25 October 1999

1. No Weight Gain for a Year
2. Calcium for Milk Allergic Child
3. Alcohol in Tempra?
4. RSV
5. Symptoms of Carbon Monoxide Poisoning
6. Amblyopia
7. Evening Abdominal Pain
8. Poor Weight Gain
9. Disclaimer

• Read Questions & Answers in Another Column

No Weight Gain for a Year

Nevertheless, we are not reassured at all because he has been at this weight for over a year now. Our main concern is his appetite, which has become poorer; he now would eat only plain rice, and sporadically at that. He does enjoy fruits (apples and pears) and sweets and drinks juices, but would hardly touch anything with protein, the only exception being breastmilk. We've tried sneaking protein (tofu, bits of meat, broth) into his rice, but most of it comes right back out of his mouth.

We have read some of your previous articles relating to slow growth and poor appetite, but our boy seems way off the charts. Please help. Thank you very much.

Best wishes,
TJ & S

Dear TJ & S: Perhaps your pediatrician has not been concerned about your son's weight because your son's linear growth (height) has been normal. While your son's weight is below the third percentile, compared to his height, it is not alarmingly low. What is concerning and cannot be ignored is that your son hasn't gained any weight for a year.

Unfortunately, there is nothing anyone can do to make a child eat any particular food. In fact, most children who are pressured to eat develop very poor eating habits. On the other hand, children who are presented with a diet of nutritious food and allowed to eat what they wish, usually do very well; however, the foods presented to them must be nutritious. Even children with good eating habits can develop poor eating habits when allowed to choose between good food and junk food.

The question is, what has changed in the past year to alter your child's diet. Since nursing is not usually the main source of any 3 year old's nutrition, is it possible that your milk supply is dropping and that your son is spending time on the breast when he should be eating. I certainly don't want to eliminate your milk from his diet if he is depending on it for protein, but only you are in a position to assess whether his time spent nursing is interfering with the development of normal eating habits.

I could recommend a product called Pediasure which is a high calorie, high nutrition drink, but I don't know if it's available in Korea. It is flavored, but I can't guarantee that your child will take it.

If your son continues to not gain weight and refuses to eat, your pediatrician must evaluate to determine if something is interfering with your son's appetite.

Sincerely,
Dr. Warren

-T

Dear T: Osteoporosis can occur in males although it is a greater problem in females. Calcium is found in green vegetables and meat. Canned salmon is also an excellent source of calcium. Fortified orange juice is not likely to affect your child's stomach since the acidity of his stomach is much greater than the acidity of the juice; however, large quantities of juice may cause diarrhea and will decrease your child's appetite for food. Children's Mylanta is also a good source of calcium even though the adult Mylanta is not calcium.

Sincerely,
Dr. Warren

Thank you

-KH

Dear KH: Tempra is a brand of acetaminophen just like Tylenol. I do not have a current listing of Tempra's inactive ingredients, but most children's medications were reformulated years ago to remove alcohol if it wasn't necessary, and I believe Tempra is alcohol-free. Both Tempra and Tylenol are safe and effective fever reducers and pain relievers for children; however, careful attention must be paid to the label to be sure that the correct dose is given since an overdose of acetaminophen can cause serious liver damage and death.

As regards economic rewards for promoting these items, neither company offers physicians anything to promote their products except samples to give to patients. When I give children immunizations which might cause fever, I give the parents a sample of acetaminophen drops. The brand I give depends entirely on what I have samples of. When parents go out to purchase more, they're free to get whatever brand they like, including the less expensive store brand generic.

Sincerely,
Dr. Warren

-RLP

-KF

Dear RLP & KF: RSV stands for Respiratory Syncitial Virus. RSV is an upper respiratory virus which spreads in much the same way as a cold. There is no vaccine yet for RSV, so at the moment, the only way to prevent RSV infection is to avoid exposure and was hands a lot.

