6 December 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
-DWB
Dear DWB: Five days is a long course for fever from a virus infection, but not outside the range of possibility. Most virus infections cause acute symptoms for 3 to 5 days. Influenza can cause fever for up to 1 week. Eight to nine days of fever have been reported with adenovirus. I have seen fever for up to two weeks with mononucleosis. If your son's main complaint and findings are a sore throat and your doctor has done a thorough exam including a culture to check for strep, and no strep was found, it is certainly possible that your son has a virus. If your son's fever persists or he has any worrisome symptoms, he should be checked frequently by his pediatrician, and if necessary, blood work, chest x-ray, and urine culture should be done to be sure nothing was missed.
Sincerely,
Dr. Warren
Thanks.
-KL
Dear KL: Premature fusion of one of the sutures (growth lines in the skull) is not common. Premature fusion of all the sutures would be even less common. The term for premature fusion of a suture is craniosynostosis. Usually craniosynostosis is suspected when the head is misshapen because when one or two sutures close prematurely, head growth continues at the open sutures resulting in asymmetry.
Sometimes the head circumference may not increase when the head grows because it grows upward like a tower. This can occur with some forms of craniosynostosis. Sometimes a measurement error may result in an apparent lack of growth. A look at the baby's head circumference growth chart would be the best way to make a judgment as to whether or not there were any measurement errors.
Even though it is uncommon, I cannot tell you what the likelihood is that your niece's head growth has been affected by craniosynostosis since I haven't seen her head. Lack of head growth could also indicate lack of brain growth which is also serious. The best first step in evaluation is a CAT scan to look at the sutures and the brain. If the baby has craniosynostosis, the baby will require surgery to repair it.
Sincerely,
Dr. Warren
-T
Dear T: There are many things one could look for in a pediatrician, but the importance of some of them will depend on what's important to you.
Some of the things you might want to know about your new pediatrician might come from observation rather than specific questions. How does his office look? How happy and helpful is his staff? How willingly does he answer questions and what is his attitude when he answers them?
You would like to know whether the doctor's usual office hours will accommodate your needs. If you work, early morning, evening, or weekend hours may be important. It's one thing to leave work for an emergency, but infants require frequent routine checkups. You shouldn't have to leave work for routine visits.
You want to know what happens after hours. Does the doctor carry a pager? Does he have an answering service? Is there always someone on call? Will the doctor give you advice after hours? Will he see you after hours if your child is very sick, or send you to an Emergency Room? Out of consideration for the pediatrician, patients should learn what the doctor's hours are and try to call about non-urgent matters during office hours, but patients sometimes need a physician's advice in order to know how emergent a situation is. Some things are best handled in an emergency room after hours. Some sick children should not wait until office hours and yet their condition doesn't warrant an emergency room visit. Patients who go to emergency rooms for non-urgent illnesses may end up waiting many hours while the more urgent cases are seen first. Good advice from the pediatrician may help you deal with your child's symptoms until regular office hours thereby avoiding an urgent visit.
How does the doctor handle routine questions and advice? Does he have a call in hour for parents to ask questions? Does he stop what he's doing and get on the phone? Remember, if you're the patient on the phone with a question it may be great if the doctor picks up the phone for every call, but if you're the patient in the office, being interrupted for phone calls might not be so great. When does the doctor return calls if he can't talk to you when you call?
Is the office so busy that the visits will be rushed? Or will the doctor take time to answer your questions? Consider that the doctor who gives patients all the time they need may fall behind schedule. The doctor who stays on schedule may not be able to spend all the time you feel you need. In fact the doctor you love for all the time he spent with you when you had your first child may be the same doctor who drives you nuts when you're waiting in his waiting room and your 3 kids each have to be in a different place at a different time.
If you plan to nurse you'll want a pediatrician who supports nursing. Not all do, so ask. If the pediatrician simply says, "I'm in favor of nursing," that's not enough. See what his responses to certain scenarios involving difficulty nursing would be. If the prospective pediatrician seems reluctant to commit to nursing wholeheartedly in the face of difficulty, he won't be able to provide the support necessary to help the mothers who are having a tough time to have a successful experience. The last thing those mothers need is a pediatrician who says "Why don't you try a bottle" when the going gets tough. If the pediatrician seems committed to supporting your efforts at nursing the next thing you need to know is how knowledgeable he is about breast feeding. Even if the doctor is committed to supporting breast feeding, if he gives bad advice it can sabotage your efforts. I'm not sure what they teach about nursing in medical school these days, but when I attended medical school, they didn't teach anything. Even if the pediatrician is a woman (a significant number are) who nursed her own children, her personal experience is no guarantee of up to date knowledge on the subject. As for the men like myself, our only chance of knowing anything about nursing is to attend conferences taught by lactation specialists. When I attended such a conference recently I was amazed at how much I didn't know about nursing, and I consider myself very supportive of nursing mothers.
