Pediatric Questions and Answers

Facial rash

2011-11-01T13:37:00.003+10:30

My granddaughter has many white lumps on her face and now on her eyelids

Is she just a few weeks to a few months old, these are so common as to be considered normal. If she is older do they itch which would make one consider allergy. If not I would not be concerned except I would check for tinea between her toes and treat it if present.
Dr D. Robinson

child sleeping excessively

2011-10-06T17:44:00.002+10:30

Dear Tiffany,
Children sleep more with any infection - infectious mononucleosis included. Does he have any other features to suggest he is ill?
Is he getting enough sleep at night or is it possible that he stays awake using his computer or mobile phone. This is a very common event these days.
A scary possibility is of some drug he has taken is the cause.
Can you wake him? If not take him to an Emergency Department.
I think a medical check tomorrow would be needed in any case.
David Robinson

On 10/6/2011 9:44 AM, Tiffany wrote:
> Tiffany has left a
> new comment on your post "Infectious Mononucleosis
> ":
>
>
> I have a question my son who just turned 7 years old has been falling
> asleep at school i picked him up today from school and he was sleeping
> in the Principles offer for an hour an a half took him home which was
> 330 and its now 730 and hes still sleeping could he have Mono. hmm im
> not to sure how to come back on here so can u please email me
>
> thanks so much!!!
>
>

Labial Fusion in a 6 Year-old

2011-06-02T20:39:00.002+09:30

My 6-year-old daughter has fusion of the labia discovered when she had a urinary infection. Her doctor has separated them with a probe which hurts and they fuse together again despite applying Vaseline as the doctor suggested.
She is now terrified of anyone looking except me (her mother) and says there is no problem. What should I do?

You could apply an oestrogen cream to the labia twice a day as this will encourage the fused area to break down without any trauma. This will happen anyway with the surge of oestrogen at puberty and if it is not causing any problems you might wait until then. If she suffers repeated urine infections then it should be dealt with now.

Toddler Chronic diarrhoea

2011-05-30T21:04:00.004+09:30

My 21 month old was experiencing a severe 'smokers' cough for about 9 months and then developed chronic diarrhoea which was frequently very milky. Suspecting lactose intolerance I changed from cows milk to soya milk (not a good idea in infants by the way), his poo changed colour but otherwise was the same. I went straight to Jan de Vries (Auchenkyle, Troon, UK) he prescribed echinacea and a herbal bowel preparation and within 2 weeks his cough was gone and he was back to his normal poo pattern. He also recommended that I switch to Nanny's goat milk formula as cows milk is extremely high in protein and can be very difficult for some infants to digest. Don't know if this is in any way the same as very few tests were done but it might be worth getting the opinion of a qualified naturopath. DO NOT give herbal remedies without consulting a practitioner!!!!

Thank you for this account of your child's problems and their resolution. I am glad he is well again. Goat's milk is very low in folic acid but these days most commercially available goat's milk feeds have it added.I am not sure what role the echinacea played but in adults with certain conditions it should not be used - no problem for children though. Infants who are allergic to cow's milk protein are also often allergic to Soy.
I am very pleased that the diarrhoea has stopped.

Email Working Again!

2011-05-30T20:58:00.003+09:30

David Robinson apologises that email questions addressed to Paediatric Questions and Answers have not been reaching him. Questions on any paediatric topic from babyhood to adolescence are welcome,and so are re-sent email questions.

diarrhoea in a 2 and a half year-old

2009-04-20T15:28:00.003+09:30

A bit of a background on my son. I had polyhydrominos (excess fluid level of 29) diagnosed at 30 weeks pregnant. My son now two and one month developed breathing problems at 2 months. (sounded like a 60 yr old smoker with emphysema) This breathing difficulty including stopping breathing intermittently went on undiagnosed for 7 months despite doctors visits and hospital visits two to three times per week. Finally he was diagnosed with a trachea which is half the size it should be therefore restricting breathing when he gets cold etc. He also was diagnosed with pnemo virus?? Which is the reason he was actually admitted to hospital ( this virus only lasts two weeks though) During his hospital stay they discover he also had Hydrocephalus which has since been changed to "benign enlargement of the subarachnoid spaces" and he is seeing a neurosurgoen regarding this who is doing MRI's at 3 month intervals to watch the fluid levels.

My question is he has diarrhea nappies approx 6 times per day every day. I have told numerous doctors this and all but the last one a paediatrition ignored this and said it must be his 'normal' The last one said he is maybe lactose or fructose intolerant and to put him on latcose free milk to see if that helps. We have done this now for 3 weeks and there has been no change if anything his poos are worse. They are a milky white slop and frequent overflow his nappy. He is off his food two out of three meals and even then we have to 'prime' him like a lawnmower and force the first bit into his mouth to get him to even start to eat. As a baby he was a hungry little bub and ate 2 hourly. I am at a loss to understand what to do for him. I end up cooking and offering a few different meals at each sitting hoping he will eat one with gusto. He if he had his chance would drink milk all day. I have decided to limit his milk to half a bottle to try to force him into eating solid food. I am open to all ideas and suggestions.

You and your son have had quite a time of it and I feel sorry for you.
As regards the diarrhoea and poor appetite, I think he should have a microurine and colony count done to look for a urinary tract infection. If that is excluded then I would try withdrawing fructose. This is done by stopping all fruit, including fruit juice for 3 weeks.
You might ask what is he going to drink and I would allow him a little milk and plenty of water. Hopefully this will improve is appetite for other solids.
How is he growing by the way? Please let me know what happens. If he has no urine infection and does not respond to the fruit withdrawal, there are other things that can be tested.
When did the diarrhoea start and did it have any relationship to dietary changes such as introducing cow's milk formula or adding solids to his diet?
David

Toddler frequently falling when walking and running

2009-04-11T17:44:00.002+09:30

I have a 3 1/2 year old grandson who falls a lot when walking and running and he also has trouble stepping up on small steps without falling. His younger brother who is 2 can run circles around him and has no problem stepping up on steps by himself at all. He has seen a chiropractor 3 or 4 times and it helps some, but it doesn't last. The chiropractor said his hip was out of place. I am concerned about this and wondered of we should take him to an orthopedic specialist and have this checked out. When he walks, it seems that his right hip is stiff and turns in a little as he steps. He also walks flat footed. I would appreciate your advice. I tried sending this through your web page, but my internet connection wouln't let it go. Thanks for your help.

I think he definitely ought to see an orthopedic surgeon who will probably want an ultrasound and/or X-ray of the hips. If nothing structural is found then a physiotherapist should be involved (the orthopod can arrange a referral) to check out the muscles in his legs.(what age was he when he started to walk independently?).
Please get back to me to tell me what is found and I can give you more information about the condition and I would be very interested to hear about the findings.

Tummy pain in an 8 -month-old

2009-02-18T10:21:00.002+10:30

I am the mother of an eight mont old premature baby boy. He is so pleasant anf friendly. I’m just a bit worried that he’s not crawling and refuses to go on the floor but beside the crawling I have a question to ask.

On Sunday day morning he woke up with a fever of 38.64 degrees. He was crying and nothing helped sooth him. He refused to have his bottle and fell asleep on my breast. He cried every time he pasted a wind down there. It was loud, continuous and very smelly. He woke up again at 3am and then at 4.50am crying and also refused to drink from my breast.

I took him to a homeopath which couldn’t rely tell me what the problem was. He gave me something for the fever which helped bring the fever down to 38 degrees. The next evening he continued crying through the night and refused to drink the bottle and breast.

Last night he woke up every half an hour, nagging and pulling his legs up to his stomach.

Today we went to another GP for a second opinion. He advised that us that our baby has a viral infection. I couldn’t wait to leave the consulting rooms as my boy didn’t stop crying. It was as if someone was murdering him. Once we got the script for the pharmacy we were on our way.

I completely forgot to ask him, what actually causes the viral infection.

Please would you be able to give me advise.

To answer your last question first, we all pick up many viral infections in our life, the commonest one is a cold (coryza). We nearly always catch these from some other human. It is often not realised that if someone sneezes or coughs onto a surface which your baby touches or you carry on your hands to the baby's face, then the baby becomes infected with a virus. I suspect your doctor saw a sore throat when s/he examined your baby.
It is possible that this virus will cause gastroenteritis and he will develop vomiting and diarrhoea. Your baby obviously has tummy pain from your description and I wonder whether he has chronic constipation. Both these conditions could explain the pain and foul wind.
Please write again and tell me what the bowel actions are like. Also has he ever had blood on his bowel action.
There is one serious condition that requires surgery called intussusception and I would go back to your doctor and enquire about this possibility if the pain has not settled by the time you get this e-mail. This is a rare condition but very important.
Finally I would not be concerned about a premature not crawling by 8 months.
David

Baby speech not developing

2009-02-12T12:50:00.001+10:30

Hello,
> We have a couple of concerns about our daughter who is 15 weeks old.
> She seems to be
> developing normally in most areas but there are a couple of things
> that we are seeing recently that
> don't seem quite right. Just as background... I had a normal
> pregnancy and delivery. She makes
> eye contact and smiles at us. She can reach for a toy but is not
> interested in rolling over at this
> point.
>
> The first issue is that she seems to be vocalizing less than she was
> a month ago. She used to
> repeat vowel sounds that we made and would say "ah-goo" when we said
> it, as well. She still
> makes noises, but they aren't the consonant sounds that we expect
> and the "ah-goos" are
> completely gone.
>
> Secondly, she has begun sucking on her fingers like there is no
> tomorrow! In fact, she sucks on
> them so much that she will lie in her very dark room looking at
> nothing (we don't have a mobile or
> any toys in her crib) for a long time (perhaps an hour?) so long as
> she is sucking on her fingers.
> For instance, last night I woke up at 2:30am because that's usually
> a time that she wakes at night
> to nurse. I just went in to turn down the heat in her room and
> realized that she was awake and
> lying there sucking on her fingers. I'm not really concerned about
> her weight gain right now; she
> eats plenty during the day. Our concern stems from the fact that we
> thought that babies her age
> were supposed to be soaking in the world around them while our
> little girl seems content to lie in
> darkness with her fingers in her mouth.
>
> We don't know if these issues warrant a trip to the pediatrician.
> She is our first child an we don't
> want to be overreacting, but at the same time we want to be the best
> advocates for her that we
> can be.
>
> Any advice that you can offer would be greatly appreciated!
>
I share your concern about your daughter's regression in speech and the possible disinterest in the world around her,
I think you should see your pediatrician and that s/he should arrange a formal hearing test.
From the way that you asked your question, it appears you are concerned about developmental retardation and/or autism. While these are possible, hearing loss is much more likely but you should raise these concerns with your pediatrician as well.
I hope I am wrong about all these things but, if they are present it is important to find out as early as possible so treatment can be put in place as soon as possible.
Please let me know what happens and don't hesitate to ask more questions.
Yours sincerely

Toddler diarrhoea

2009-01-14T16:20:00.003+10:30

Nice to hear from you again, I am a bit of a heretic about 'flu immunization. The best study about the long term benefit of 'flu immunization in children was done in Britain many years ago in a boy's boarding school. Half of the boys were immunized each year and the other half received no immunization for 'flu. In the first year the non-immunized boys caught the 'flu much more frequently than those who had the immunization. However, after 3 the number of episodes of 'flu were equal over the 3 year period despite 1 group having annual shots. I think we can conclude that catching the'flu gives a better immunity than the immunization.
That said I think if I had neutropaenia, I would have them immunized - not logical but I would feel terrible if they developed an ovewhelming secondary (to 'flu) bacterial infection which they could not fight very well.
If your 18 month old seems well and is gaining weight, I doubt that he has lactose intolerance - they are usually miserable with lactose intolerance. Your local doc can do a simple test on a fresh stool sample to exclude lactose intolerance. As regards the fruit, there is another sugar intolerance called fructose intolerance. Fructose abounds in fruit. It has the same stool pattern as lactose intolerance and as you describe it.
To exclude this condition there is a fancy test but you can know by excluding all fruit (don't forget the juice!) for 3 weeks and then put him back on fruit and keep a diary of his bowel actions throughout. If he is fructose intolerant he will improve markedly in the fruit-free period only to revert when fruit is reintroduced.
If he has neither lactose or fructose intolerance another 3 weeks off all milk products and no Soy! may be needed but we can discuss that when the time comes.
All the best.
David

>
> Dear David,
>
> Mum passed on your details to me because I was asking
> her a couple of questions. One is about the flu immunizations. Here
> in the USAit seems to be standard for all children and many adults
> to
> have a flu shot every year.Our children have had the other
> immunizations but I suppose since I never felt as though I needed a
> flu shot I wonder about them.They had it last year because we were
> moving to Colorado Springsand I just thought it might be helpful.
> Our children are now 3 and 18 months. Our 3 year old has chronic
> benign neutrapenia (I spoke to you about her previously)
) but apart from one cold and one 24 hour vomiting
> bug has been well throughout the year.
>
> I was also wondering if our 18 month old is lactose
> intolerant….although I’m not so sure now. He is healthy, putting
> on
> weight, and eats almost anything. The only thing is that he
> frequently wakes up with an overflowing pooey nappy in the morning
> and sometimes this happens during the day too. He would regularly
> have 3-4 pooey nappies per day. I have experimented with soy milk
> and sometimes it seems to make a difference and sometimes it
> doesn’t. We do eat quite a lot of fruit and vegetables and whole
> grain foods. I’ve cut back on him eating pears and mandarins but
> still think it’s important for him to have some fruit. What do you
> think?
>
> Thanks for your help

Red spotty rash in well 8 month-old

2009-01-02T22:19:00.002+10:30

My 8 month old son having red spot rashes in face and arms and few
> in
> legs alone.
> No fever and the baby is active all the day.
> What could be this rashes as this is bothering m a lot?

