the case with your baby.
A stool reducing substances of 1-2% suggests a carbohydrate malabsorption, but it isn't clear which carbohydrate. Since fruit juice and soy formula have different carbohydrates, either of them could cause a problem. While most babies tolerate human milk well, human milk has lactose (milk sugar) just like cow's milk based formulas, so if a child has a severe lactose intolerance, nursing could conceivably cause a problem. No matter what milk a child eats, he must have some form of carbohydrate in his diet. If your child is having severe diarrhea, it will be necessary to determine which carbohydrate is causing the problem. This can be done by giving the infant a carbohydrate challenge of the suspected carbohydrate after a 4-6 hour fast and measuring the breath hydrogen.
Whether or not to go to this much trouble is highly dependent on how sick your baby is. If the stools are loose and green, but your baby is happy and thriving, I wouldn't do anything. If the baby is doing well, you could try a challenge with a milk based formula any time. If it causes diarrhea, then it is clearly a problem. If the baby does well on the milk based formula, then it can be continued. The American Academy of Pediatrics does not recommend switching infants from formula to milk until 1 year of age.
Sincerely,
Dr. Warren
She has had blood in her urine for about the past 4mos. The bacteria that have been present are not the normal type found in UTI's.
They did a Renal Sono, a CVUG, and an IVP and all have been normal.
When they did a urine sample via catheter, there was still blood, but no bacteria present. The last check they did they found more bacteria than before, but this was without a catheter. They do feel that this time it's probably NOT from outside contaminants since there's so much.
She's already done all of the things at home that she can do to get rid of all perfumes and harsh soaps for her child.
What do you think this could be? They want her to come back in another month, but my sister is getting quite tired of coming back every month and not getting any answers.
Thanks!!
-CC
Dear CC: There are many causes for blood in the urine besides urinary tract infection. The presence of blood in a catheterized specimen can be difficult to interpret since there may be enough urethral trauma during catheterization to cause a small amount of blood.
If the question of whether or not the child has a urinary tract infection remains unresolved, repeat specimens should be done until the issue can be resolved. In that case I wouldn't wait a month between specimens. And if a reliable culture can't be obtained, then a catheterized specimen should be obtained again. On the other hand, if the blood had been present in the urine at the time of the catheterized specimen, and that specimen showed no bacteria, it would appear that infection is not the cause of the blood.
Since the imaging studies of the urinary tract have all been normal, the remaining things that might be done to assess the cause of blood in the urine are a 24 hour urine collection for a Calcium/Creatinine ratio, and blood tests for kidney function and rheumatic diseases including C3 and C4 complement, BUN, Creatinine, ANA, and ESR (sedimentation rate). If all these things are negative and the child's blood pressure is normal, the child is not edematous, there is no visible blood in the urine (the amount of blood is microscopic), there is no significant protein in the urine (proteinuria), and urinary tract infection has been excluded, then the child should be observed with periodic repeat urinalyses.
Blood may be present in the urine for up to a year after a strep throat. It may also occur after any illness with fever, or from urethral trauma during bicycle riding. The other causes are mostly forms of glomerulonephritis (kidney inflammation) which are only treated if there is progression to gross (visible) hematuria (blood in the urine) or protein in the urine. The exact diagnosis of glomerulonephritis is generally made by a kidney specialist after doing a kidney biopsy, and this would not be done if there is only microscopic hematuria without proteinuria.
Sincerely,
Dr. Warren
-K
Dear K: The treatment for hives, which result from allergic reactions, is an antihistamine like Benadryl. If the hives become severe resulting in swollen lips or tongue, wheezing, or swelling in the throat, then emergency medical attention is required. Antihistamines help to control an allergic reaction, but they cannot make what is happening in the body go away. The reaction must subside on it's own. In more severe cases, adrenaline can be given for emergency treatment and steroids can be given for longer term control of the reaction, but these treatments must be prescribed and managed by a physician.
If you have been on Benadryl around the clock for 3 days and your allergic reaction is escalating, you may need emergency medical treatment. If any of the more severe symptoms I mentioned above have occurred, or you are extensively covered with hives, you should get medical care immediately if you have not yet done so.
Just a note to you and other readers of "Ask Dr. Warren":
I try to answer all my e-mail as quickly as possible, and I generally read my e-mail every day, but if you have an emergency for which you need immediate advice, you should call or go to an emergency medical facility when your own doctor is not available. Since I take care of my own patients all day, sometimes late into the evening, and sometimes late at night, it can sometimes take me a few days to get all my e-mail questions answered. And I'm rarely at the computer at 3 AM since I have to be awake for my patients in the morning. So to be quite honest, it's unlikely that I will be able to answer 3 AM e-mails before their senders can get medical attention in the morning.
Sincerely,
Dr. Warren
Thank you,
-Travis
Dear Travis: It is hard to be sure what something is by a description when the diagnosis is best made by seeing it, but your description sounds like thrush. Thrush looks like flat patches of cottage cheese in the cheeks or lips, or on the tongue. Thrush is a yeast infection in the mouth. It is not serious or dangerous, and generally doesn't bother the babies. It can be treated with antifungal medication which your doctor will prescribe.
Sincerely,
Dr. Warren
-Robin
Dear Robin: Children are born with their own unique personalities. Some have great difficulty with change and are very clingy and demanding. It really has nothing to do with how stable their home lives are or how much love and attention they get. On the other hand, you must consider how much love and attention you get returned from such a child. There is a plus to every minus, and not only will your child outgrow this, but the day will come when you will cherish whatever time he finds for you.
In the meanwhile, the answer is to be reasonable. Give him the attention he craves when you are free to do so, and gently extricate yourself from his grip when you have other things to do. If he carries on, reassure him briefly about what will happen next and when he will have your undivided attention, and then go about your business. If there is a chance that he will vomit, have a bucket handy.
When children don't adapt to change well, sometimes it is helpful to plan their day with them. This will become more useful as your son gets older. It helps a child to see that each day has a routine, and that sure as the sun rises and sets, Mom and Dad come home and find time for their precious angel. The down side to advance planning is that sometimes plans have to change. Children who don't like change tend to view the blueprint as if it's set in stone, but if these children learn that you can be depended on to follow a plan, they can also learn how to deal with the occasional, inevitable need to change a plan.
Sincerely,
Dr. Warren
-NR
Dear NR: Your description of your son's tongue sounds like Geographic Tongue, also known as Benign Migratory Glossitis. It is a mild inflammation of the tongue which some people are prone to and is considered a variant of normal. There is no treatment, but it is harmless, so no treatment is needed.
Sincerely,
Dr. Warren
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