Does the doctor handle most illnesses by prescribing medicine? If your child has a fever will he prescribe antibiotics? I don't personally agree with that approach, but as much time as I spend trying to make patients understand what their illness is, what its natural course is, and what treatment (if any) is appropriate, some patients still get mad at me because they think I'm withholding vital treatment and want that prescription. On the other hand, some patients, when offered a prescription would prefer to know what other options they have and if they can avoid taking medicine. Does the doctor spend the time to explain everything? Not everyone wants that. Some patients want the doctor to take charge. They may find too many facts and choices confusing and ultimately want someone they can put their faith in to make the decisions.
What emergencies is the doctor equipped to handle in his office? This may not determine for you if the doctor you're interviewing is Dr. Right, but it's a good idea to know what your doctor can handle in his office before you show up at the door.
And certainly, what is the doctor's training? What are his credentials? Is he board certified? What does he do to keep his medical knowledge up to date?
Other factors to consider include the age and personality of the physician. These factors make a difference to some people. If you have a brand new infant the best pediatrician in town may not be the right choice for you if he's retiring in a few months or if you feel uncomfortable with him.
What is the size of the group? Large groups may be able to provide a broader range of office hours, but you may have to give up the personalized care that comes with a smaller group if you see a different doctor every visit.
Finally, what insurance plans does the doctor participate in? Unfortunately, these days more patient/doctor relationships start with an insurance provider directory than any other way. With companies changing their insurance plans every few years in order to get the best deal many patients have to change physicians just as frequently. If a physician participates in many major plans there's a better chance of maintaining a long term relationship with one physician. On the other hand, there's no question that the insurance plans can significantly alter the nature of a practice. A patient of mine who was so pleased when we joined her insurance plan once commented, "I liked this place much better before you started taking all these insurance plans!"
Sincerely,
Dr. Warren
-NN
Dear NN: Normal values for blood counts vary with age. The normal white blood count for a 1 month old is 4000 to 19,500. For a 6 - 12 year old it's 4500 to 13,500. The white count may go up or down in response to virus infections. Platelet counts usually range from 150,000 to 350,000. They often go up in response to infection. Platelet counts may sometimes drop in response to some viruses, especially mononucleosis. No matter what the cause, very low platelet counts can cause bleeding and requires close medical management. Sedimentation rates are usually below 20 and go up in response to inflammation or infection. Segmented cells or Polys are a kind of white cell. These are usually involved in fighting bacterial infection. Virus infections may cause low poly counts. Extremely low poly counts increase the risk of bacterial infection.
Sincerely,
Dr. Warren
My husband's brother had Kleinfelters syndrome and died of Non-Hodgkins Lymphoma at 28. He required a bone-marrow transplant and so we are a bit paranoid.
-Red
Dear Red: You pose an interesting question for which medical training provides no answer. If you had a crystal ball, you'd know what the eventuality of needing stem cells would be. The vast majority of people will never face such a situation. Since it is not possible to anticipate or prepare for all future possibilities, it would never occur to me to store stem cells for a child of mine, but it wasn't an option 17 years ago when my youngest was born. $1000 is a big investment, but if it is a one time investment, over a lifetime, it's an inexpensive insurance policy. If you can afford it, it will provide you peace of mind since you are anxious about the possible need for stem cells in the future. If you can't afford it, you have to consider all your other future needs before you commit the funds to an unlikely future need. If you lean toward doing it, you need to know what guarantees you get for your money that your stem cells will be available if you need them in 10 or 20 or 50 years. That answer is dependent not only on technology, but also record keeping and the stability of the enterprise to which you entrust your stem cells.