As he is well, I would not be too concerned. There are a multitude of
possible causes but by far the most common are insect bites. As I don't know from where you are writing, it is hard to guess which is the most likely.
I would spray the mattress with a non-toxic (ie safe for humans) insect spray. If mosquitoes are likely then spraying the corners of the room where they meet the ceiling may help.
If the problem continues you should see your local doctor.
Please tell me what happens.

reddish, non-tender lesion on foot

2008-12-19T12:19:00.001+10:30

I am not sure what this redness is due to but as it does not hurt and there is no pain, I am not too concerned. If it starts to hurt or she seems unwell generally, you best have your local doctor look at it.
By far the majority of foot problems at this age are due to ill- fitting footwear. I wonder if her foot is sliding back and forth within the shoe giving the reddish appearance but that is only a guess.
David

>
> I have twin daughters and recently in the last week I've noticed one
> of the girls (23 months old) has been presenting with a reddish,
> irregular shaped, bruiselike, non-raised lesion on the bottom of the
> inside of her heel/back of arch....is it possible she is stepping on
> toys wrong lately?I've also notice she likes to stomp her feet on
> the floor, but never seems like it is painful. I can rub the area
> without any discomfort to her, but I've noticed she's been studying
> this area of her feet as well. The other twin has nothing on the
> bottom of her feet. Their feet measure the same size and are both
> wearing the same design of sketcher size 6 1/2 shoes when we go out
> for 2-3 hours a day. Otherwise the girls run around with just socks
> or no socks inside the house.
>
> I am alittle unnerved by the red bruise, but was wondering if this
> is
> normal?
>
> concerned mom,
>

28-month-old falling a lot and walking into objects

2008-12-15T12:23:00.001+10:30

Dear sir.
I read your answer to a grandmother who had a grand son or grand daughter at the age of 34 months that was falling a lot. I have been trying to find something about this issue online and that's how I ended up on your web page.
I am a guardian of a toddler who is 29 months and he has the same problem. He falls and stumbles over the smallest things and a lot of times he will walk into things like a table or the doorway etc. We have baby gates in the house to protect him from falling in any stairs and the house is really kid safe. He walks normal, seems to have a normal hearing and he is talking well for his age.

He has a sister that is 4 years old and she is very athletic and she never had any problems falling or walking into things like he does. The two kids spend one week with their mom and one week with their dad and are also in preschool five days a week when they are with dad. The toddlers preschool teacher asked me if we had noticed that he is always bonking into things and falls a lot. He also comes home from his mom with bruises so we know this happens here, at his mom's and in preschool.

He is also showing early "warning signs" of learning disability. He is left handed, his fine motor skills are not quite there , and he can't put a 4 piece puzzle together even if the picture of the shape is on the puzzle board. We know that he cant be diagnosed until he hits second grade, but we have been made aware of early warning signs. His dad has learning disability so we don't think it is unlikely that one or both of his kids could end up with some sort of a learning disability as well. The toddlers dad and I are doing things to try to prevent this from ever happening and we are doing it in form of fun play. The toddler loves to try to thread beads on a string, he has a box with different shaped blocks that has to go in one certain hole, we have easy wooden puzzles and building blocks to boost his imagination. And he plays the games only as long as he has fun doing it. I don't know if this can be a part of him always falling or walking into things as far as his motor skills goes.

we would be very happy if you have any ideas of what we could or should do if anything to help the "little guy" from hurting himself so much.

If you could please send me a mail back we would be very thankful.

                  On reading of your grandson's problems, the first thing I thought of was "Has his vision been checked?" This was because he is walking into things but as you noted he may have a muscle problem predominantly affecting his legs.
An optometrist or an ophthalmologist can check his vision while his muscles can be assessed by a physiotherapist who can also show you exercises to help any problem detected. If necessary your local doctor can refer your grandson to the above specialists - ones with expertise in assessing children would be best.
Please let me know how things turn out.
David

baby with Sore on chin and chest problems

2008-12-08T11:19:00.002+10:30

I would have been very alarmed if I had seen the baby when he/she had the chest problem. I would have feared that the probable Staph. infection on the chin had spread to the lungs and Staph. pneumonia is a life-threatening condition. However, the fact that the baby has recovered is against such a diagnosis.
Probably the sore on the chin is unrelated to the chest problem. Probably the chest symptoms were due to a viral infection known as bronchiolitis. This sounds as though it was a mild episode and that the body defences have overcome the virus - most commonly one known as respiratory syncitial virus which nearly all of us catch for the first time between 0 and 2 years-of-age.
No action need be taken about the chest now that he/she is recovering and I presume the local doctor has given something for the sores on the chin.

infant mouth ulcers

2008-11-18T20:38:00.003+10:30

I am so sorry your daughter has this painful mouth ulceration. If your doctor thinks it is cold sores. Then she has caught it from someone else - possibly an adult or older child with a cold sore on their lips. All of us caches this infection in the first few years of our lives. The first attack usually shows as mouth ulceration - mainly inside the mouth but often on the outside too where it looks like a cold sore on an older person. Once we have had this infection 60% of us have no further problem but the other 40% are unfortunate and have cold sores on the lips whenever stressed either physically or emotionally. The commonest stress that does this is the common cold hence the name cold sores.
It is very important to keep pushing the fluids although they are painful. A small proportion of children who have this initial infection become dehydrated and need hospitalisation.
The fact that the ulcers are near her uvula suggests that they may be due to a less common viral mouth infection, called Coxsackie. The result is much the same with reduced food and fluid intake because of a sore mouth. After this form of mouth ulceration heals we don't suffer the repeated sores as do 40% of the cold sore sufferers.
You are in for a few miserable days whichever virus is responsible. Keep up the fluids.

>
> Hello,
> I just brought my 8 month old daughter to her pedia for her 2nd half
> of her flu shot while the doctor wasdoing some exams we found out
> that the inside of her mouth has cold sores,right next to her
> uvula.I was so afraid and did not realize that causes her so much
> pain when she's eating or drinking her milk from her bottle. I was
> so
> anxious that's why i wanted to ask you if this kind of viral
> infection cangive herproblem in the future or will it happen
> again?What causes this break out?
> And why would appear it by her uvula which is very unusual?Her
> doctor
> gave her a prescription to ease down the pain which is good for 7
> days.I just cant help seeing her like this.
> Please i need your response,my email is mrlflorencio@gmail.com
> again,Thank you very much for reading my letter.

cows milk intolerance

2008-11-13T21:53:00.000+10:30

Dear Peter.
It sounds as though your granddaughter is having a very rough time.
The fact that she responded to the Dairy-free diet but did not have lactose-intolerance, suggests that she has cow's milk protein intolerance.
Despite your strictness with the diet, the recurrence might be due to inadvertent exposure to cow's milk. It is amazing the solids that have milk protein in them. You need to check whether any product states that it has cow's milk solids or casein in it and avoid these. The only margarine that is safe is Nuttelex.
If all this has been done, and the problem, continues, she may have developed an allergy to some other food. Just about anything can provoke an allergy, but the most likely at her ages would be eggs.
Please let me know what happens and we can pursue some other approaches.
David

>
> I hope you can help us,our 1 year old granddaughter had diahorrea
> and
> vomiting which resulted in a stay in hospital the stool was like
> clear mucus with what appeared to be seeds in it.She had a barrage
> of
> tests these showed nothing conclusive.A dietician was consulted and
> she was put on a dairy free diet.The Vomiting and diahorrea had
> stopped and her appetite seemed to have recovered however she has
> gained no weight.
> The original problem started at the begining of september but 4
> days ago the diahorrea started again and seems to be getting worse
> our daughter has been very careful to ensure she has had no dairy
> products in either her or the baby's diet and as you can imagine is
> at her wits end.Can you give us any advice?
> Yours sincerely Peter Morgan.
> P.S.The tests eliminated Lactose intolerance and Celiac disease.

constipated 2-year-old

2008-11-08T12:34:00.001+10:30

> Hello,
> I have a 2 year old daughter who suffers very badly from
> constipation
> and has done since she was eight months old.I am at my wits end we
> have been to gp and tried several medication with no luck. She is
> currently on lactulose and senna. It seems to work then just doesn't
> work for while. I was advised to increase dose from 2 5ml of
> lactulose twice day to up to ten a day. This just seems such a lot
> to
> give her but did it sometimes works and other times doesnt. She has
> also had suppository aswell which didn't work well. When she tries to
> go she is in so much pain screaming which can last hours and has
> even
> hurt her back trying to do it. She can go several days trying with
> no
> luck. I dont know what to do have tried obvious diet changes etc
> with
> no luck. What would you suggest? Could she have any other medical
> problems that cause this? Could being on these medications cause
> problems later in life?
>
> please get back to me my email is danagray19@hotmail.com i would
> really appreciate it.
>
> Many thanks
>
>

I am sorry your daughter is having so much pain on using her bowels. From your description, she has a fissure-in-ano.
This is a small crack in the anus where the bowel meets the skin. When she uses her bowels the crack is torn open and causes pain. This tends to stop her using her bowels making her more constipated.
She needs a local anaesthetic ointment applied to her anus as a thin smear at night after her bath and again in the morning on waking. You can buy the ointment over the counter at the pharmacy. You can also apply the ointment during the time she is using her bowels if it is hurting.
Lactulose and senna are fine. I recommend giving the senna at night. If she fails to use her bowels in the next 24 hours then double the dose. If this does not produce a result in the next 24 hours give her half glycerin suppository and continue with the higher dose of senna. Failure to use her bowels means redoubling the dose of senna and if this does not work another half suppository. After a week of success of using her bowels the dose of senna can be halved. So 1 day of failure means doubling the dose, a week of success means halving. She may get up to quite a high dose of senna but it will do no harm. Throughout all this you continue with the twice daily local anaesthetic ointment.
These instructions are quite complex, so don't have any hesitation in asking me a question. I will be happy to hear from you.
David

Frequent falls

2008-09-18T14:47:00.003+09:30

> Dear David:
>
>
> It has been over a month now and my granddaughter is falling way
> less due to the fact that she is
> wearing those good shoes. I believe her ankles were not strong
> enough, etc. What is your
> professional opinion of this small turn of events?
>
> Thanking you in advance.
>
>
>I am delighted that she is falling less. Good shoes certainly do help weak ankles.
Did you ever get her assessed by a physiotherapist or a home visitor as I suggested?
David
>

Childhood Warts

2008-09-13T17:58:00.001+09:30

Warts

Our son has a number of warts on his hands and knees. They look very ugly and he wants to get rid of them. I have heard of many different cures from friends but my doctor says there is no cure. Is there anything that can be done?

Common warts as you have described are a viral infection of the skin. Your doctor is correct to say there is no cure. They can be cut out or burnt off but will come back. This approach is reserved for those warts in an inconvenient place, for instance a wart on a finger that is interfering with writing.
As with other viral infections such as a cold, one has to wait until the body’s defence system destroys the virus. In the cas of the cold this takes a few days but with warts it takes months or years. So after having the warts for a long time, our body kills the virus and the warts disappear overnight.
The sudden disappearance of a long-standing condition, id the reason there are so many miracle cures such as burying a dead cat by moonlight – taking glucose rather than sucrose was the one I chose as a child and after many months it worked, the warts suddenly disappeared. Unfortunately my mother was still putting sucrose in her cooking. Recent medical studies have suggested that hastens the departure of warts is to cover them with duct tape. If this is true, you need to go to the hardware store – not your doctor.

