Recently Asked Questions — And Their Answers
by Robert R. Jarrett M.D., M.B.A., F.A.A.P., M.R.O.

Thank you for perusing my site. As you know, I am a pediatrician and so my experience is limited pretty much to those under 21; but, as a managed care medical director responsible for credentialing and quality improvement – physicians, I DO know. And from what you describe, you didn't get a very satisfying exam or deliberation. Having a "too kinked" nasal passage does not, in itself, cause frequent sore throats- which you said was why you went to the doctor in the first place. If you have chronic sinusitis as a result of the "crookedness" that might be a different story. Also, you didn't say that he found any abnormality in your tonsils (which at your age shouldn't be of substantial size- as they decrease with age.) and you didn't mention that you had problem with recurrent TONSILLITIS (not just a sore throat). So the information you gave didn't really indicate rational for tonsillectomy. And, although infrequent, there could be a voice change following the procedure.

As you can tell, I'm not able to diagnose or recommend via the Internet on the problem you described. HOWEVER, it is a primary rule that no-one should undergo a surgical procedure without complete faith that the doctor has spent enough of their time and talent to correctly diagnose the problem, has explored and explained alternatives at all levels short of invasive surgery AND that they have rapport and trust enough that they have the skills and expertise to do the best job possible. Doesn't sound like you have that so should either go back to the same doctor loaded with questions and make it so, or see another physician. A physician board certified in internal medicine might be a good place to start, having no bias toward surgery, realizing that would only cover part of the issue. You still need to have faith in the surgeon performing the procedure so need to either work it out with the one you've seen or see a new one- explaining your situation to the internist might res ult in a referral to one with a bit better perceived "people skills"... Hope this helps a little

From what you tell me the child does NOT yet meet the criteria for tonsillectomy set up by specialty boards. It doesn't surprise me that someone could find a physician who takes tonsils out with less stringent criteria especially if there are financial remuneration issues. Additionally a "controlling" person might not have difficulty talking until a physician agrees with them.

I would demand of a physician that the child's entire medical history be reviewed and insist on documentation in the record of "sore throats"- their cultures and treatments- of a trusted pediatrician (trained specifically for children) before making the decision on tonsillectomy.

By the way: "acute tonsillitis" just means that the child is in the initial onset phase. "Acute" is what everyone gets first and if it lingers on and on it becomes "chronic." The term "acute" is not used to describe the severity (or importance) of tonsillitis. Throat cultures should usually have been taken before both instituting antibiotics and switching to another one.

If there are any smokers around the child - don't! Hope this helps you work with your trusted physician.

Wow, it sounds like quite a story, and, frankly it probably "looses something in the translation to Email," but there is probably more than one issue going on. It would be nice if everything was related and one answer would solve it all, but more likely than not, there is an infectious illness, a stomach problem and her "heart" problem all in the setting of what WAS "prematurity."

Prematurity itself is a significant problem, while it is happening; but, as the child gets older it means less and less. By 3 the child usually is developed enough to have "outgrown" most issues of being born too soon (EXCEPTing those inflicted upon them during their prematurity care - like respirators, surgeries etc. etc.)

The heart of a premature infant is also not usually any different than full term infants EXCEPT that, on occasion, the Ductus Arteriosus (bypass shunt used before birth - which normally squeezes shut with their first breath and oxygen) can stay open and sometimes need to be closed off artificially. But you don't need to "open the heart" in order to do it. It is usually closed by placing a "band" around the duct on the "outside" of the heart.

Actual "open heart" surgery (like for a mis-formed valve etc) would truly be a different matter and could occur whether the baby was premature or not. So they wouldn't normally "grow out" of the issue with age. Which of these your daughter had I cannot tell from your letter.