Sincerely,
Dr. Warren
-GK
Dear GK: Adenoids are lymphoid tissue just like tonsils. They may swell in response to upper respiratory viruses and given time they may shrink. A decision to do surgery to remove the adenoids should be based not only on size, but also, symptoms. Enlarged adenoids may contribute to ear infections, and by causing chronic mouth breathing, may affect facial and palatal growth and development. If your daughter breathes through her nose with no difficulty when she is asleep (which is probably 50% of her day) and has not had a problem with ear infections or sinus infections, it wouldn't be unreasonable to allow the adenoids time to shrink and the face to grow. Usually children with enlarged adenoids and tonsils have a greater problem with upper airway obstruction during sleep.
If there is a good reason to do surgery on your daughter's adenoids, she isn't too young, although often at this age the adenoids are crushed rather than removing them. I have not heard of using nasal steroids on an infant. I don't believe that use has been tested or approved by the FDA.
An x-ray of the adenoids is reasonably reliable to determine adenoid size. It wouldn't be unreasonable for an ENT to look at the adenoids with mirrors or a nasopharyngoscope before committing to surgery. CAT scans or other imaging studies would be unreasonable. A second opinion need not mean additional procedures. A specialist should be able to give you an opinion of the x-rays and your daughter's clinical status and with that information in mind tell you what additional information he would hope to get from additional studies. Remember, you don't have to agree to tests just to get an opinion. But your specialist may need to explain the limitations of his opinion if he feels more evaluation is needed.
Sincerely,
Dr. Warren
Is what we're doing in trying to shift her sleep ok? or is it causing her to lose sleep? I hear of other 1-yr-olds that they're put to bed at 9PM and they sleep till 9AM straight. Our daughter never did that. And we're afraid to try to put her to sleep that early fearing that she would be up and needing attention at 4AM.
Any advice on this question is much appreciated.
-GK
Dear GK: Your daughter appears to be responding to her own internal clock. I don't think you will change it by putting her to sleep later. Sure some children sleep late, but most infants are up with the sun. I'd suggest adjusting to her schedule and getting her into bed at a more reasonable hour.
Sincerely,
Dr. Warren
My 16 month old had a cold that lasted a month. I gave her every cold medicine I could find. The doctor even prescribed amoxil. But nothing seemed to help. During this time she periodically ran a fever (between 100 and 102). She was sometimes hoarse and in the beginning had a bark-like cough. That barking eventually turned into a rattling cough. With the exception of sleeping a lot during this time, she remained happy and playful. Now most of the symptoms are gone, but whenever she sneezes she produces thick yellow mucous. I heard this is a symptom of a cold that has lasted too long and is now a sinus infection. What do you think? The interesting thing about this is that she hardly ever sneezes at home and her nose rarely runs at home. Is it possible that this is not an infection but at allergy to something or someone at daycare? Or maybe her daycare room is too cold? How serious might this be? What treatment would you recommend if you were her doctor?
I also have another question. I would like to change Pediatricians. What questions should I ask in order to get a pediatrician who is as honest, knowledgable, and caring as you seem to be? Thanks for all of your help.
-KM
Dear KM: Daycare has many advantages, but one distinct disadvantage is the large amount of exposure to infectious diseases, primarily gastroenteritis and upper respiratory infections. It is possible that your daughter has had more than one cold in the past month. Colds are caused by viruses. Neither antibiotics nor cold medicines will cure them. Colds must run their course. The purpose of cold medicines is to provide symptomatic relief. The decision to use a cold medicine and risk the side effects of drowsiness or crankiness should be based on the degree to which the cold symptoms are bothering the child and NOT just the fact that the cold symptoms are visible or obvious. Check my article Upper Respiratory Infections (URIs).
Thickened and discolored mucus may be seen in the nose if it has had an opportunity to dry in the nose and does not necessarily imply that there is a sinus infection. Pus from a sinus infection often is moist and drains continuously. The longer a cold persists (if it is indeed one cold and not many) the greater the likelihood that the persistent symptoms are caused by a sinus infection. If your daughter's sinuses are infected, she should be treated with a decongestant and an antibiotic.
Allergies generally result in clear mucus, so your description does not sound like allergy to me. Neither is it likely to be from the room being cold. These symptoms are not serious, but if they persist or your daughter becomes acutely ill with fever or other worrisome symptoms, she should be reevaluated.
Check my article Choosing a Pediatrician to see what questions to ask. In the end, finding a pediatrician who suits you may require getting to know the doctor first to see if he or she meets your needs. Be sure to get recommendations from people who have children your age.
Sincerely,
Dr. Warren
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