2008-09-09T17:30:00.002+09:30

My son, who is 18, caught acute mono over 5 months ago. He had a severe case and was unable to attend the last 3 months of school, and was one of the worst cases his doctor has seen. The severe part of his mono has gone away, but since then he still struggles daily. He has little or no appetite, strength, and seems to be constantly not feeling well. We've taken him in to get bloodwork and the results have come back 'normal'. My question is: Is this common? If not, what should we do?

The older the patient, the more severely they are affected by Infectious Mononucleosis.
A period of post-mono with the symptoms you describe is common. This may last as long as 6 months although 3 is more usual. This is despite the blood work becoming normal.
There is little you can do.You might try tempting him with his favourite foods.
David

high fever danger

2008-09-09T16:30:00.001+09:30

What is a dangerous temp for an eight-month-old?

We usually become anxious when the temperature reaches 41 degrees centigrade or 105.8 and really worried at 42 or 107.6 in children. The younger the child the higher the fever they run. The figures cited above would be lower for an adult.

newborn jaundice

2008-09-02T18:44:00.002+09:30

Our 3-day-old baby boy has developed jaundice. The doctor told us it was "physiological jaundice" and not to worry. I have heard that jaundice can be dangerous to babies. Can you he;p me?

You are right that severe jaundice can damage a baby's brain in the first week or so of life. About 40% of babies develop mild jaundice in the first few days of life. If the level is low, no risk occurs. Your doctor will (or has) measure the level to be sure that there is no danger.
The reason "physiological jaundice" happens is that the fetus in the womb needs more hemoglobin (the red pigment in blood)to carry enough oxygen than it does after being born. The bay's body breaks down the unnecessary hemoglobin which makes a yellow pigment known as bilirubin. Bilirubin is the cause of the jaundice and will go away after a few days in "physiological jaundice". If the breakdown of hemoglobin is excessive (due to a number of rare diseases that can affect babies) then severe jaundice occurs which can damage the immature newborn's brain. There are a number of treatments used if this seems likely to happen. Older children and adults may also become jaundiced but their mature brains are not damaged by it.

Exercise cramps

2008-08-16T12:38:00.000+09:30

My son is almost13 very active. He has a problem with leg cramps. A friend who is pharmacist said to give him potassium supplement and have him chew a couple of Rolaids before game. We have eliminated soda on game day and drink water all day. He will then drink power aide during game and more water after game. He still having problems. He is never sick. He is great eater loves veggies and fruit can’t figure it out can you help?

Firstly your son is perfectly healthy. Cramping during or after sport is very common. I am afraid that I don’t know what Rolaids are and therefore what they contain.
If the potassium supplement does not help, I would try a quarter teaspoon of salt and a glass of water about half an hour before the game (DO NOT GIVE MORE SALT THAN THAT). I APPROVE OF Poweraide during the game – it contains both sodium and potassium.
If he still gets cramps after the game the quarter teaspoon of salt plus water can be tried again. The liberal water before and after the game is fine.
Please tell me what is in Rolaids, how he goes and (out of interest) what sport he plays. Tell him I am sympathetic as I was a sufferer with cramps after exercise.

Urinary frequency in a 3 year boy

2008-08-09T09:37:00.000+09:30

My 3 and half year-old son urinates frequently. He will just have gone to the toilet only to wee a few minutes later. He sometimes remembers to go most times but often not and will wet his pants. We have had him tested for diabetes insipidus but the results came back normal. He also under went an MRI of the brain. His fluid intake is normal. Any ideas of what the next step could be.

Your son has certainly had very sophisticated investigations for his urinary frequency. I presume he has had a test for urinary tract infection and diabetes mellitus. I would very much like you to inspect the tip of his penis. If he is uncircumcised push the foreskin back gently (DO NOT FORCE IT BACK) and see if there is any infected material under the foreskin. If he is circumcised look for a small ulcer adjacent to (and possibly running into) the hole at the tip. If either of these is present you need to see your doctor again.
Is he fearful of going to the toilet. All these ideas are to see if he is only letting out a small quantity of urine at each visit.
I would be interested in what happens.

vomiting and sezures

2008-07-26T16:53:00.001+09:30

I have a 4 year old daughter with a history of seizures (seizure

free for over a year) and a history of reflux (not a problem for over 2

years.) In April she had an episode of repeated vomiting.

Then, it happened again in June. Then, July 10th it started. We have

not had more than 24 hours vomit free since July 10th. She has also

had diarrhoea part of that time. She has an immuno compromised sister

who has been totally healthy through this. That virtually eliminates

the possibility that it is contagious.

My children are already gluten free. However, even the gluten free

foods are making my child sick now. The only things she can keep

down are rice crackers and chicken with rice soup. She wakes up vomiting

in the middle of the night and we are worried she is going to choke.

We have done blood work to check for food allergies and are waiting

on those results. We are going to do an x-ray just to make sure

there isn't something there. We are going to try Pepcid to ensure it's not

reflux related. Since this started she has also started seizing

again. They aren't sure which condition is causing the other, so

they are talking about a brain MRI as well.

Do you have any other suggestions of things that we can check for?

We will be doing more blood work in a few days so I want to include

anything we can so we don't have to do it again. She is a petite

child to begin with and she's already lost some weight. In our

family we often deal with "rare" things. So, even if it is rare I still

want to hear about it.

Thank you.

Chelsea

Dear Chelsea,

How very distressing this must be for you.

The combination of seizures plus vomiting would make me very keen indeed to have an MRI of her head.

Blood tests for food allergies are helpful but not conclusive and you may find that your doctor wants to withdraw a food for 3 weeks and the challenge her with it again after the 3 weeks has been completed.

Toddler Falling a lot

2008-07-24T19:59:00.002+09:30

My 34 month old granddaughter falls a lot. Loses her balance a lot. She is very bright with no speech or hearing problems, although she failed her birth audio. but when she went back for a 2nd test,passed. My daughter took her to an ent specialist a few months ago and she failed her test in one ear, but they were puzzled by this and wanted to put her to sleep for testing. She does have flat feet and her left one turns out very slightly. This situation is of great concern to me.
Thanking you in advance.
Nancy

Dear Nancy,
I note your concern. I doubt that ear problems are connected to the falling, even though the inner ear is responsible for balance. If she does have the hearing test while asleep, find out if the hearing loss (if any) is of a conductive type. It most likely is and that would not be connected with her falling.
Flat feet at 34 months can be considered normal. Toddlers have very lax ligaments and the arch of the foot contains a pad of fat which disappears as the toddler grows older. The turned out foot is probably OK too but with the frequent falls makes me wonder if her local doctor has assessed her legs for stregth and normality of (tendon) reflexes. If these are normal, I would be prepared to wait and see. It is normal for toddlers to fall a lot so much so that they usually have bruises on the front of their legs and often on their foreheads. Falls on flat surfaces are not a worry but your daughter should be protected from falling down stairs by a gate at the head of the stairs.

Physical child abuse and neglect

2008-07-02T14:25:00.001+09:30

I have been seeing so much about child abuse and neglect in the media lately. Why do you think this is happening so much these days? What can be done about it?

I will restrict my answer to physical abuse and neglect. This is not because sexual abuse is not important but because it is, in my opinion, a different problem for which we do not have a satisfactory answer other than gaoling the perpetrators.

At least 80% of parents who abuse their children were themselves abused as children. These parents have a very poor model of parenting and very poor self esteem. While they hated being abused and swore they would not do it when they grew up, under stress they revert to the model they experienced as children. They are, in fact, sad parents.

Of the remainder psychiatric disease, if one includes depression and alcohol and drug abuse under that heading, is the main reason. Very few abusers are simply evil people but unfortunately those that are capture most of the media attention.

At this point I should point out that if you were abused as a child it does not mean that you will become an abusive parent. 75% of abused children do not abuse as parents – a triumph of the human spirit! Also child abuse was not non-existent in the old days. It simply went unrecognised as a problem. It was not taught to me or any medical student in the nineteen fifties. There was a famous case of an abused girl who was brought to the attention of the courts at the end of the nineteenth century. The case was thrown out because a parent was totally responsible for their child. The case was brought again but under the Prevention of Cruelty to Animals act and was successful!

What can be done about it? The simply evil (bad) parents have to have their children removed and face the law. The psychiatric (mad) parents need psychiatric treatment and in many cases the children may need alternative care at least on a temporary basis.

However, the vast majority (80%) need support in their parenting and many organisations attempt to do this. In the old days family and neighbours did this but this often not available in modern society. Unfortunately, the main need is for emotional support – not budgeting, housekeeping etc (although this may also be needed)-and this takes time: more time than society can afford to pay if one uses an employed social worker, visiting nurse or any paid supporter. The most successful program was introduced by the late Henry Kempe in which he used trained volunteer mothers whose task was to “mother the mothers”. This program has been emulated in many other places around the world. I ran one such program with the high success that Kempe found but it took 20 hours per parent per month. Society simply could not afford to pay a salary for such parent-helpers given the rates of child abuse that we currently have.

In the last 50 years we have recognised the problem of physical abuse and neglect. We have learnt a lot about its causes and I think we have found a successful treatment for many cases. It is a dismal picture at the moment but I believe there is cause for hope.

persistent diarrhoea and abdo pain

2008-06-17T14:13:00.002+09:30

Thank you for writing back so quickly, my daughter has had a stool sample taken last week that came back clear. She also has been on a dairy free diet since January. The doctor said to put her on a wheat free diet to see if we can get an improvement but she is still in a lot of pain at the moment. I will let you know the outcome once she has been on it for a couple of weeks. Thank you for your time and advice.
Kerry

A routine stool sample will not detect Yersinia and may not detect Giardia. Your doctor has to specifically ask the laboratory to look for Yersinia. Giardia is so often missed that I would treat her for Giardia anyhow.
I am sorry you are having so much trouble. If the above does not detect the reason or cause improvement, she should have a urine collected and analysed for infection.
Please do let me know what happens.
David Robinson

persitent infantile diarrhoea

2008-06-16T13:52:00.002+09:30

Hello: my 12 month daughter has had diarrhoea for the last 2 weeks. She is opening her bowels up to 10 times per day and is having really terrible stomach pains. She also has severe reactions to dairy produce. Could you advise me on the cause of this?

Dear Kerry,
This sounds like she has lactose intolerance probably brought on by a gastro bug. She needs to go on a milk product-free diet. This means no milk, no cream, no cheese, no icecream and no commercial products that contain milk such as bread, biscuits,most margarines and yogurts. Check commercial products to make sure they don't contain "milk products or "casein"-this means you will have to do a lot of home cooking. She should stay on the milk-free diet for 2-3 weeks to let the gut heal although you should see an improvement long before that time.
If this does not work ask your doctor to look for Yersinia and Giardia in a faeces specimen and treat her for Giardia anyhow as it is sometimes difficult to detect. Uncommonly diarrhoea can be due to a urinary tract infection but it is so difficult to collect a suitable urine sample, I would wait until all the above have been done.
If none of these work ger back to me as there are further things that could be considered. I would be interested in what happens in any case.
David Robinson.

severe infectious mononucleosis

2008-06-14T11:41:00.002+09:30

Hello:My daughter is 7 and has been diagnosed with mono. She started with a low grade temp for 12 days off and on. Then she got the "bad attack". She has had high temps for the last 5 days. They get up to 104.5-105.4 if I am not giving her tylenol and/or ibuprofen every 4-6 hours. Her spleen is swollen, tonsils are very swollen, bad headache and in bed for 5 days. Yesterday she had difficulty even walking because of weakness. It is my understanding that children this age typically do not get mono this bad. Will this last longer for her because of the severity of her symptoms and how long should she have this high fever? She is also taking codeine for the pain. Thank you for any information you can offer me. Leanne.

Dear Leanne,
You are correct, the younger the sufferer of mono the milder it is in most cases. This usually means that children under 6 do not have the diagnosis made although they certainly do catch it.
I presume your doctor has confirmed the diagnosis and a blood test has been taken.
I guess there are always exceptions to the rule. I don't think she will have an unusually long course because it is so severe - this is based on my own observations and I am not aware of any proper scientific study that has measured length of illness against severity in mono.
I would not base the giving of Tylenol on the presence of fever but more on whether she is in pain or not. Fever is one of the body's defences against viral infection, which mono is. Temperatures around 105 are rare in adults but quite common in children.
Regrettably, there is little modern medicine can do to help your daughter to overcome mono but she will recover.
David Robinson

?diabetes

2008-05-31T13:57:00.003+09:30

My 6 year old seems to be drinking more frequently and urinating more frequently as well. About every hour she seems to have to go. I don't want to jump to conclusions that it could be juvenile diabetes but I don't want to ignore any symptoms either. She has no other abnormal behaviours. What do you think this can be or is there nothing to worry about at all?

