Medicine Mondays: Circumcision; Discipline and Young Children; Vitamins and Children; Bug Spray and West Nile Virus

Hi Everyone!

Welcome back to Medicine Mondays where each Monday I post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and the medical advice that your family doctor can provide.

Circumcision

Question:
My 2 year old son had a circumcision at birth, it seems as though it were incomplete, his foreskin is mostly still intact, although “loose” I still have to retract and clean underneath, he absolutely hates it. With that being said, my middle son’s circ. was complete and perfect. I’ve had this on my mind since his birth, he had several resistant ear infections, so placing ear tubes at 9 months took priority. So, all along both of my pediatricians have said the same things, wait, it will get better, it would only be cosmetic, the risk outweighs the benefits– infection, sedation… So, what to do? My husband wants the extra foreskin removed, in my heart, I do, too , he will look “like” his brother, but medically speaking, it’s not necessary. Why now? Well, I don’t want to wait any longer, he’s already 2, potty training… and the 2 older ones are in school. My close friends say, do it, even my medical friends, they’ve had close friends who have regretted not doing it. Let me know what you think!

Answer:
You're right, a circumcision or revision of a circumcision is not medically necessary. If you ask a hundred people you may get a hundred different opinions but really the best answer is what your family wants to do. There are plenty of people who still circumcise their child and a growing number of people who do not. What is boils down to is what you're comfortable. Make a decision that feels right for you and then discuss it with a pediatric urologist. They will be able to guide to as to what time is best for your son if you do decide to revise the procedure.

Discipline and Young Children

Question:
How should I discipline my 15 month old as far as hitting other kids at school is concerned? Was told she had some alone time today because he hid another toddler and pulled her off a toy outside, (of course it is the teachers kid!) She has an older brother that is a bit pushy and I think she is projecting on other kids.

Answer:
A 15 month old is too little to exhibit a lot of self control but this doesn't mean that it's okay! At this age if they get upset they can hit or bite to get their way. It becomes particularly effective if they then get what they want following the incident. I have found that saying firmly, "We don't hit our friends!" and then having the child say their sorry or offer a hug is the best response. Don't expect your child to be perfect and remember that it does get better! Time outs can be effective but make sure that it's no longer than one minute for each year of their age.

Vitamins and Children

Question:
A friend’s child just had her 2 year check up at Kaiser and had blood work done showing her child’s iron levels were low. She was told to begin giving her daughter a children's vitamin with iron. However, my son didn’t have this blood work done when he had his 2 year appointment at your old office. What is your opinion on vitamin supplements for toddlers? My son is a pretty good eater, though he’s not a big fan of meat. I can usually get a veggie or two in him, but his favorites are fruit, yogurt, and oatmeal.

Answer:
Each pediatric office does their screening a little different. At my previous office we screened at 9 months of age. If the hemoglobin was low then we placed children on an iron rich diet or iron drops and then rechecked in a few months. The next routine screening was at 4 years of age- sooner if they were shown to have a problem. I haven't routinely recommended vitamins for a child unless it was clear that their diet was lacking. If a parent is concerned then just a plain chewable multivitamin is fine- liquid if they are under 3 years of age. Your dentist can also determine if your city has fluoridated water and whether you need a fluoride supplement.

Bug Spray and West Nile Virus

Question:
A case of West Nile Virus was found in a dead bird in our neighborhood. What are symptoms of West Nile Virus? Should bug spray be used on kids anytime they go outside?

Answer:
The Center for Disease Control and Prevention has a West Nile Virus Home Page that can guide you in whether your city is at risk for contracting the disease.

The CDC reports that The Symptoms of West Nile Virus are:

• Serious Symptoms in a Few People. About one in 150 people infected with WNV will develop severe illness. The severe symptoms can include high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness and paralysis. These symptoms may last several weeks, and neurological effects may be permanent.
  
• Milder Symptoms in Some People. Up to 20 percent of the people who become infected have symptoms such as fever, headache, and body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin rash on the chest, stomach and back. Symptoms can last for as short as a few days, though even healthy people have become sick for several weeks.
  
• No Symptoms in Most People. Approximately 80 percent of people (about 4 out of 5) who are infected with WNV will not show any symptoms at all.

The best defense is to apply mosquito repellent to protect your child against being bit.

EPA recommends the following precautions when using insect repellents:

• Apply repellents only to exposed skin and/or clothing (as directed on the product label.) Do not use repellents under clothing.
• Never use repellents over cuts, wounds or irritated skin.
• Do not apply to eyes or mouth, and apply sparingly around ears. When using sprays, do not spray directly on face—spray on hands first and then apply to face.
• Do not allow children to handle the product. When using on children, apply to your own hands first and then put it on the child. You may not want to apply to children’s hands.
• Use just enough repellent to cover exposed skin and/or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, then apply a bit more.
• After returning indoors, wash treated skin with soap and water or bathe. This is particularly important when repellents are used repeatedly in a day or on consecutive days. Also, wash treated clothing before wearing it again. (This precaution may vary with different repellents—check the product label.)
• If you or your child get a rash or other bad reaction from an insect repellent, stop using the repellent, wash the repellent off with mild soap and water, and call a local poison control center for further guidance. If you go to a doctor because of the repellent, take the repellent with you to show the doctor.