Young infants who catch RSV infections may develop bronchiolitis, a condition where the virus infection spreads into the bronchial tree and causes wheezing. The wheezing associated with bronchiolitis is treated with bronchodilators (medications that open up the airways) just like asthma. Anti-inflammatory medications such as steroids, which are useful for treating asthma, are not useful for treating bronchiolitis. Since RSV is a virus, it does not respond to treatment with antibiotics, but just like most other viruses, the body fights off the infection and children recover.

The severity of the illness is largely determined by the degree of difficulty breathing it causes and varies from child to child. The more difficulty a child has breathing, the more vigorously his respiratory symptoms must be treated. Severely ill children should be treated in a children's hospital ICU where the staff is experienced in administering inhalation treatment with the antiviral agent Ribavirin. In my 20 years as a pediatrician, I have never treated a child whose bronchiolitis was that severe.

RSV does not tend to cause recurrent infection. Those infants who appear to wheeze every time that get a cold are more likely to have asthma than recurrent bronchiolitis.

Sincerely,
Dr. Warren

Thank you

-KC

Dear KC: Carbon Monoxide poisoning causes headache, weakness, dizziness, nausea, vomiting, abnormal breathing, and collapse. It does NOT cause fever. Since upper respiratory infections are more common during the winter than other seasons, that may explain your daughter's higher frequency of symptoms during the winter. If your daughter were chronically exposed to carbon monoxide, you would expect the rest of the family to be equally affected, unless your daughter is exposed via a space heater in her room.

Carbon monoxide binds onto hemoglobin at the same place that oxygen does. Its affinity for hemoglobin is stronger than oxygen's. As a result, carbon monoxide poisons people by preventing red blood cells from carrying oxygen to the organs. When a person doesn't have enough oxygen in his blood, his membranes turn blue instead of the normal pink. When a person's hemoglobin is saturated with carbon monoxide, his membranes turn cherry red. This is probably the appearance of the fingernails to which you are referring.

Sincerely,
Dr. Warren

1. Is this condition genetic? (both of my husband's sisters had lazy eyes - one of them never regained the use of the affected eye...)
2. Since the amblyopia showed up at such an early age does it mean that his case is more severe?
3. The opthamologist is what I would term "vague" when I ask him about non-surgical options, he mentions something about my son's young age and the degree of the turn of the eye...Are there other treatment options? Do children ever "outgrow" this condition?
4. My son often has fitful periods where he point-blank refuses to wear a patch and tears them off as soon as we can put them on.. Any tips? (Please know that at 18 months my son has absolutely no reasoning skills...)
5. Is it possible to delay treatment 6 months until we can reason with him about wearing the patch?(I understand that all treatment for amblyopia must occur before the age of seven to be successful)
6. If we do have his bad eye operated on, will the other start to turn? Does this depend on the cause of the lazy eye - either muscle deformity or brain problem?
7. If he won't wear the patch, are drops to dilate the good eye and force him to use his bad eye a realistic option?
8. Do you think all this forceful care for our child (holding him down to patch him or medicate him) is psychologically harmful to a child? Will he remember all this and resent us later?

Thanks!

-Lisa

Dear Lisa: The term lazy eye is somewhat vague, referring usually to an eye that drifts or turns (in or out), but sometimes referring to the decreased vision in the eye. The term amblyopia refers to a decrease in vision in one or both eyes which cannot be fully corrected by correcting refractive errors (near sighted, far sighted, astigmatism). Amblyopia of one eye may occur because of because of lack of use (only one eye is being used). One of the most common causes of amblyopia is an eye turn. If both eyes are not looking at the same thing, the brain must pick which image to use. In some instances, the eye turn and the eye that is used alternate, but if one eye is chosen to use and the image from the other eye is always suppressed, the vision in that eye deteriorates. There are other causes of amblyopia besides eye turns. If something obstructs the vision of one eye such as a cataract, a drooping lid, or a growth, that eye will not develop normal vision. If one eye is much more severely nearsighted than another, the good eye will be used and the other eye ignored. If the cause of disuse of one eye is discovered early and treated, amblyopia may be prevented or at least successfully treated. The treatment depends on the cause of the amblyopia. Now to your specific questions:

1. Eye turns (strabismus) may be genetic as may other conditions which affect vision.
2. The diagnosis of amblyopia at an early age may, in fact, improve your son's chances of successful treatment. His eye turn may have been more severe making it easier to notice, but the severity of the amblyopia is not equivalent to the amount of strabismus. The treatment of the strabismus will likely be affected by the amount and cause of the eye deviation.
3. If your son's strabismus is caused by a refractive error, such as a high degree of far-sightedness, it may respond to treatment with spectacles. If there is overaction of one of the muscles that control eye movement, surgery is the primary treatment. It is not likely that the condition will be outgrown, but as long as the vision of both eyes can be maintained, there is no urgency to choose a definitive treatment.
4. Keep in mind that as much patching as you can get your son to do is better than none. If he sometimes refuses to cooperate, all is not lost. Try to make it more of a game and give your son some choices by providing different colored patches or putting a sticker on the patch and letting him choose his patch. Get patches for the other members of the family and let him put patches on them. Let him patch a doll or a toy. He may even like to play out the battle so that he sees what it's like to be in control.
5. Since maintaining and/or improving the vision of your son's weaker eye is so important, it would be foolish to postpone treatment. As I said in answer to your previous question, the more patching you can do the better, but any patching is better than none. In my experience, 2 year olds are not significantly more reasonable than 18 month olds.
6. Some children who have strabismus surgery do require future surgery for fine tuning or further correction. If only one eye has a deviation, the other eye should not develop an abnormal turn because of correction of the problem.
7. Drops are an alternative to patching. Putting in drops can also be a battle and there is the rare possibility that a patient may be sensitive to the drops. A contact lens to block or decrease the vision in the good eye is also an alternative (but I doubt an easier alternative in an 18 month old).
8. When it comes to psychic scars, it isn't even necessarily what parents do as much as how children perceive it and remember it. There is a big difference between forcing treatment on a child and abusing him. When a child grows up, if he remembers or questions the actions, it will not be discussed in hushed tones or denied. There will be no veil of secrecy, blame or humiliation. Society will reinforce the value of what was done and the child will come to understand that he was not hurt. What's more, it is likely that your child and other children in this situation have enough positive experience and love in their day to prevent the battles from being psychologically significant.

   There is no question that some of my patients who are subject to repeat procedures like ear cleanings when they are very young develop a stronger reaction to seeing me, yet, when they are older, all of them appear to be able to distinguish between the way I treat them and the things I do that hurt or frighten them.

   Whether it is a matter of discipline or administering a medical treatment, I always advise parents to pick their battles wisely and, when possible, to be inventive rather than resorting to brute force; however, if you must do battle on this matter, let me assure you that it is reasonable for you to do what is necessary to guarantee that your child's amblyopia is treated. The price is too high if it isn't treated, and your son is not capable of making a wise choice on this matter.

Sincerely,
Dr. Warren

-E

Dear E: Gastroenteritis, an intestinal infection, is sometimes referred to as intestinal flu. Most gastroenteritis is caused by viruses. Viral gastroenteritis generally runs its course within a few days, but occasionally, it takes longer for the intestines to heal. It does not make a great deal of sense that your daughter's pain comes only in the evening, therefore, you might want to look at what she is eating before the pain begins to see if some temporary diet changes might alleviate her symptoms. Since a week is a long time for these symptoms, you should stay in touch with your doctor to decide when further evaluation is warranted if the symptoms don't improve soon.