There are a number of causes of extra intake of fluid and increased urinary output. A common cause of urinary frequency is a urinary tract infection but this does not cause increased drinking. However, it affects some 6% of schoolage girls.Your doctor can chek for this.

You are right to consider sugar diabetes. Your local doctor can easily check for this if you can collect a urinary specimen in a very well cleaned jar or the surgery can give you a proper specimen container.

There are rarer causes of these symptoms which I am sure your doctor will consider if the urine is normal. Excessive drinking can just be a habit with no disease and, of course, the extra fluid has to be passed out as urine.

Best of luck and please do tell me what happens.

David Robinson

"Mono" experience

2008-02-02T14:34:00.000+10:30

I’m 15 and I currently have Mononucleosis. I have been sick for about 2 weeks now. I first woke up with an extremely sore throat so badly I couldn’t even swallow my own spit. The sore throat continued for about a week and then my spleen enlarged and I could feel pressure on my stomach. My neck was so sore and my whole upper body ached. Now I just feel tired and weak all the time.

I hope my experience helps in a way.

You have described a typical attack of infectious mononucleosis. You have my sympathy because you have had a fairly severe attack and I am glad you are on the mend. Unfortunately the feeling weak and tired may last for some time – up to 3 months – but it gradually gets better.

I am sure that others suffering “Mono” will be grateful to hear of your experience and the fact that it does get better, Thank you for sharing with us.

Questions not getting through

2007-12-04T13:44:00.000+10:30

It has come to my attention that due to a technical glitch, questions to Pediatric Questions and Answers may have not got through to be answered. We think we have the problem fixed. So if you asked a question and received no reply please submit again. If there is still a difficulty please contact me directly at: http://childhoodillnesses.blogspot.com

David Robinson

Nephritis

2007-11-26T17:16:00.000+10:30

My mother tells me that I had nephritis as a child of 3. She says that I might need dialysis and a kidney transplant. What is this and what should I do? I feel fine and have not had any trouble since.

Nephritis is a term that means an inflammation of the kidneys. There are many forms of this condition and the outcome varies as to which form it is. As you had yours in childhood and you have had no trouble since it is likely to be “acute post-infectious glomerulonephritis”. In some people with this an infection, commonly Strep. throat or school sores, it triggers a response from the immunological (defence) system to fight the infection. The kidney is not infected but is attacked by the immunological system causing inflammation (the body’s response to any insult).

The good news is that if this is what you had, there is a 90% chance that your kidneys have recovered completely and there should be no problem.

If you want to be certain that you have no problem, your doctor can send some of your urine to see if there are any signs of glomerulonephritis and some blood to see if your kidneys are functioning normally.

Painful foot

2007-11-20T15:28:00.000+10:30

My 5-year-old son often complains of a sore left foot. It looks normal and he is generally well with a good appetite. He enjoys school. What could be the cause of the painful foot?

Probably the commonest cause of sore feet is poorly fitting shoes. If this has been checked and excluded, a fracture or a foreign body may be present. So an examination by your doctor and possibly an X-ray would be warranted. He/she can also look for any other causes but these are extremely rare. I can only recall 2 cases where a sore foot (with no other joints involved) was the way a more general disease presented.

Pain around the ankles, especially with feet that roll in could be helped by a podiatrist. However if the pain is in a foot and there is no obvious abnormality would probably represent poorly fitting shoes, a fracture in the foot or foreign body. Plantar warts on the sole of the foot are painful but obvious.

Persistent diarrhoea after gastroenteritis

2007-11-07T14:51:00.000+10:30

Our 4-year-old daughter has diarrhoea. It started with vomiting at the time when a lot of her Kindergarten friends had vomiting and diarrhoea with blood in the stools. Everyone else has settled down but our daughter still has diarrhoea and tummy pain. Our doctor has looked for a germ in her bowel but nothing was found. Have you any suggestions?

When diarrhoea is bloody, especially if there is a high fever as well, we think of gastroenteritis germs that are slightly unusual. Blood can occur in any form of “gastro” but it is commoner with the rare germs that cause “gastro”.

Because your doctor has not found a germ I would suspect one called Yersinia. Young children with Yersinia usually settle down in 2 weeks but it can persist and cause on-going diarrhoea and tummy pain. Yersinia does not show up on the standard tests that the laboratory uses to grow the “gastro” germs. To find Yersinia the laboratory needs to be told that your doctor suspects it. They will then test the stool specimen in a different way. I suggest you ask your doctor to send another stool specimen specifically to detect Yersinia.

There are treatments for Yersinia but some doubt whether they clear the germ from the gut faster than nature would anyway. I think if it were my child, I would want to be certain that Yersinia was present before considering treatment.

gastroenteritis

2007-11-01T21:32:00.000+10:30

What is gastroenteritis and how should it be treated? One hears so many different opinions.

Gastroenteritis (often called “gastro”) occurs most commonly in the late winter to early summer, although it can occur at any time of the year. It is an infection of the gut but in a previously well child antibiotics will NOT

PRODUCE A QUICKER CURE THAN NATURE.

The major symptoms are diarrhoea and vomiting (D&V). Often the vomiting comes before the diarrhoea by a day or so. There may be some minor tummy discomfort but severe pain makes another cause for the D&V likely. However, by far the commonest cause for D&V is gastroenteritis.

The greatest danger of gastroenteritis is fluid loss leading to dehydration. The child becoming quiet and lethargic suggests that this has happened. This or refusal to drink mean medical attention should be sought urgently.

Parents by administering large amounts of clear fluids can prevent the dehydration in many cases. Food or milky drinks may make the dehydration worse and should not be given. The doctor or pharmacist may recommend and electrolyte mixture that contains easily absorbed sugar and minerals. These will rapidly travel into the body (be absorbed) with the water. This will prevent the onset of dehydration in most cases. The electrolyte mixture is dissolved in a stipulated amount of water and it is most important that these instructions be followed exactly.

Often before dehydration the child may complain that the mixture tastes too salty in which case more water can be added or clear lemonade (&-up etc) can be used instead.

Although al formula and other milky drinks should be avoided, breast-feeding should continue. Breast milk is rapidly absorbed and does not make dehydration worse. It also contains a number of agents for fighting the infection causing the gastro (see a previous answer about breast-feeding), leading to quicker recovery.

If dehydration is significant the child will be admitted to hospital and fluid given by intravenous drip or by naso-gastric tube depending on the severity of the dehydration, age of the child and other factors. A naso-gastric tube is a plastic tube passed through the nose down into the stomach.

Most of the bacteria and viruses that cause gastroenteritis are highly infectious. Hand-washing after contact a gastro sufferer is the best defence against infecting someone else including family members.

Cluster headaches in a 17 year-old

2007-10-12T15:15:00.000+09:30

Our 17-year-old son has bursts of headaches. They are severe and come out of nowhere. The pain is around his eye, which runs as does his nose. He can have 4 a day for several weeks and they last for half an hour or longer. He becomes very agitated with them. Is this migraine?

We have an expression in Medicine “Are you a lumper or a splitter?” By this we mean some doctors will lump closely related conditions all in the same box and then say there are variations. Other doctors split conditions into finer and finer categories. The lumpers would say that your son’s condition is a form of migraine. The splitters would say this as a Cluster Headache. Both groups agree that whether migraine or cluster headaches, both are due to changes in the size of blood vessels inside the head.

Cluster headaches are commoner in males than females but occur in both sexes. Although mainly around the eye and temple, they can spread to other parts of the head. The pain is sudden and severe with no warning. It usually lasts half to 2 hours and may be accompanied by watering of 1 eye and nostril. The commonest time for them is at night. The bouts usually last a month or 2 with the patient being well in between for up to 6-12 months.

Preventer medication can be used during the bouts and pain relievers do help the pain when it occurs. There is sometimes an obvious trigger with perhaps the most frequent being alcohol; during the bad month. If such a trigger is identified it should be avoided during the bouts.

High Blood Pressure at 15 years

2007-10-08T16:21:00.000+09:30

My 15-years-old daughter has been complaining of headaches and was found to have high blood pressure. Isn’t she too young to have high blood pressure?

High blood pressure is much less common in children and adolescents than in adults but it does occur. In younger people it is important to look for an underlying cause such as kidney disease, narrowing of important arteries and other conditions which are causing “secondary high blood pressure”. I well remember a young nurse who told me that her doctor was treating her with high blood pressure pills. I encouraged her to have someone look for an underlying cause. She was found to have a narrowing of the main artery to one of her kidneys. The narrowing was repaired at operation and she has had no problem with her blood pressure since.

Measuring blood pressure in children and adolescents can be tricky. If one uses an arm cuff that is too small for the patient’s arm, a false high value can be obtained. Also, at any age, if one is nervous then blood pressure goes up moderately.

I think your daughter should have her blood pressure checked again and if it is still high, she should see a specialist to arrange tests looking for an underlying cause.

Flat feet and falls in a toddler

2007-09-27T13:59:00.000+09:30

My daughter, who is 2,has very flat feet. She walked at 13 months and is very active but falls over a lot. What should I do?

Toddlers often have flat feet. They are due to lax ligaments (structures that hold our joints together) and the fact that the area where the arch of the foot is located contains a lot of fat, so that little or no arch can be seen in toddlers. Walking at 13 months is normal and of no concern.

It is normal for toddlers to fall a lot- they usually have bruises on the fronts of their legs and their foreheads are often bruised. falls on flat surfaces are not a worry. However, you should protest them from falling downstairs (by a gate at the top) because serious damage can be done. Likewise, the play area outside should not have steep areas or cliffs where a toddler can fall and do themselves harm.

Fever and rash in an 8-month-old

2007-09-26T13:46:00.000+09:30

Our 8-month-old son has been very hot for the last 4 days. I have seen his doctor who has not been able to find a cause and just prescribed Tylenol when he is irritable. He has developed a red spotty rash today but seems less feverish. Is this measles?

No, this is not measles. From your description he has had Roseola. It is also known as “erythema subitum”. Erythema means redness and subitum refers to the subsidence of the fever. Thus, as the fever stops the rash appears.

This is a viral infection that is very difficult to diagnose until the rash appears. The rash will disappear in a couple of days and your child will be happy and well.

Febrile Convulsions

2007-09-24T14:36:00.000+09:30

My 25-month-old daughter has been in hospital for the second time with a febrile convulsion. I have been told that it is not epilepsy but they look like an epileptic convulsion that I saw on a video once. What is the difference?

The convulsion of febrile convulsion and that of the commonest form of epilepsy (generalised tonic-clonic or Grand Mal) are identical in appearance. The difference is that febrile convulsions only occur in young children (usually under 3 but sometimes up to 6 years). Commonly there is a family history of febrile convulsions. If a father, mother, sister or brother had febrile convulsions there is a 16 times greater chance that a young child will have one compared to a child with no family history. Because you and her father would not recall having had them at such a young age, it is worth checking with your parents or an older relative about the chance that you did.

Because an epileptic convulsion may be triggered by a febrile illness in a child, who has epilepsy and they look identical to febrile convulsions it is usual to wait until a second one occurs. In 60% of children with febrile convulsions there is only 1 episode but in 40% they are repeated. If a second episode of convulsing happens an electroencephalogram (E.E.G.) may be performed. This is a painless procedure in which the brain’s electrical activity is recorded while not fitting. If this is normal it is very unlikely (although not impossible) that the child has epilepsy.

A reassuring fact is that febrile convulsions are much commoner than epilepsy at your child’s age.

Eczema in a 10-week-old

2007-09-11T13:44:00.000+09:30

My doctor has diagnosed my 10-week-old son as having eczema. We have been given some cream but could you explain eczema to me?

Eczema means a scaly rash. Most doctors mean “atopic eczema” when they just say “eczema”. There are other scaly rashes that are called eczema. Another eczema that is common in babies is seborrheic dermatitis. As both it and atopic eczema improve on corticosteroid creams telling the difference may not seem important. However, the course of the condition will be very different.