For more information go to The Center for Disease Control and Prevention West Nile Virus Home Page.

OK everyone, thanks for the questions! I'll be back next week!

Medicine Mondays: Children and Twitching; Pregnant and Breastfeeding; Hair Loss after Pregnancy

Hi welcome back to Medicine Mondays-

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and medical advice that your family doctor can provide.

The following comes from a reader on my personal blog- DrCason.org

Children and Twitching

Question:

My baby does this thing a couple times a day where her left foot twitches, and when I say twitches I mean TWITCHES, it usually only happens if there is a little bit of pressure on it, like if she is pushing on my hands with her feet. What’s that all about?

Answer:

What you are describing is called clonus. Clonus is a series of involuntary repetitive movements that occur when the muscle is stretched. It is usually found at the ankle. This is a normal finding in newborns. If it is present when you are older it can be a sign of neurological injury. It is best to go to your pediatrician so they can exam your baby and determine whether this is still within a normal range for your child.

Anemia and Getting Pregnant

Question:

When having my baby I lost a lot of blood and ended up have 2 blood transfusions. MY hemoglobin are back to normal now(I’m an iron champion!) but she still told me that I should wait until my baby is at least 6 months before we start trying to baby number two. THAT SUCKS! I do NOT want to be like 7, 8, or 9 months pregnant in my middle of summer. Do I really have to wait?

Answer:

I can't answer this as an OB so it's best to go to your doctor to find out her reasons. But as a pediatrician I can say that the baby's iron level is heavily dependent on the mother's iron stores. So the health of your baby is really dependent on you! Just because your levels have now come up to normal does not mean that your stores are at a normal level. Go back and talk with your OB. It may be that she will be flexible with her recommendations and you can work together to create a plan for your next pregnancy!

Pregnancy and Breastfeeding

Question:

If I increase my food intake by a gazillion times is it safe to breast feed while being pregnant?

Answer:

I have heard of a lot of women doing this. Most people are concerned with 1. The possibility that the growing fetus will be deprived of essential nutrients and 2. That the hormone- oxytocin- that is released during breastfeeding could induce labor. Only your OB can tell you what they are comfortable with and what precautions you need to take.

Hair loss after Pregnancy

Question:

When will my hair stop falling out by the handfuls? My hair is everywhere I’m like a big shaggy dog!!

Answer:

Oh my goodness this happened a lot to me as well! In pregnancy one of the reason that your hair gets so thick is that it goes into a resting phase. That is you actually cont to grow hair but the shedding stops. The American Pregnancy Association says this about hair loss and pregnancy:

The most common period of hair loss occurs approximately three months after delivery. The rise in hormones during pregnancy keeps you from losing your hair. After delivery, the hormones return to normal levels, which allows the hair to fall out and return to the normal cycle. The normal hair loss that was delayed during pregnancy may fall out all at once.

Up to 60% of your hair that is in the growth state may enter into the telogen resting state. The hair loss usually peaks 3-4 months after delivery as your hair follicles rejuvenate themselves. As noted before, this hair loss is temporary and hair loss returns to normal within six to twelve months.

There you go everyone. More Medicine Mondays next week. Drop me a comment or an email if you have a question for me!

Medicine Mondays- Early Intervention, Teething, Allergy Testing, Hidradenitis- Suppurativa and Infertility

Hi Everyone!

Welcome to my second installment of Medicine Mondays!

I started Medicine Mondays just last week on my other website DrCason.org and have had such a good response that I've decided to move it to my professional site. This way even more people can benefit from these great questions!!

As suggested by the title, each Monday I'll post the answers to questions that I have collected over the week. If you have a question please feel free to send me an email or leave me a comment. I welcome every comment and hope to help answer some questions. Just remember that my advice is not a substitute for a physical exam and the medical advice that your family doctor can provide.

Okay! Lets get started:

Early Intervention and Speech Delay in Children

Question:
When should Early Childhood Intervention be called in on a situation? My daughter now 15 months old really doesn’t say anything. I discussed with our pedi at her 9 month appointment in preparation for her 12 month appt. where she is supposed to be saying 6 words including mama and dada. Well, at 15 months says mama and dada occasionally and doesn’t really say anything else - audible that is. I think she tried to say her brother’s name and maybe ball or milk, but not much else. She I ask for Early Intervention to come in and work with her? I know the little ones all talk at their own pace and I am thinking it will just come, but what if there is something going on that I am ignoring.
We are starting sign language which she does: more and please. Jakey spoke late right?

Answer:
Yes. Jakey spoke later than my other two girls and I wasn't so much getting worried as I was just getting overwhelmed with all the screaming!! His language blossomed with signing!

Each child moves at their own pace and even little goobly gook could actually mean something to them. Be patient and use sign language to augment her language. I wrote an article giving you some Tips to Using American Sign Language if you need some suggestions.

Now in regards to Early Intervention. I have one rule. If I am really concerned then I refer any time there is something suspicious.