The term "throwing up" is usually reserved to mean the "forceful expulsion" of stomach contents by the contraction of it's musculature and diaphragm. If it is severe (like out into the room) that could mean Pyloric stenosis which would require surgery (which you didn't mention, so is probably not the case). True vomiting more than a few times a day would most likely result in dehydration and hospitalization. More likely, what your child had was regurgitation/reflux (often seen in premature's) from the "valve" at the opening of the stomach not closing well and formula/food etc "bubbling," or refluxing, back up into the mouth. That sometimes requires surgery to close (you didn't mention that either); but, most often is treated by keeping the baby upright, especially after feedings. Sometimes a "reflux" board is used to strap them upright during sleep etc. Preme's usually "grow out" of the problem; but, other things can precipitate it as well- like being overweight, eating before lying down, hiatal hernia, gassy foods etc. By 3 years old, "reflux" is not related to being premature. It could be any of the things I've mentioned- or some others that your pediatrician could discuss with you. At any rate she should be completely off the bottle by now; not be fed within 1-2 hours of bedtime or drink within 30 minutes of bed; especially not take "gassy" foods; and watching growth so as not to cross body stature growth lines (i.e. get overweight for height); etc. Reflux has nothing to do with "nasal passages."

Recurrent ear infections are somewhat related to "nasal passages"; but, more likely related to anyone smoking in the same enclosure as the baby and being put to bed with a bottle.

The NORMAL child has 100 "illnesses" (cold's, flu etc) by the time they are ten! Smokers kids have even more than that. Premature's also are "more prone" to respiratory and gastric "illnesses" but that resolves as their lungs and other organs grow. Some, if not most, of those illnesses produce cough and congestion; and, if she has a "weak stomach valve," would be more prone to gagging and vomiting with coughing spells.

Some of those illnesses are sore throats which usually resolve by themselves without antibiotics. And some of those sore throats are STREP throats which require antibiotics; but NOT before a test for strep has been shown to be positive. In that case you must use the antibiotics as directed for the full course in order to prevent complications.

The doctor would not be able to see "puss sitting on the lungs." If there is exudate (puss) on the tonsils he/she should have done a strep test. IF that was positive he should use antibiotics. Arbitrarily putting a child on antibiotics by "looking and guessing" is an old fashioned practice which has led to the development of dangerous and deadly bacteria strains and is no longer considered proper for pediatricians.

A doctor does not need a child to "get bigger" in order to diagnose tonsillitis. That can even be done in preme's just by looking and cultures.

The steps to resolve any problem such as this would include:
1- Realize that the regurgitating, vomiting, colds, tonsillitis are probably separate problems. A child is "supposed" to be ill many times in childhood in order to develop resistance to viruses etc.
2- Make sure that any of the problems are not being "caused/inflicted" by anything that can be stopped. (like the bottle, smoking, overfeeding, etc); and stop any practice that you are suspicious might be precipitating or aggravating the problem.
3- Seek advice from a medical professional who is not only trained (for example a board certified Pediatrician) but who has "people skills" such that he/she can explain and communicate. A Pediatrician is trained in solely children's diseases. There are other generalists and family doctors who's training in children's diseases is no where near as extensive.
4- If you ARE seeing a board certified Pediatrician who is answering questions and communicating well then the next referral source would probably be a pediatric gastroenterologist who will, in addition to the things I've mentioned above, possibly do other testing (like x-rays or endoscopy). Controlling "stomach" reflux can be done by: diet, sleeping position, medications and surgery- preferably in that order.
This may help you formulate your plan for identifying and resolving the problem with your physician.

Thanks for your interest in my site. I must tell you that I receive nearly 3 questions about tonsillectomies for every one question about anything else. So there still seems to be a lot of confusion about the topic DESPITE the American Academy of Pediatrics and boards of Otolaryngology having published fairly good "guidelines" for physicians.

You expressed great concern about your son's upcoming surgery and asked if there was anything else that could be done and I also heard the unstated implication "does this really need to be done?" Your fears are telling you something - if only that you haven't been given enough credible information. And, you would be in the best position to answer the questions.