Atopic eczema is part of atopy in which some combination of the following may occur: asthma, hayfever (allergic rhinitis) or a tendency to allergies. Seborrheic dermatitis tends to disappear by 2 years, only to reappear as dandruff in adolescence. Many cases of atopic eczema also disappear by 2 and most have resolved by 6. Some remain life-long.

It is important to emphasize that your child may grow out of his eczema and never develop any of these conditions in later life, no matter which of these 2 common scaling rashes he has.

Eczema does not produce permanent scarring by itself. If it is scratched (and eczemas are very itchy) it may become secondarily infected and antibiotics needed. If this secondary infection is severe, it may cause scarring.

Babies with eczema in the diaper region (usually seborrheic dermatitis) may have repeated and very difficult to control diaper rash. This will require antiseptic baths as well as corticosteroid cream – this require medical attention and advice

Anaemia in a 2-year-old girl

2007-09-10T14:22:00.000+09:30

What is anaemia and how do I find out if my daughter has it? My mother tells me that I looked very pale as a child and was diagnosed as having anaemia. My 2-year-old daughter looks pale but she is otherwise well.

Anaemia is a reduced number of red cells in the bloodstream. These red cells contain haemoglobin and use this to carry oxygen from the air in our lungs to all parts of the body. If we become anaemic slowly, the body compensates, for example the heart beats more strongly and more rapidly. So we may not notice that we have a problem but if the anaemia is bad enough the anaemic person looks pale.

Some people, both adults and children, are naturally pale without having anaemia. To find out if your daughter is anaemic she needs to have a blood test. This can be organised by your local doctor.

If anaemia is present it is necessary to find out why. Most of the many causes of it are readily fixed. In a 2-year-old the most likely cause would be an inadequate amount of iron in the child’s diet. The best source of iron is red meat. If a significant iron-deficiency is found, this can be fixed by giving iron medicine by mouth in a single dose per day

Glue ear in a 2 and half year old

2007-09-04T20:16:00.000+09:30

Last week you answered a question about infection in the middle ear. My 2 and a half-year-old son has a condition called glue ear and his paediatrician has referred him to an ENT surgeon for possible operation. What is this condition, what causes it and does he really have to have the operation?

“Glue Ear” (or serous otitis media to give it its medical name) is a condition in which there is a collection of fluid in the middle ear on a persistent basis. This is due to poor drainage of the middle ear by the tube, which drains into the nose (even though the common cold is not present).

This may lead to repeated ear infections because the fluid provides a suitable place for bacteria to grow. It can also cause a hearing loss. The ENT surgeon can cut the eardrum under general anaesthesia. He/she can suck out the fluid and place a tiny drainage tube in the eardrum that will drain fluid and prevent the fluid from rea cumulating.

If there is temporary deafness speech development is inhibited but this will pick up once the deafness resolves. Glue ear usually resolves by itself and studies done comparing children who have their glue ear treated by surgery with those in whom no surgery was done have found no difference between the 2 groups after 5 years. Even the speech had picked up so that the 2 groups had similar speech and intelligence at the end of the 5 years. There is no doubt that surgery restores hearing immediately.

I hope this helps you make up your mind as to whether to have the surgery done on your son.

otitis media in an 18 month old

2007-08-31T11:52:00.000+09:30

My 18-month-old has had 3 bouts of otitis media. I am confused as some doctors say that antibiotics are needed to clear the infection and others don’t think they are needed. Can you tell me about this condition and how it should be treated?

Otitis media or middle ear infection (sometimes called ‘ear infection” which is wrong) is a frequent problem in early childhood although it can affect any age – I had it at 17 years of age. It is usually a complication of the common cold. The middle ear has a tube which drains mucus made in the middle ear into the nose. Swelling of the lining of the nose, caused by the cold, blocks the drainage of the mucus. Bacteria like to grow in any trapped fluid in our bodies and will grow in the mucus setting up a middle ear infection (otitis media).

It is possible for this infection to develop into an abscess, which in turn may burst through the eardrum causing pain and then discharge of pus out through the outer ear. For this antibiotics are compulsory. Such rupture of the middle ear drum is very rare in well-nourished basically healthy children but is common in poorly nourished third world children where it is a common cause of a permanent hole in the drum which causes significant hearing loss.

In the last 25 years we have come to realise that a well-nourished child will get over otitis media without the need for antibiotics just as fast as those given them. It has been estimated that one has to give antibiotics to 14 children with otitis media to help 1 – the other 13 will resolve their infection just as quickly without any medication. Thus, you are likely to see less and less prescribing of antibiotics for middle ear infections in future.

Chronically constipated 2-year-old

2007-08-30T19:53:00.000+09:30

Our 2-year-old daughter has repeated problems with constipation. We have tried a number of medicines, which do help, but as soon as we stop them she becomes constipated again with very hard bowel actions like pebbles and sometimes there is blood on them or the toilet paper. We can see that she holds back on using her bowels because of fear that it will hurt which it often does. What is your advice?

This is a miserable problem for your daughter. The blood suggests that she has a crack in her anus (technically called a fissure-in-ano). When this is torn open by the hard bowel action it hurts so that she is reluctant to do the job.

There are two steps I would suggest:

Firstly use one of the medications that has worked again but for 3 months! Ask her to go and try to use her bowels after the 3 major meals.

If she fails to pass anything for 24 hours then increase the dose – I usually recommend doubling the dose. If that fails then she needs a suppository or enema, which your pharmacist can give you.

Secondly I recommend some anaesthetic ointment put on at least twice a day – after her bath and then about 12 hours later. This is applied to the anus and does not have to be inserted, just put it on the surface. This is to stop the passage of the bowel action from being painful. Once the process is painless you can stop the ointment.

I strongly emphasise the importance of continuing the use of medicine for 3 months even though she may seem cured much earlier. Towards the end of the 3 months you can try reducing the dose say halving it for a week. If there is any failure to use the bowels for 24 hours, double the dose again.

This is a difficult and complex matter and I would be only too happy to answer supplementary questions. Best of luck.

Repeated Cold Sores

2007-08-26T19:28:00.000+09:30

I need your advice on cold sores. I get them but only once or twice a year and my wife does not have them at all. My son who is in his final year of High School and is studying very hard, is having multiple attacks. Do you think they may be stress related? Is there any protection we can practice? Given that we never kiss him on the lips, where are they coming from (he does not have a girlfriend)?

Cold sores are an herpes infection. We all have an initial herpes infection in our first few years of life. Then it causes mouth ulcers. After the infection is over the herpes virus remains in the nerves that supply our lips. Most of the time we suffer no harm from this carrier state. Unfortunately, for about 40% of the population, when they are stressed, the virus becomes active and the ulcers appear on and near the lips again.

The most common cause of that stress is the common cold, hence the name cold sores. However, the stress may be emotional and it seems likely that is the case for your son.

There is an anti-viral cream that is effective in herpes but as each attack is self-limiting, it should only be used in the most severe cases for fear of the virus becoming resistant to it. Babies or the very elderly can get the herpes virus in their blood stream when it is frequently fatal without this anti-viral agent. In my opinion, we should reserve this agent for these cases or particularly severe skin herpes.

Anyone with active cold sores should not go near a newborn baby (under 1 month of age). If avoidance is impossible, a mask can be worn. However, the mask must be changed and hands washed every 20 minutes if the contact with the baby is to be prolonged. I must say it is rare in my experience for the mother with cold sores to give the virus to their baby.

I am one of the 60%. Who do not have repeated cold sores, but I feel very sorry for those who do.

Childhood Illness

2007-08-16T14:45:00.000+09:30

Why does my 3-year-old daughter have so many coughs and colds?

Coughs and colds are the commonest illnesses that children suffer. As coughs can be due to serious illnesses such as pneumonia or asthma, the parental anxiety a child’s cough can cause is quite understandable. Pre-school children have an average of about 9 upper respiratory infections (colds) per year and more if spending a lot of time with other children (being in child care for example).

The vast majority of colds are viral and do not respond to antibiotics. A very small number of children will develop a secondary bacterial infection such as bacterial tonsillitis which will require antibiotics. This secondary bacterial infection is so infrequent that the use of antibiotics to prevent it is not justified, especially when one considers the side-effects that the antibiotics may cause. 40% of patients given erythromycin develop nausea, abdominal pain vomiting or some combination. Two thirds of children when given amoxicillin under the age of 2 years will develop loose bowel actions.

So what is to be done? Medical Science has not found a way of shortening the common cold. It is important to keep up the fluids, as fever causes the child to lose water through sweating. If the child is uncomfortable they may have paracetamol (acetophenetidin or phenacetin). Regular paracetamol is not necessary; it will lower fever but fever is one of the defence mechanisms that help the body fight infection.

Aspirin is a definite no-no in young children.

If the child will not drink or looks obviously sick (listless, drowsy, struggling to breathe) then see a doctor. The person who discovers a cure for colds will become very rich and probably win the Nobel Prize

Childhood Illness

2007-08-09T14:53:00.000+09:30

Should I have my baby boy immunized against chickenpox? I have heard that sometimes it gives them chickenpox.

The short answer is “Yes you should have him immunized for chickenpox”. Of course it means an extra needle and the very low risk of side-effects that all immunizations have.

Chickenpox (varicella) is one of the most infectious of the infectious diseases with about 90% of household contacts, who have not had chickenpox, catching it if one person in the house develops it. While more than half of cases occur in children under 10-years-of-age, 25% happen in people over 15. Ask anyone who contracted chickenpox when 15 or older and they will tell you that it is a miserable disease with intense itching.

Also 1 in 100 people (adults or children) will develop a secondary pneumonia requiring antibiotics and often hospitalization. Some children develop an involvement of the brain called encephalitis. Overall the complication rate of chickenpox is 5 to 10% and one in 400 children being hospitalized.

What are the risks to the chickenpox immunization? About 10% will develop a fever and half it will be quite high (greater than 38.degrees Celsius or 101.3 degrees Fahrenheit). One in5 children will develop slight swelling, pain or tenderness around the injection site. This clears up without any need for treatment. About a fortnight after the immunization approximately 4% will develop some chickenpox lesions around the injection site and about the same number will develop them somewhere else on the body. However, the number of these lesions is 5 or less. Compare this with more than 300 chickenpox lesions in naturally caught chickenpox and each of those 300 itches!

Both my older brother and sister had escaped chickenpox through primary school. I developed it when I was 9 years-old. Of course they both caught it from me during their summer break. My illness was relatively mild but my brother and sister itched horribly and they were not impressed with their kid brother! My last 2 children also caught it in adolescence, the older one did not sleep for 2 successive nights because of itch and this was despite excellent nursing care from his mother and generous medication from his father.

Eczema atopic & seborrheic dermatitis

2007-07-23T14:53:00.000+09:30

My doctor says my 10-week-old son has eczema and prescribed some cream. What is eczema and will he have it all his life?

Eczema means a scaly rash. Most doctors mean “atopic eczema” when they say “eczema”. There are other scaly rashes that are called eczema. A similar rash to atopic eczema that affects babies is seborrheic dermatitis. As both these types of eczema (atopic eczema and seborrheic dermatitis) improve on corticosteroid creams, knowing which form of eczema it is may not seem important. However, the course of these 2 conditions will be very different. Atopic eczema is part of atopy and babies who have it may develop asthma, hayfever and an undue tendency to allergies. Seborrheic dermatitis tends to disappear by 2 years, only to reappear in adolescence as dandruff.

It is important to emphasize that your child may grow out of his eczema and never have any of these other conditions in later life, no matter which of these 2 scaling rashes he has.

Eczema does not produce permanent scarring by itself. It is itchy and if scratched, it may become infected and require antibiotics. If this secondary infection is severe it may cause scarring. Babies with eczema in the nappy region (usually due to seborrheic dermatitis) may have recurrent and very difficult to control nappy rash. This will require antiseptic baths as well as the corticosteroid creams- this needs medical attention and advice.

Gastro-oesophageal reflux in babies

2007-07-17T14:28:00.000+09:30

Our 2-month-old baby cries a lot and the doctor has diagnosed reflux and given an antacid. The baby vomits a lot and seems unhappy but is growing satisfactorily. Can you explain reflux to me?

The full name for this condition is Gastro-oesophageal-reflux. Other kinds of reflux can occur elsewhere in the body. I don’t blame your doctor for using the shortened name and I will too for this answer. In this condition stomach contents pass back up (reflux) from the stomach into the gullet (oesophagus).

Such reflux is common in babies as they take a large quantity of fluid for their size. If an adult was to take the same amount of fluid per kilogram body weight, he/she would drink 7 + litres per day.

