22 November 1999

1. Infrequent BMs
2. A Career in Pediatrics
3. Head Injury
4. Risks of Saunas
5. Attachment to Patients
6. Skin Suddenly Dry
7. Spitting Up
8. Elevated CPK
9. Disclaimer

• Read Questions & Answers in Another Column

Infrequent BMs

Thanks.

-Steve

Dear Steve: It isn't necessary for a baby to have a BM every day. Many nursing babies have BMs as infrequently as every 4 to 6 days. As long as the stool remains soft and the baby does not struggle to have BMs or have abdominal pain, there is nothing to worry about. If the stools are hard, then it may be necessary to use a stool softener. Prune juice is a good place to start to soften the stool. To be used effectively, it must be taken regularly and not only on the days the stool is hard. Enemas should be avoided unless there is an extreme problem. If you are not sure whether or not intervention is needed you should discuss it with the baby's pediatrician.

Sincerely,
Dr. Warren

1.What could I be doing in high school to prepare me for this career??

2.What kind of "Career Ladder" exists in this career??

3.How easy is it to transfer locations is this career??

Thank You very much for your help!!

-EL

Dear EL: To prepare for a career as a physician you need to study hard. Even if you are brilliant, learning to work hard is very valuable. Pay particular attention to science courses and learning good communication skills.

In private practice there is no career ladder. You open an office, participate in insurance plans, and make yourself available to meet your patients' needs. In hospitals, especially teaching hospitals, one can advance through the ranks to department chairman, but it really isn't the same as a corporate ladder. Those who make it to the top in academic circles must combine clinical skills with extensive knowledge and research.

There are always jobs for physicians in every city across the USA and even in every country; however, one must meet licensing requirements wherever he chooses to practice. There are many areas that have physician shortages and other areas where there are many physicians.

Sincerely,
Dr. Warren

-TE

Dear TE: Immediate serious signs in head injury include loss of consciousness and seizures. If neither of these occur, loss of memory for the event is an important sign in older children. Nausea, vomiting, and lethargy are signs of head injury which demand further evaluation. Dizziness and headache are important complaints in older children. Poor balance may be a sign of dizziness in a younger child and irritability may be seen with headache.

Sincerely,
Dr. Warren

-Just a Concerned Mom

Dear Concerned Mom: The risks of saunas are related to the high temperatures. The added heat stresses the heart by dilating blood vessels and raising body temperature, forcing the heart to pump harder. Dehydration, lightheadedness, nausea and extreme weakness can be the result. These risks are the same for adults, especially after vigorous exercise. Children may be more sensitive to these risks because of their larger surface area to body mass ratio and their higher metabolic rates and fluid needs. A 3-1/2 year old may not recognize when it is time to get out, but hopefully a supervising adult would. My advice would be that a young child should only visit a sauna briefly and with adult supervision attuned to signs that the child isn't tolerating it. This is especially important since parents often respond to whining children imploring them to be patient.

Sincerely,
Dr. Warren

If you ever get attached to your patients, what are the dangers?

-MS

Dear MS: The danger in getting attached to patients and treating people you know is loss of objectivity. It not only interferes with a physician's ability to make appropriate diagnostic and therapeutic decisions, but also, the physician's visible emotional response may make it difficult to provide the patient reassurance. On the other hand, caring involves a great deal more than objectivity. The therapeutic relationship between physician and patient involves not only faith in the physician's diagnostic skills, but also, a belief that the physician cares about his patient and will do the best thing for his patient. It is not possible to care for a patient without caring about the patient, and over time, that has to create some degree of attachment.

Sincerely,
Dr. Warren

I've noticed for the past several days my skin has been VERY dry, all over my body. Everything from my legs, to arms, to face, is very dry. The slightest scratch will show on my skin.

My diet has not changed, nor has my fluid intake. The only other symtom I can speak of is being very tired...but I suspect that is related to simply staying up too late.

Any suggestions as to what my be going on with my skin?

Thanks for any info you provide,

-Scott

Dear Scott: When a person has a sudden and significant change in his body that can't be explained by lifestyle changes or natural processes, it a sign to see the doctor for a complete physical. With fatigue and dry skin as the primary complaint, one has to consider the possibility of nutritional deficiencies or hypothyroidism. Call your doctor and schedule an appointment.

Sincerely,
Dr. Warren

-M

Dear M: If your son does not tolerate his current formula and tolerated the previous formula, you should see if you can switch him back to his previous formula. If you are using a formula supplied by the WIC program, your doctor may write a letter certifying the need for him to be on a specific formula.

If you are using a concentrate or a powder, make sure you are diluting it properly according to the directions. Ready to feed formulas do not require dilution. Diluting the formula more than the usual amount is not beneficial in the management of spitting. In fact, if the baby consumes a larger volume as a result, the spitting may increase. Dark Karo syrup is not helpful for spitting and should not be used for infants since it may carry a risk of infant botulism just like honey.

Spit up smells acid because it contains stomach acid. The longer the formula sits in the stomach before the baby spits, the thicker it will become because the protein curdles as it is digested.

If your baby has an unusual degree of spitting, you should have his weight checked by his pediatrician and discuss with the pediatrician whether or not there is a need for further evaluation or a formula change.

Sincerely,
Dr. Warren

Thanks for your advice.

-BD

Dear BD: CPK is a muscle enzyme found in heart muscle and other muscles. Significant elevations of CPK can be seen after heart attacks, muscle injuries, and muscle diseases. Fractionation of CPK can distinguish between cardiac CPK and CPK from other muscles. Degenerative muscle diseases like muscular dystrophy and inflammatory diseases like dermatomyositis can cause high elevations of CPK. Muscle injuries can cause transient elevations of CPK.

Even though spasticity puts the muscles under constant stress, I do not know that it would cause muscular injury raising the CPK; however, you raise an interesting point which could only be resolved by doing a study. Is the baseline CPK of patients with muscle spasticity higher than the established normal range? I do not know if such a study has been performed.

The CPK should not rise from a seizure unless it is vigorous enough to cause muscular injury. Such an elevation would be transient, and such a seizure would be evident to you.

The Neurologist may have no interest in doing a muscle biopsy unless he sees evidence of muscle disease on examination. Even though it may seem obvious that most of your daughter's problems stem from her premature birth, the question always remains as to whether or not there was an underlying problem which caused the premature delivery. If your daughter's current balance problems cannot all be explained by her neurological status, then it may be appropriate to look further into the elevated CPK for any clues that might affect her management.

Sincerely,
Dr. Warren

If your questions haven't been answered here, perhaps you would like to

ask Dr. Warren a question?!?