Sincerely,
Dr. Warren

She has had a poor appetite since about 5 months old. But at around 11 months her appetite picked up and up until 3 weeks ago (before houseguests and a bad cold broke her routine), she was eating everything in site. Yet, not gaining much (if at all) weight. Finally, the Pedi is concerned about this and has referred her to an Endocrinologist. But the earliest I could get an appointment is late February. I'm afraid to wait that long. I'm afraid something serious might be wrong. What can I expect? What should I be prepared for? What does an Endocrinologist check for and how do they treat problems related to slow weight gain? There is a drug called Megestrol that is used to stop wasting in sick children and AIDS patients. Yet, my doctor keeps says my baby doesn't need it. I'm so scared and frustrated, I don't look at the charts anymore. But I imagine by now, she is probably at or below the 5th percentile. How can I get my doctors to treat her case more aggressively?

Otherwise, she is a happy, active, smart little girl. What could be wrong with her?

-KM

Dear KM: It is somewhat of a concern that your child hasn't gained anything in 3 months, but if she seemed to gain when she was well and then lost weight during an illness, that isn't a cause for alarm. Small skinny children can sometimes take weeks to regain what they lose during an illness.

Since you didn't tell me anything about your daughter's height, I can't assess her growth or the relationship of her height to her weight, but if your daughter is tiny and growing slowly, her low weight represents low growth. That is a far cry from wasting. The endocrinologist is a specialist in glandular diseases, and since many glands affect growth, he is the expert who usually evaluates poor growth to determine the cause. The treatment, of course, depends on the cause. I don't have enough information to speculate on the cause of your daughter's slow growth, but I have no reason to think it is something serious. It may even be her normal growth pattern.

You must distinguish between that which requires thorough evaluation and that which requires urgent attention. Slow growth with poor or no weight gain in a child who is neither malnourished nor dehydrated requires evaluation, but not urgent action. Be careful about letting your anxiety push you into seeking unnecessary procedures for evaluation or treatment.

If you are as alarmed as you sound, you need to sit down with your pediatrician and review your daughter's growth chart including the relationship of her height to her weight so that you can understand exactly what her situation is. Tell your pediatrician to explain the significance of his findings to you rather than just reassuring you that he doesn't think you should worry. That way you will deal with the real possibilities rather than letting your imagination run away with itself.

Sincerely,
Dr. Warren

Dr. Warren:I wish you had a clone in Xxxxxx, XX. Finding a good Pediatrician who is pleasant, honest and thorough has been difficult to say the least.

Anyway, regarding my child's height: she is 30 1/4 inches and 18 lbs., 9 oz. She was born at 6 lbs., 4 oz. She is 15 months old. I was quite ill during the pregnancy, as I was carrying a 15 pound fibroid tumor. I lost 25 pounds between the 4th and 8th months. I vomited almost constantly and had constant indigestion (when I did eat). Could the problems I experienced during pregancy be effecting her now? I was also prescribed at least 10 different medications to treat nausea and/or dizziness. Should I look into this to find out if the medications I took harmed my fetus and are causing my daughter's problem now?

-KM

Dear KM: I do not believe that any problems you had during your pregnancy are contributing to your daughter's slow weight gain.

At 30-1/4 inches, your daughter's height is almost on the 50th percentile for a 15 month old. Unless she had been previously on a much higher percentile, it suggests that her growth has not been affected by her poor weight gain. There are some glandular conditions to consider, but since most endocrine disorders affect growth adversely, the endocrinologist may not provide any answers for you. Still, he will provide another opinion for you, and after seeing your daughter, he may point you in the right direction.

If I were you, I would consult a nutritionist in order to devise a diet that your daughter is willing to eat that will adequately meet her nutritional needs. Be prepared with a record of the foods she is eating with as accurate estimates of amounts as possible so that the nutritionist can evaluate your daughter's current diet.

Here's the toughest part. Even though your daughter is skinny, you mustn't let your anxiety about her eating contribute to mealtime stress which could adversely affect her appetite.

Sincerely,
Dr. Warren

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