This huge intake of fluid puts a lot of pressure on the valve-like mechanism that normally stops fluid from passing from the stomach and back into the gullet. Forty percent of babies vomit after feeds because of this reflux and in most cases it does not cause a problem. There are 3 complications of reflux that do cause problems:

The acid made in the stomach may cause irritation to the lower part of the gullet. This is painful and makes the baby irritable. It seems this is what your doctor suspects.

The refluxed stomach contents may come up to the point where the gullet and the windpipe branch of the lower throat. This causes a potential for those contents to be inhaled. The first part of the windpipe has a trapdoor (epiglottis) which closes when we are eating, vomiting or refluxing. If this fails then we can inhale the refluxed material causing chest disease. This is quite rare in normal babies – only 1 in 500 refluxing infants have this complication.

The baby may bring back so much of his/her milk, that not enough is consumed. This would make the baby hungry and demanding. After some time growth would be noted to be inadequate. This complication is extremely rare- in 40 years of paediatric practice, I don’t think I have ever seen it.

Reflux disappears spontaneously as the baby drinks less per kilogram and adopts the upright position. The average age of it stopping is 10 months but there is a wide range of ages at which it stops. Most adults have occasional episode of reflux when we are aware of fluid coming back up into our throats – we just swallow it and do not worry.

2007-06-25T16:32:00.000+09:30

Our 6-year-old son has lots of bruises on his arms and legs. He is still active but I am terrified that he has leukaemia. What should I do?

I am not surprised that an active 6-year-old boy is collecting many bruises. Because you are terrified, I suggest you see your local doctor who will do a blood test to exclude it and other possible causes for excessive bruising.

Bruising by itself is not a common way for leukaemia to show up. Other signs of leukaemia are anaemia with paleness and being less active, an unusual number of infections or unusual types of infections such as mouth ulcers, bone pain or tenderness and sometimes lumps may be found in the neck – although there are many other causes for these.

If the bruising is excessive and he is otherwise well, he may have Idiopathic Thrombocytopenic Purpura (or ITP for short). This will show up in the blood test and is treatable.

Even in the unlikely case that it is leukaemia nowadays the most common type can be cured in 80-90% of cases but I doubt that your son has leukaemia

When a child should attend Emergency Room

2007-06-06T13:03:00.000+09:30

When is a child sick enough to go to the Emergency Room?

A sick child can be an enormous concern to a parent. The normal young child can have up to 12 colds in a year so what are the signs that should prompt you to go through the unpleasantness of attending an emergency room? In my opinion the main ones are:

Drowsiness

Refusing to drink at all

Vomiting everything

Excessive irritability

Marked pallor

Struggling for breath

I could make a list that would go on and on for instance convulsions or coma but these are so obvious that I have not included them or other signs that would prompt any parent to seek urgent attention.

The child who is active &/or drinking well is unlikely to have a serious illness, whereas the combination of drowsiness, severe irritability when disturbed, absolute refusal to drink (not just less drinking) and vomiting is a particularly worrying one.

The experienced parent is able to recognize the pattern of minor illnesses and give Tylenol for discomfort, keep up the fluids and rest for their child. Unfortunately, when we first have children none of us are experienced and will often consult the doctor with minor ailments but it is the doctor’s job to look after such children as much as the sicker ones.

If a doctor is patronizing or otherwise makes you seem silly he/she probably does not

have children or is stressed by their job or some other factor. If you are worried it is better to put up with such an attitude than to be sorry that you did not see the doctor.

Baby with difficulty in breathing (bronchiolitis)

2007-06-04T15:49:00.001+09:30

My 4-month-old niece has just been admitted to hospital with bronchiolitis. She looks very distressed and is struggling to breathe. What is bronchiolitis and can my baby catch it – we visited when my niece had a cold 4 days ago?

Bronchiolitis in babies is a viral infection of the smallest airways in the chest (called bronchioles). It causes at least 1% of children under 2 years of age to be admitted to hospital and is one of the major reasons for the children’s wards of hospitals to be very busy over late autumn and winter. It is most commonly due to an infection by the Respiratory Syncitial Virus (RSV). This virus is highly infectious and can survive outside the human body for eight hours. So, if you touch a surface that has been sneezed or coughed upon you will pick up the virus on your hands. If you then rub your eye or nose you will infect yourself. Except in babies or asthmatics this will only mean an adult or older child will develop a cold or “chest cold” but the carrier of the RSV is a walking time bomb for any baby you handle. This is why hand washing is an obsession for nurses, doctors and other staff who handle children. It also means that it is likely that your baby probably has become infected with RSV but remember every child under 2-years becomes infected with RSV. Only 1-2% have to be admitted with bronchiolitis the other 98-99% just develop a bad cold.

The infection of the bronchioles causes swelling of the lining of these small tubes. This makes it difficult to move air in and out and the baby has to breathe harder and their oxygen levels may fall. As drinking from the breast or bottle is the hardest work a young baby has to do, they may become too tired to take in their daily requirement and many hospitalised bronchiolitics become dehydrated. Fortunately the body’s defence mechanisms against infection mean that on about the 4^th or 5^th day of hospitalisation most babies will start to become better but they may need intense medical/nursing care before this happens.

The hospital management of bronchiolitis is to give oxygen if the oxygen levels in the blood are low and extra fluid by a tube through the nose into the stomach or by a drip into a vein if dehydration is likely or has occurred. One patiently waits for the baby’s defence systems to fight off the infection. Death from bronchiolitis is extremely rare unless a pre-existing heart or lung condition compromises the baby.

Please remember to wash your hands before handling a baby so that you are not responsible for transmitting RSV infection.

Bedwetting in a 6-year-old

2007-06-01T15:25:00.000+09:30

How can I stop my son’s bedwetting? He is 6-years-old and wets about 6 nights in 7. His older brother was dry from about 4 years of age but I wet until I was about 10 years and was very embarrassed by it. I want to save my son that embarrassment.

We all wet the bed when we were babies. We first learned to not pass urine (even though our bladders were full) while awake when it was socially inconvenient to do so. Later we learned how to hold on while asleep. The time when a child learns these skills varies from one child to another just as some children will learn to ride a bicycle later than others.

The usual age at which a child is dry both day and night is 4 years but 25% of children are still wetting the bed at 5. Each year about 10% of these children will learn the skill and stop wetting the bed. Late control often runs in families and does not represent disease. There is no association between bed-wetting and general intelligence.

A somewhat more serious situation is the child who has been completely dry for some time then starts to wet again. Such a child should see a doctor to check for illness – the most common being urinary tract infection- or emotional disturbance. The emotional disturbance may appear trivial to an adult e.g. changing school.

As bedwetting is difficulty in acquiring a skill threats, punishments and bribes are doomed to fail. A not-promised reward for a dry night is fine. The parent’s attitude should be matter-of-fact: “Oh, you have wet the bed, just put your sheets in the washing machine.”

When the child is motivated (parental motivation does not count) to stop, the best method is the bedwetting alarm that makes a buzzer sound as soon as the child starts to wet. However, the child must “psyche” up him/herself, so when the buzzer goes they wake up. Hence, the child’s motivation to stop is essential.

There are some drugs that bring temporary control for a sleepover or school camp but these do not cause a permanent cure as the alarm can

Repeated vomiting in a 7-year-old

2007-05-31T13:48:00.000+09:30

Our 7-year-old son has repeated episodes of frequent and severe vomiting. He has just been seen by a paediatrician who diagnosed cyclical vomiting. Our boy is often hospitalized, as he needs a drip to treat dehydration. Can you tell us more about cyclical vomiting?

Cyclic or cyclical vomiting is a most unpleasant condition, the cause of which is unknown. To accept this diagnosis, your child should be completely well between episodes. Cases due to psychological upset have been described but are very much in the minority. Rarely the use of preventative anti-migraine therapy has proved beneficial suggesting that the episodes are due to abdominal migraine – again these are very much in the minority.

So what can be done for the majority of cyclic vomiters for whom no underlying cause is found? Dehydration is the life-threat in these patients and if it occurs an intravenous drip is necessary. To try and stop this from happening a very powerful anti-vomiting agent ondansteron is given. It is a very expensive drug but is worth it if it can reduce the vomiting so that a drip &/or hospital admission is avoided. Sometimes corticosteroids are also given. Despite these measures the patient still has to be hospitalized in many instances in my experience.Fortunately most children (but not all) “grow out” of the condition, so that it ceases after some years without any reason for the cessation. This condition is very frustrating for the patient, the parents and the conscientious medical practitioner who spends much time considering other possible causes, trying anti-migraine and other treatments while feeling very sorry for the families

Inhaled corticosteroids for asthma

2007-05-29T14:42:00.000+09:30

Our 2and a half-year-old son has repeated asthma attacks that usually respond to nebulizers at home but he has been hospitalized twice this year. His doctor and the hospital want to put him on a steroid preventer twice a day. I am concerned that the steroids will stunt his growth and give him other problems. What do you think?

Your concern is very common. So much so that a term “Steroid Phobia” has been coined for it. The term phobia is a bit harsh because corticosteroids can cause serious and minor side-effects if given in big doses. However, the dose of steroid given by puffers is so small that it will not cause these side-effects. The great beauty of the inhaled steroids is that they are delivered to where they are wanted – into the airways. They do not go to the rest of the body as they would if swallowed or injected. Any inhaled steroid that is absorbed from the lungs or accidentally swallowed, is 90% destroyed by the liver in 1 second. This means it does not get to other parts of the body and cannot cause side-effects.

Thus, if the correct dose is given, an effect on growth or side-effects is very unlikely. Occasional patients (I have only seen 1 in my career) are unduly sensitive and this will first show up as excessive weight gain. In this case some other preventer is tried. The other group of preventers are also inhaled and stop the release of chemicals in the airways that cause asthma. These are very safe but unfortunately only work in 75-90% of patients. You will need a 4-week trial of giving them twice a day before knowing if they will work or not. Yet another class of drugs called leukotriene inhibitors are relatively new and again seem not to work in everyone.

You specifically mentioned concern about stunting of growth. This has been well looked at by a 25-year trial in which 3 groups of children were followed. These were normal children, asthmatic children not given inhaled corticosteroids and a 3^rd group with asthma who were given inhaled corticosteroids. The normal group grew best but importantly the asthmatics on steroids grew better than the asthmatics not given inhaled steroids. Also, the children with asthma given steroids were only a little bit shorter (about 1 inch or 2.5 centimetres) than the normal children.

As he has been hospitalized twice this year your son should be on a preventer.

Toddlers Diarrhoea

2007-05-22T15:33:00.000+09:30

My 2-year-old boy has loose bowel actions and is filling his diaper very frequently. He seems well and our doctor says he is growing ok. A number of tests have been done and none show a problem. What do you think is causing this?

Your son’s problem is quite common. Sometimes it is due to a persistent infection in the bowel and I imagine your doctor has sent off bowel actions to exclude this. One bowel infection that can be difficult to pick up in this way is due to a bug called Giardia and often treatment for Giardia is given even if it is not detected.
A persistent infection elsewhere in the body can also cause diarrhoea and one that is often hard to find just by looking at the child is a urinary tract infection. If not already done, it would be worth sending a urine sample to the laboratory to exclude infection.
As he is growing well it is unlikely that his gut is having difficulty in absorbing his food which is another cause of large quantities of bowel action. For the same reason and his young age he is unlikely to have inflammatory bowel disease such as Crohn’s Disease.
Sometimes an allergy to cow’s milk can cause diarrhoea. You might like to try him on a milk free diet (that is no milk, ice-cream, cheese, dairy products or manufactured products that contain milk such as bread and biscuits) for 3 weeks. Then put him back on his normal diet. If there is a dramatic improvement in the milk-free period followed by a resumption of diarrhoea when milk is taken then he probably has milk allergy. You should then consult a dietician for advice on a long-term milk free diet with calcium supplements. He will need to be on the diet for months before another milk challenge.
The commonest cause of persistent diarrhoea in an otherwise well toddler is called “Toddler’s Diarrhoea”. We do not know the cause of this condition and there is no treatment but the good thing is that it gets better by itself. Because there is no test for the condition, we like to exclude the known causes of diarrhoea that I have described before diagnosing Toddler’s Diarrhoea. The use of agents to slow down the bowel can be dangerous in that there is only a very narrow gap between the effective dose and the dose that is toxic in children. This makes it very easy to “poison” the child accidentally – a sorry outcome for a nuisance condition rather than a true health threat

Caesarian Sections

2007-05-21T15:02:00.000+09:30

Why are Caesarian Sections so frequent these days and do they harm the baby?