I have found that you really can't go wrong. There really is never too early of a time to call in for an evaluation. If a child is suspected of having a problem, such as speech delay, it can help to refer them early and get some additional services going.

Speech delay by itself is not that worrisome at 15 months- some babies just develop on their own. Such as my son. But I will look really closely at whether the child is socializing well. Are they looking at you for social cues? Do they point to what they need? If you point at something, do they follow your finger and look as well. These are very important markers in detecting autism. Autism that is detected at an early age can be helped a lot with early intervention.

Having said all of that, it might be that your child is right on target. Make an appointment with your doctor so they can evaluate her again!

Teething and Analgesics

Question:
Is it true that you can give tylenol or motrin for up to 5 days for teething? Then is it 5 days off and back on again?

Answer:
I don't give Tylenol or Motrin for that long. You shouldn't need to either at least not for teething. I would talk with your pediatrician to see if there is something else going on. If they are uncomfortable try teething rings or Orajel. Hyland make some teething tablets and some people swear by it!


Children and Biting

Question:
How do I get my 15 month old to not think her brother (3.5 years old) is a piece of meat she can just bite all the time? We really think she is a tiger and he is her prey! We tell her no, but she just laughs at us and then goes back in for the kill.

Answer:
LOL! Mine have all done that too. Most kids are just testing boundaries. Let them know that this is not acceptable by firmly saying no and then redirecting them. But don't go overboard! I have found that if you get too dramatic about the event then they are intrigued by the response and will seek to repeat the offense. Then you're in trouble!


Allergy Testing in Children

Question:
My eldest (14yo) daughter just had allergy testing (not nearly as involved as your son’s) because she reacted to some almonds she ate…but the testing came up negative. Ummmm…can you explain to me why she would still be reacting to them if she tested negative? We’re not talking anaphylaxis…just some mild swelling. They did do a RAST at the clinic...I don't know the results of that one...we never saw those results. The tests the allergist did were scratch tests on her arms, and the only reaction she had was to the control.
The allergist made a comment about her having just an oral reaction to the almonds, but not being truly allergic. I wish he'd explained more!


Answer:
Ahh! this is a little tricky. What most people are talking about when they talk about food allergies is an immediate IgE mediated allergic response. This is when the mast cells that contains histamine come in contact with an allergen and break open inducing an allergic response. The reaction can be as simple as some hives or mild swelling or as dangerous as an anaphylactic reaction.

We can test a child's blood for their IgE level in response to a certain allergens (RAST testing) and this can help in predicting what their reaction to the food or allergen will be. I say "help"and "predict "carefully because we don't know EVERYTHING we need to know about allergies in kids. We do think that the gold standard for whether a child is allergic or not is actually what happens when they eat the offending agent never mind what the RAST level is. In the future I will be writing a deeper in-depth article about this using all my info that I have gleaned from my son's allergies.

Now what to do about your child's allergic reaction? With a RAST that's negative and a skin test that's negative and an allergist saying she's not allergic, then she's probably not allergic. At least not with an IgE mediated allergic response. BUT you need to be absolutely sure about this before you give her almonds in the future.

I have heard of Almonds inducing a contact dermatitis. This may be what you are talking about with your child. This can cause redness and painful fissuring of the lips.

Hidradenitis-suppurativa

Question:
Do you have any ideas on how to help Hidradentitis- suppurativa?
I am trying only over the counter medications or herbal remedies as I don't have a doctor. I've had this condition for the past 30 years, but only a few weeks ago found out the name for it. I've gone to doctors in the past for help but have never had any success.

Answer:
This is a tough condition to have. It is chronic skin inflammation that we think may be actually be a severe form of acne. I recommend that you seek the help of a dermatologist. They will be able to help you in the management of your condition. There is no reasons to be treating yourself- unless its so mild that you can control it!

Your doctor may suggest some topical or oral medications as outlined in the article I've highlighted above. (I know that you've seen this as you sent me the link!)

One thing that I will mention as a side note is that we are currently learning more about acne and its relation to diet and inflammation. A low glycemic diet rich in veggies, fruit, seafood, and grass-fed meat can help control acne because it controls inflammation. Since Hidradenitis-supportiva is acne related this may help it as well.

Infertility

Question:
Hi Dr. Cason! I just found your site (DrCason.org)today and I love it already! I have a question and maybe you can answer it. My husband and I have been trying to conceive for over a year and have been extensively tested for various things. The only thing that has been abnormal has been my progesterone and estrogen ( both are low). I purchased progesterone cream, do you think this will do the trick? My husband is in the army and it is a fight to get anything done at our military treatment facility. They do not want to help us. Every last thing has been a struggle!

Answer:
Welcome!! Now I'm not an OB/GYN but I will say that if your progesterone and estrogen are low it may be contributing to your infertility problems! You need estrogen to ovulate normally and progesterone to help make the endometrium viable.

I know so little about infertility issues that I found you another expert! Edward Joseph Ramirez, MD, FACOG.I just searched and searched and found you someone who is Army trained!! Yeah !! It just might make a difference in your case as he may still have some contacts in the military and may be able to point you in the right direction!

Good luck everyone!

Please let me know if I can answer any more questions or point you in the right direction!