First, ask yourself "what are we trying to improve or prevent" - i.e.. "why are we doing this?" What happens when your son gets a tonsil infection? Does he miss more than a couple days of school? is he otherwise healthy? How are the infections diagnosed - by a "screen" or have "real cultures" been performed? If they were caused by Strep more than a few times have follow-up cultures after he was "well" been performed to make sure that he just isn't "a carrier" for the strep which then "incidentally" is found whenever someone has done a culture? "Snoring" by itself is not an indication for tonsillectomy nor are multiple ear infections indication for adenoidectomy as long as they resolve by treatment. Has there been any hearing impairment demonstrated over 6-8 months? Is there any "emergency" reason to perform the surgery now - especially going into summer when the incidence of "colds" and infections go way down?

If you stand back and take a fresh look at the answers to these questions it should help you make a decision. You should know that there have been studies which have shown the incidence (frequency) of sore throats most frequently don't get any less after the tonsils are removed (their severity may diminish somewhat.) Also that x-rays are not the test for diagnosing soft tissue. Bone is what they show best so if someone looking for air passage on an x-ray would most likely only be able to comment on the bony nasal passages - you didn't mention him being scheduled for nose turbinate surgery. X-rays are not in the guidelines as diagnostic measures for tonsillectomies.

It sounds like there are those pushing you faster than you feel comfortable in going. Ask yourself: what will happen if I wait? a month or a year? one or two more sore throats? or anything else?

A Rand study showed that in the US there is much surgery (and procedures) performed without adequate indication. I'm not sure whether your son's would fall in that category or not - but, before you allow any incisions you should REQUIRE that your son's physicians convince you with facts and logic and that the benefits (whatever they are) outweigh the risks.

A second opinion may be in order from an unrelated physician.

Thanks for responding to my column. To which article are you referring? Tonsillectomy? - if so that article was originally written about 6 years ago so the figures may need a bit of updating.

Although in a "layperson" type article I couldn't list the sources like I prefer to in my scientific based articles, information for those articles usually came as I was reading medical journals. I used Pediatrics, Journal of Pediatrics, etc. mingled with official publications & pronouncements of the AAP and AMA with the occasional, applicable other sub-specialty journal as well.

About a year ago, I answered another question on tonsillectomies for a grandmother and did a MEDLINE search to update some figures. Although I can't remember I most likely went back to the original article and updated the figures (I usually do). 600 million must have been a meta-analysis of some sort.

Thanks for visiting the website... I've re-reviewed clinical guidelines for tonsillectomy to see if they have gotten any more simple over the past 3 years and unfortunately they have NOT.

Indications for tonsillectomy as a treatment for any speech disorder is VERY rare indeed. That being said, I realize you were trying to streamline your question, but the clinical information and indications you gave weren't adequate for me to proffer an opinion on the necessity of tonsillectomy.

Additionally, at least some of the evaluation is direct examination of the throat, neck, chest and ears of the patient.

It is clear, however, that the risk of morbidity (worsening physical illness) and Mortality (death) of a child who is subjected to such an invasive procedure is substantially greater than most people realize. Even physicians who make their money on performing such procedures are backing up and revising their guidelines UPward (performing LESS tonsillectomies).

There is very little clinical literature which show clear evidence of improvement in any speech pathology due to the removal of tonsils.

It would probably be wise to consult a board certified Pediatrician before making a decision of this significance for your child.

In all of my years I've never seen, or heard of, a case where hypertrophied tonsils cause malocclusion.

You didn't say how old your child is; however, I used to practice in a town where several patients of mine told me the same story about a particular ENT physician in our town (who took out more tonsils than almost all other ENTs in the town put together). He would look in the child's mouth and drop his chart and exclaim "they're as big a teenagers!" -- the truth is that tonsils waste away with age and I've seen many many healthy 6 year olds with larger tonsils than most teenagers.