Caesarian Sections are done more frequently now compared to 40-50 years ago. This is happening all around the world and the major reason is to protect the baby. Natural (i.e. vaginal) childbirth is heavily promoted these days and in general the mother recovers more quickly than a woman who has had a Caesarian. However, while it is the right of any patient to refuse treatment for themselves, the rights of the baby need to be considered in the decision as to Caesarian Section.

Caesarian Sections can be life saving for the baby and sometimes for the mother. At other times they may be necessary to prevent permanent brain or other damage to the baby (and/or the mother). An example of this is the fact that caesarean Section for babies who would otherwise been born in the breech position (that is bottom first) has markedly reduced the risk of damage to the nerves of the baby’s arm and other problems.

Having a discussion as to the need for a Caesar when you are in labour and the obstetrician is worried for you and/or your baby is definitely not optimal. You should discuss this with your doctor and/or midwife during pregnancy, well before delivery.

Babies born by Caesarian Section are more likely to have a short period of breathing difficulty than are vaginally born babies. This Transient Tachypnoea of the Newborn is only for a few hours and much less serious than the condition being avoided – usually some form of brain damage for the baby.

One of my children was born by Caesarian Section because he stopped kicking. He turned out to have a severe ankle deformity. He has done very well, sailing through his University course and now holding a prestigious position in his profession. Ironically he was the best kick at football of all my children but he did spend the first 18 months of his life in night plasters to correct the deformity

Attention Deficit Hypertactivity Disorder

2007-05-18T21:01:00.000+09:30

Our doctor has diagnosed our 6-year-old son as having Attention Deficit Hyperactivity Disorder (ADHD) and has prescribed a stimulant (Ritalin). What is ADHD and what causes it?

Attention Deficit Hyperactivity Disorder (ADHD) is a relatively common disorder which affects more boys than girls although girls certainly can have it. It causes the child to have difficulty in concentrating, be overactive and disruptive.

It is easily confused with behavioural problems due to stress from the child being upset by events at school (such as being bullied) or at home (for example warring parents or parental separation).

It is really known what causes ADHD but there is some evidence that the frontal lobes of the brain (which are behind the forehead) are slow to gain their function. The frontal lobes generate intelligence and help regulate our emotions. In a bid to stimulate the function of the frontal lobes doctors try stimulants – which seems strange in a child who is already overactive. However, the giving of these stimulants can be spectacularly successful.

Whatever the cause of ADHD it should be managed because it will interfere with learning at school and make it difficult for the child to make friends. This in turn will lead to the development of Oppositional-Defiant behaviour in late childhood or early adolescence.

Psychological counselling can also be effective in ADHD but waiting lists to see a Child Psychologist are often long. Thus, a child’s doctor may decide on a trial of stimulant medication.

One of the reasons ADHD appears to be a modern plague is that we feel the need to protect our children so much. I think that if I was a child now, I might wear that label. In my case my behaviour was related to my parents unhappy marriage. I was a child when it was easier for such children with such behaviour. From a young age I was able to leave home after breakfast to visit friends with whom I spent much time playing physical games with considerable enthusiasm but limited talent. I returned home for meals or going to bed only. So my behaviour and that of others like me caused little concern for our parents. Yes it did affect my schooling and to this day I find it difficult to stay on task for more than half an hour and one hour is tops. However, I found ways to cope and ADHD usually improves in adolescence if the Oppositional-Defiant problems have not occurred.

There is also Attention Deficit Disorder (ADD) which is like ADHD but without the hyperactivity. The inability to concentrate interferes with doing schoolwork. This may not become evident until primary school; its management is much the same as that of ADHD.

Both ADHD and ADD overlap with Auditory Processing difficulties. In Auditory Processing difficulties the child can hear normally but has a lot of difficulty to in processing the messages from the ear to the brain – it is similar to listening to a foreign language. If given complex instructions such as “Go outside, rake the leaves and put them in the rubbish bin”, the child will go outside but no be able to remember what to do once there. This condition is tested for by hearing experts using specialised techniques and information given to school teachers and parents about how to help the child.

Breastfeeding

2007-05-17T13:10:00.000+09:30

I have noticed a lot of argument about the advantages of breastfeeding what are your views, Dr. Robinson?

Breastfeeding is best for babies until 4 to 6 months of age. This does not mean that a baby who is bottle-fed will suffer disadvantage for the rest of their life. A bottle-fed baby will take more work but a perfectly healthy baby can be obtained by bottle-feeding.

The 4 main advantages of breastfeeding are:

Nutritional

Infection Prevention

Allergy prevention

Emotional.

NUTRITIONAL

Breast milk contains substances that are not in formulas. Gradually these are being measured and many are being put into formulas. It is not enough just to put the same amount of them into formula as is in breast milk. A good example of this is iron, which is needed to avoid anaemia and has other beneficial qualities. It was discovered that the baby’s gut would take up iron from breast milk at a greater rate than it will from any formula. Thus more iron has to be put into formula than is naturally in breast milk.

Poly-unsaturated fatty acids (PUFAs) are another example. PUFAs are essential because humans cannot manufacture them – they have to be eaten. Breast milk contains them in significant quantities while, until recently, formulas did not.As these PUFAs are found in brain as well as other tissues, and the brain grows rapidly in the first year of life, trials of supplementing baby formulas with PUFAs have been undertaken. Once again it is not simply a matter of putting in the same amount as is found in breast milk. The ratio of the PUFAs to other fatty acids that are found in formula is critical.

Science around the world is trying to make formulas as similar as possible to breast milk. This work is slow and clinical trials need to be conducted with each change. The cost of this work is reflected in the cost of baby formulas which makes them a much more expensive option than breastfeeding.

INFECTION PREVENTION

Breastfeeding will make a baby less likely to pick up infections than a bottle-fed baby. The reason for this is that breast milk contains a number of substances that fight germs (bacteria and viruses).

One class of these germ-fighters are live cells from the mother. There are several different types of cells. Perhaps the most important are called macrophages. Macrophages attack any germs that enter the baby’s gut helping to prevent infection such as gastroenteritis (“gastro”). The cells will be particularly effective if mother has recently had an infection that she has passed on to her breastfeeding baby. This is because they instantly recognise that it is the same germ and know how to fight it.

Another class of germ-fighters are called immunoglobulins. If we have an infection such as measles we generally never get it again. One of the reasons for this immunity is that the cells in our body that make immunoglobulins that circulate in our blood and help to destroy the measles virus. We keep the ability to make this immunoglobulin against measles for the rest of our lives. Immunoglobulins are present in mother’s breast milk and help protect the baby from infections to which she has been exposed.

There are other protective agents in breast milk. Do all these substances really help in practice? Yes – it has been shown that baby’s who are breastfed are less likely to develop gastroenteritis than bottle-fed infants. Also if a breast fed infant does catch ‘gastro’, they will recover more quickly if breast-feeding is continued.

ALLERGY PREVENTION

Exclusive breast-feeding might help prevent the development of allergic diseases such as cow’s mill allergy, atopic eczema and asthma. The reason for this potential protection is that until 4 months the baby’s gut allows whole proteins (taken in any form of food) through into the blood stream where they can cause allergic reactions.

Scientific studies on whether there is an actual benefit from exclusive breast-feeding in the first 4 to 6 months are contradictory with some showing that it does help prevent the development of eczema and/or asthma and other studies saying it does not. Part of the reason for this is that exclusive breast-feeding is rare – a recent British study found that only 1% exclusively breastfed for 6 months (The target they set). Breast-feeding alone does not supply sufficient nutrition after 6 months of age. The infant gut has matured enough to block the uptake of whole proteins by 4 months. Hence it is recommended that solids be started between 4 and 6 months.

EMOTIONAL

Another advantage of breast-feeding is the promotion of emotional attachment between mother and child.

All mammals are breastfeeders of their young and all develop a unique bond between mother and baby soon after birth. This bond is called emotional attachment.There are many accounts of how determined mother mammals are to protect their young. Human mothers are the same in most instances.

A number of studies in non-human mammals have shown that breast-feeding promotes the formation of this powerful bonding process. Are there consequences if this unique emotional attachment does not occur? Harlow showed that the answer in monkeys is “Yes”. He took the babies of monkeys away at birth and bottle-fed them. When they were returned the monkey mothers showed few “mothering instincts” and were often violent towards their babies. Of course in the wild, mammalian babies that are not breastfed die from starvation and dehydration.

In humans, where the baby is separated from mother and not breast fed (e.g. due to prematurity) the early studies suggested that emotional attachment was slower and more difficult to achieve.

This led to considerable concern among those in child health and welfare. But we came to realise that the emotional attachment did eventually occur in nearly all cases. Also the separation was part of the problem, not just the absence of breast-feeding. Most neonatal units now allow unlimited parental visiting of premature babies or any other baby that has to be there. It is hoped that this will foster emotional attachment.

Thus the conclusion is the same as it is for nutrition and infection prevention: emotional attachment is easier to achieve if breast-feeding is undertaken but it can be achieved along with adequate nutrition and infection prevention in babies that are bottle fed. It is just quicker and easier in breastfed babies.

Childhood Illnesses

2007-05-12T13:01:00.000+09:30

Childhood Illnesses

My 4-year-old gets his colours confused. Could he be colour blind?

It is unlikely that your son’s difficulty in correctly naming colours is because he is colour blind. It is not unusual for a 4-year-old to have this problem.

Sophisticated testing has shown that the ability to distinguish colours develops quite early. The problem for the toddler is being able to attach the right name to the colour. A 4-year-old is 3 times more likely to make this error than a primary school child is.

Development of colour naming shows wide variation between individual children and generally occurs earlier girls than in boys. My wife still corrects me on the names of colours I use!

Colour naming problems are much more likely to be the reason than colour blindness in your son and this will become better with time.

Colour blindness can be tested at this age. Not all doctor’s consulting rooms have the booklet that is needed to do the testing. So, it would be a good idea to check if your doctor has the equipment to test for colour blindness before making an appointment.

Remember that the problem is more likely to be difficulty in naming the colours rather than in seeing them and that the naming process will come with time.

Children learn what they are taught. I used to think that my older children were all very smart because they knew their colours early. Their mother pointed out that when they said a word incorrectly (EG “ird” instead of “bird”) I would reply “Yes there is a brown bird”. I did this so they would hear the word correctly but not in the way that was a put-down. An unintended result of this was that they learnt their colours early.

Infectious Mononucleosis

2007-04-12T14:59:00.000+09:30

Could you tell me more about Infectious Mononucleosis (“Mono”)? My 9 year-old daughter contracted Mono last year. She was sick and tired for a good 6 weeks and finally seemed to return to normal about 3 months after diagnosis. Since then she has been sick a lot! She is constantly getting viruses and then secondary infections from them. She also seems to gets rundown more easily than previously. Before the Mono she hardly ever got sick. She is generally a very healthy child with no other medical problems. Some doctors say that once the mono has gone, it is gone. But I have heard that once you have Mono, you always have Mono and relapses are likely, especially when someone does not get enough rest. Could you please tell me your opinion? I am curious if the Mono is playing the part in her getting more sick more often, and staying sick longer.

In the vast majority of cases once the virus that causes Mono has been eliminated, it does not come back. A period of fatigue after Mono is well known and usually is noticed more often in older patients – adolescent and adults. At age 9 some months of fatigue would be less common but not unknown.

It is well recognized that a small sub-group of children and adults have a very prolonged period of fatigue, fevers and predisposition to sore throats. This sounds a bit like your daughter. I don’t think that extra rest is necessary. If she feels fatigued let her rest, if she wants to exercise let her even if she feels very fatigued afterwards. The reason for some boys having this persistent problem is an impaired ability to fight infections but as your 9 year-old is s girl and previously well that is very unlikely. Medical science does not find a cause in most cases with the prolonged illness.

It would be worth having a blood test (Full Blood Examination) done to reassure everyone that the cells that fight infection are there in the right numbers and are healthy. Otherwise I would give her 12 months to recover. If she does not then more extensive evaluation by a paediatrician would be warranted.

Adolescent moods

2007-03-17T13:34:00.000+10:30

Adolescent Moods

While adolescence is the time when we are physically most healthy, it is the most difficult emotionally. The adolescent has a number of developmental tasks; becoming used to a markedly changed body, developing their own identity, learning to be able to be intimate, developing a sexual identity and preparing to become economically independent. Recently there has been much interest in a study which showed that a hormone that has a calming effect in young children and adults has the opposite effect in adolescence. This was shown in adolescent mice – it will be some time before it is demonstrated in humans and even longer before anything can be done about it. However, it may explain why adolescents fly off the handle so easily.

Also, sometimes your teenager is in “child: mode" and sometimes in “young adult” mode. It is necessary for adults to work this out and respond appropriately depending on whether it is the “child” or “adult” talking.

Some adolescents have difficulties in completing all the tasks listed above. This may lead to serious consequences (suicide, drug taking, unacceptable risk taking such as driving cars fast) but it is important to realize that most will successfully complete these tasks at their own rate. During this time of uncertainty they may adopt the behaviour of a peer or adult model which can be quite distressing to other family members and friends.

A classic study by Parcel and co-workers in 1977(1) showed that the majority of adolescents wanted their doctors to supply information about drugs, sex, sexually transmitted diseases, birth control and getting along with parents. 1 in5 also wanted help with one (or more) of the following – acne, depression, obesity and sexuality. More recent studies have shown similar results.

If an adolescent is having troubles, a very useful idea is to send them to a service for adolescents only – no parents allowed. These can be found in the telephone book. If you wish to accompany your adolescent, your local doctor is probably the first port of call. Parental presence may stop the adolescent from expressing their true concerns. I might have talked about acne with my parents present, but any of the other topics – NO WAY!

1 Parcel G S, Nader P K, Myer M P. Adolescent health concerns, problems and patterns of utilization in a triethnic urban population. Paediatrics, 1977, 60, 157-164

Food allergy

2007-03-17T12:08:00.000+10:30

Three years ago our then 5-year-old daughter was hospitalised with respiratory problems. She was put on oxygen and steroids. Asthma was mentioned but I didn’t want to put her on albuterol and steroids for the rest of her life so our family changed our diet. For 3 years, she has not eaten dairy, gluten or many chemicals e.g. nitrites.

Last weekend at a relative’s house, she ate a taco with just a little bit of dairy in the seasonings for the meat. Next day her eyes were watery, red and swollen. In the past 3 years she has had watery eyes at times (if she ingested some food dyes for instance), but has not had any breathing problems or vomited. 2 days after the taco she vomited and did not try to eat until later that afternoon. That evening she had ear pain for the first time since pre-school. 6 days after the taco she had pink eye.

It would seem that your daughter did have a food reaction although from the timing, pink eye may be a coincidence. The question is: to what did she react? The taco shell probably contained preservatives. Milk allergy is rare (but not unknown) in 8 year olds. As her reaction, although unpleasant, was not life threatening, I would be inclined to expose her to milk and note the response.

To do this, put a few drops of milk on her tongue and see what happens. If there is no reaction in 24 hours try an ounce of milk as a drink. If there is still no reaction, in the next 24 hours, give her 2 ounces of milk and gradually build up in that way.

The next thing I would challenge her with is gluten, as this not usually a trigger for asthma. Again start with a small quantity and build up. If she can tolerate both it is likely that food additives are the allergy-producing culprits.

By the way asthma is not for life. 80-90% of children grow out of it. For children who have asthma early in life (as did your daughter) 50% have grown out of it by 6 years of life.

Best of luck and I would be interested to hear what happens.

Vomiting infant

2007-03-16T19:10:00.000+10:30

I have an 8 month-old son who projectile vomits at least 3-4 times a day. I have had him to his Doctor many times now and he just says it is teething and this is normal behaviour.
My son is underweight and I worry about this as well as him dehydrating. I have never seen a teething baby projectile vomit and certainly not multiple times a day, spitting up maybe, but not to this extreme.
He has seen other Doctors in the same office and their opinion is that he has a virus. This has been going on now for 6 months.
What do you think?

I can understand your concerns. If it is projectile vomiting, it suggests he has a high but only partial gut obstruction which is at the bottom of the stomach or in his intestine very soon after. Projectile vomiting is where the vomit comes out like water from a fully turned on hose. It clears the baby’s bib and usually mother’s lap. Copious (and even forceful) vomiting that is not truly projectile suggests gastro-oesophageal reflux (a complex term that I will just call reflux from now on).

Reflux is due to a failure of the valve-like mechanism at the bottom end of the gullet where it enters the stomach. We all suffer reflux from time to time when we can feel fluid coming back up our gullets. Adults just swallow it down again, but babies let it flow out.

I agree this problem is not due to teething. All you get with teething is teeth, misery and excess salivation.

As this has been going on for 6 months, your son should be investigated. The first test should be a barium meal which will show any high gut obstruction and reflux if they are present.

Any high part obstruction will require surgery. Reflux will resolve by itself over the next few months. As he is underweight, a high calorie formula while you are waiting might be warranted. A dietician can help you with this.

Tics

2007-03-16T17:12:00.000+10:30

My 4-year-old grandson has just developed a tic. He blinks his eyes a lot. His mother, my daughter-in-law, also has this same tic, so I am wondering if this is genetic? I’d like to learn more about tics in general and what if anything can be done about them. While we have noticed this tic, we have not commented on it to him as we don’t want to call attention to it as assume it is not under his control. Is the right approach?

I read recently that this could be caused by a magnesium deficiency and wonder if you agree with this statement?

Transient tics involving the facial muscles and eye blinking occur in one quarter of children. You have done absolutely the right thing in not drawing his attention to them. Stress usually makes them worse and as he cannot control them, commenting on them will only make them worse too. In fact constantly mentioning them can make them permanent – did this happen to his mother? They usually only last for a few months.

No treatment is effective or needed. They are much commoner in boys than girls.

Tics do occur in some illnesses but if he is otherwise well and does not exhibit any other strange behaviours, looking for these is not warranted.

The fact that his mother has tics also does not necessarily mean that the tics are genetic. Often symptoms that do not appear to have a cause run in families e.g. if mum has a headache when stressed often her children will have headaches with stress.

As regards magnesium deficiency, this can cause epileptic fits and other muscle jerks. However, magnesium deficiency is very rare – I have only seen it in 2 children who had very serious underlying diseases

Strep. throats

2007-03-16T16:07:00.000+10:30

6 months ago my son had 90% of his tonsils removed along with the adenoids. He also had a nosebleed fixed. When we came home I noticed his nostril was closed off, well it did not get any better. It is like it was welded together. The Dr. said the scar tissue attached itself to the other side of the nostril. But I think it is something the Dr. did on the day of the surgery. Because it was like that on the same day. Also he has had Strep 4 time since then. Is there anything that I can do to prevent him from having strep so often?

When any part of the body is operated on, it swells. Swelling is a part of inflammation which is the body’s response to any insult such as injury or infection. Thus, the initial blockage was due to this swelling. The swelling would be long gone by now. The attachment now could have happened as the surgeon said although I have never seen such a case. One can function quite well on only one open nostril.

As regards the Strep. throats, penicillin or amoxycillin are very good at treating them. However, your son may be a carrier – when the bugs live in the throat area but do not cause disease. But if he has a virus infection in the throat, like a common cold, this changes conditions in the throat in such a way that the Streps can multiply and then they cause disease. I had some success in getting rid of the carrier state by giving an antibiotic called lincomycin (or its close relative Dalacin-C) while the patient is well.

If the Strep. throats continue, consideration would have to be given to removing the last 10% of the tonsils.

By the way has your doctor proven that the sore throats are due to Strep. by swabbing the throat for laboratory investigation? It can be difficult to tell the difference between a viral throat and a Strep. throat.

Crohn's Disease

2007-03-16T15:05:00.000+10:30

I have a 15yr.-old diagnosed as Crohn’s disease 5 years ago. Her bowels were impacted and she spent 5 days in hospital to clean her out for scoping. After 3 years of medicine she saw another Dr. who said she didn’t have Crohn’s because she suffers from constipation and not diarrhea. What do you think?

The 3 most common symptoms of Crohn’s disease are diarrhoea, abdominal (tummy) pain and weight loss. However, it is well known that diarrhoea may not occur. One quarter of Crohn’s sufferers have anal fissures(cracks) which make using the bowels painful. As a 10-year-old, your daughter may have been holding on and not using her bowels because of the pain. This would lead to constipation.

I would be most uncomfortable arguing with a diagnosis of Crohn’s disease made on scoping her bowel, especially if a biopsy of the bowel was taken.

Did she improve with her medication for Crohn’s? If so that is strong evidence that the diagnosis was correct. I gather that the medication was stopped 2 years ago. If she remains well since stopping that does not say the diagnosis was incorrect as Crohn’s has times when it is quiet with no symptoms only to flare again later.

I wish your daughter luck with this unpleasant disease. She needs regular medical review as the symptoms and signs of Crohn’s can be elsewhere than in the gut. Poor weight gain or actual loss may be the main sign in children.

Acne

2007-03-08T14:43:00.000+10:30

My son has terrible pimples, and no creams seem to cure or prevent them. His confidence is down, as are his school grades and his self-esteem. He thinks he is ugly and that he’ll never attract girls. Can they be cured, and what can I do to help his emotional problems?

I feel sorry for your son – many of us can remember how miserable pimples made us feel. As you’ve found, creams and ointments are next to useless. He should not squeeze his pimples as this leads to more pimples forming.

Because of the psychological problems you describe, further treatment is needed. Ask your doctor to consider prescribing a daily antibiotic for your son. If that is not successful, ask for a referral to a dermatologist because there is a very effective (but expensive) medication that he/she can prescribe.

Usually, effectively treating the acne (as pimples are called) will improve his psychological health. It may help to have an adult who suffered bad acne talk to your son, especially if he has a photo showing his pimples. He will be able to assure your son that he will eventually grow out of the problem.

Appendicitis

2007-02-28T15:25:00.000+10:30

A surgeon has told me that my 10 year-old daughter should have her appendix removed because of repeated tummy pain. He said she had a “grumbling appendix”. My local doctor says there is no such thing. What is your take on this?

The party line in medicine is that there is no such thing as repeated appendicitis. Appendicitis is an acute illness with pain starting around the belly button and then moving to right side of the lower abdomen (tummy).

Having said this, I have met many people who swear that having their appendix out cured their repeated pain.

Children tend to have tummy pain with illnesses elsewhere in the body - for example, with sore throats. It is rather like adults developing headache when unwell from something that is not in their head. I would ask your local doctor to give her a thorough going over in the next episode i.e. look carefully at her Ear, Nose and Throat and other body systems as well as the tummy. A urine sample to exclude infection would be useful as 1% of girls her age suffer urinary infection and this can be a cause of abdominal pain.

Just as adults have headaches with stress, children suffer their stress pain in the tummy. The major causes of stress at this age are a problem at school, e.g. bullying, or problems between the parents which cause the child to want to stay at home and keep an eye on things. Migraine can cause abdominal pain rather than headache in children.

Thus, there are many things to be checked before a child should be subjected to an operation for repeated tummy pain.

Tonsillitis

2007-02-07T20:18:00.000+10:30

I took my 6 year-old daughter to the doctor because of her sore throat. She said my daughter had tonsillitis, and swabbed her throat for the laboratory. My daughter has been given antibiotics to start immediately but I am to telephone for the laboratory result in 2 days’ time. Can you tell me about tonsillitis and why the throat swab was necessary?

Tonsillitis is a common infection of the tonsils in the throat. In about half of the cases the infection is due to a bacteria called Streptococcus, in the other half it is due to a viral infection. Your doctor can make the diagnosis of tonsillitis by seeing pus on the tonsils but cannot tell whether it is bacterial or viral. The laboratory will do that by culturing the swab.

Because there is a 50% chance that it will be the Streptococcus it is reasonable to start antibiotics. If it is due to the Streptococcus then a longer than usual course of antibiotic will be given.

In cases of tonsillitis it is important to tell the doctor if there is any family history of rheumatic fever because the Streptococcus can trigger this serious disease in those who are genetically predisposed. This aggressive approach demonstrated by your doctor has helped to make rheumatic fever uncommon in first-world countries.

Repeated tonsillitis will prompt your doctor to suggest having the tonsils removed. Otherwise tonsillitis is just an unpleasant infection except in those who are liable to develop rheumatic fever because there is a family history of it.

Introduction

2007-02-05T18:45:00.000+10:30

This blog is to provide answers to questions from parents about childhood illnesses.

I’m David Robinson, a recently retired paediatrician, and I ran a successful and popular Q&A press column for some years.

I’ve always believed it’s better to answer the questions asked by parents rather than write articles about what I think they want to know.

I have six children, now adults, and three grandchildren.

To get the ball rolling, I’ll feature some answers to questions I’ve received in the past.

If you want to ask a question, or require a more detailed follow up question or answer is needed, please email me. I look forward to your questions!