I believe you are right to be skeptical about the relationship - I am.

unless tonsils meet in midline - causing solid food dysphagia - have a specific number of recurrent infections of a specific organism - or meet other well established guidelines the risks of surgically removing them outweighs the benefits of their removal and is not deemed medically necessary... hope this helps

It sounds as though you have a perplexing problem. I wonder if I could ask where (in the world) you are located. I ask that because, although I understand all the words that you have written, I'm concerned that I don't understand all the issues. Different areas of the world use different terminology and experience different grouping of germs and I'm not sure I yet know how to "interpret" your question. You use the term "pediatrician" - in the U.S. that means a licensed physician who has undergone three additional years of specialty training and passed the "national board" examination in Pediatrics. What is the training of the doctor that you are seeing? And could you give me a little bit more description of your child's episodes of illness? What happens to him, and what do YOU see before you take him to the doctor? Then, what does the doctor see and: how does he confirm the diagnosis? i.e. any lab tests? cultures? etc. Are there any other medical problems associated with the "sore throat."

Because of the extensive nature of this answer - it has been converted into a full-fledged article entitled "the Hitchhikers' Guide to Sore Throats," which can be found by clicking Here.

Thanks for your perusal of my web site. I had no idea that my first article would generate interest sufficient to require a second article and responses to so many varied, and specific questions. As you can tell from the articles, despite their clear indications and usefulness in many instances, they are not without their risks. They are NOT performed NOW with the almost knee-jerk, cavalierity that they once were.

You didn't mention what the indications for the adenotonsillectomy your daughter had, which limits my ability to assess the situation; however, it is not unheard of, or uncommon, to have some amount of change in vocal quality following an adenoidectomy (less so a tonsillectomy).

Additionally, I'm not sure what you mean when you use the term: "high pitched." I did have a patient once who came to me complaining that her son's speech always sounded "nasal" to her. He didn't have any medical indication for the tonsillectomy (which her nurse-neighbor had told her she should obtain), and I told her so. We had a good enough relationship that, after she had seen a local ENT on her own- and had her son go through the procedure, she returned to me for follow-up. He then had what she described as "a higher voice," but, to me, it had changed very little, and mostly in quality (resonance). To her, he still sounded "stuffed up," and it was true, he did have some nasal quality to his speech- which, if anything, an adenoidectomy would have made more pronounced.

Anatomically, the vocal chords are separated a distance from tonsilar tissue. One of the ways the procedure is performed is with a wire loop on the end of a trigger like mechanism. The loop is placed around the tissue and, when the trigger is pumped, it tightens, cutting through the tissues (like a wire cheese cutter). As you can guess there is a bit of bleeding which needs to be controlled with the laser. The surrounding tissues do contain vascular and neural tissues; but, the most prominent concern, when performing the procedure, is to avoid blood vessels in close proximity.

To INCREASE the pitch of one's voice, the vocal chords need to be TIGHTENED. That is why when someone suffers nerve damage to the vocal chords they nearly always speak with a "lower" more "hoarse" voice- not "higher." Your daughter speaking with a "higher" voice (in pitch) would presume that the chords had somehow gotten tighter. One would have to conjecture that there would have to be just the right amount of swelling (which theoretically should resolve) or some scar tissue formation which pulls in just the right way on the vocal chords (and which would take some time to initially form then could resolve with age as well.) One would think that both of those scenario's would be unlikely; especially, without a more pronounced change in the "quality" of her voice (i.e. raspy, hoarse, etc).

If your observations persist over a few weeks, an ENT specialist can directly observe the vocal chords with a scope to see if there has been any damage; BUT, that is yet another procedure.

One of the things you might do to try and delineate the issue further in your mind is to play a singing game with her (if she is old enough to sing.) You can have her try and match your "Me, My, MEE, MOO- I Love You TOO" at various pitch levels to see if she has trouble matching, or any difficulty with lower notes.

In short, I would be surprised, with the symptoms you describe, that there has been any permanent damage to the chords. If they continue to concern you, ask your Pediatrician what he/she thinks. If he needs, he could refer you to a trusted Pediatric ENT to evaluate her chords directly.

Ms H... Your child should see a pediatrician for potential dehydration, a serious problem in a child under two... Hope this helps

Thank you for perusing my site. I must confess that your question is a bit out of my field. I do remember very well, several, unfortunate, if not misguided, treatments- such as radiation for acne- performed with dubious rationale. Unfortunately, there were numbers of techniques all described as "radiotherapy" from ultraviolet, to magnetism, to actual radiation- x-ray or other type. Not actually haven prescribed/performed or recommended the procedure, I'm not intimately acquainted with the issues and problems. My thinking would be that the dose of radiation, and it's spread or penetration, would also be a function of the type of device, coning, and shielding that was used. One would hope that some effort was made to "cone" the exposure to very small and limited areas. To the extent that was done, one might believe that it would be unlikely that tissue anywhere but the face would be affected. Namely, that one would expect more facial skin effects (i.e. skin cancer etc) than chest, b breast, abdomen etc. problems. IF what you received was true radiation. It is rare in medicine that a procedure has enough experience and data that choices can be made with much certainty. The best one can do is keep up with the medical literature, use the best information available, and make the best choice you can. If it were me, I'd be talking with radiation oncologists who were reading and keeping up with all the latest literature- that I hadn't had the time or knowledge to do for myself.

Have you made contact with a radiology department at a university medical center? Additionally, at such centers there are usually individuals (and clubs) who are medical history buffs- who might be more aware of the technical aspects of such "legacy" treatments.

I wish you well in your quest- doubt this helps much. You should definitely have a discussion about your concerns, with your board certified oncologist and/or radiation oncologist. With your history, they should be able to advise you on treatment plans for your current problem. I would not make a choice about the treatment plan for your current illness without such specific discussions. Believe me, I've looked at most of the medical related type of information available on the web; and, it is most certain that you would not get the specific information you need from a web source, of any kind.

I had a similar query a couple of weeks ago and several within the past few months. There must be a resurgence in either parents asking their dentists for children IDs or those searching for secondary services to sell. Or I guess there could have been a news/magazine article about it but I haven't seen any.

My article is a reprint from one written about 9 years ago. I'm looking into it in order to update it but haven't found the information I need. At my first glance it appears the two sources I've referenced have either changed or discontinued. As I say, I'm still looking into it but as yet have been unable to locate a Web presence for either of the companies. If you find a source before I do I'd appreciate hearing from you.

Thanks Dr Y for perusing my site. I was asked the same question about a month ago by another dentist and am sorry to say that the companies have seemed to "gone away." I tried several avenues to track them down and even talked to a dentist friend of mine who used them a lot in his practice to no avail. He said that the "kid identification phase" seemed to nearly dry up and he quit ordering them.

From my standpoint, however, it seems that the fear of child abduction and harm is more prevalent than ever, I'm not sure why parents seemed (at least in his practice) to have stopped desiring "dental ID" solutions.

I thought of yanking the article from the site but the other content is still, I feel, relevant and have not done so. I guess I just keep hoping that someone, such as yourself, will write in to correct my sources with new information.

If you should run across a source of similar ID I would appreciate the follow-up so I could share it on my site.

I think you may have stumbled on an excellent way to not only maintain fitness but to "hook" your child on doing some "sweating" before she/he enters the "black hole" of adolescence where almost nothing seems "fun."
Stretching is probably even more important in a child than in an adult although it's very important there too. You say you keep your fluids up - which is good - remember, if you "feel" thirsty you are already behind in fluids; and, good nutrition is MUCH better than sugar based drinks.

The actual episode of running must take into consideration the temperature, humidity and the child's current health. Modify either the intensity, duration or location (i.e. inside) when any of the parameters become troublesome. And of course there is no point running injured or ill.

With that said, a mile shouldn't be problematic for either child you mention - although the pace and duration could be vastly different. The more runners that get involved the more complicated it is to keep everyone happy and challenged. I used to run a "couple of times around" fast then be joined by a "grandson" when I was ready to go at his pace for a few more. A younger child could ride their bicycle along with you.

Be very watchful of the condition of the children's feet, ankles, muscles and overall condition. Children with Pes Valgo Planus (flat feet) or tibial torsion's (turned in or out) oftentimes get "tired" or "sore" more quickly (see my other articles) and should be managed before they just "give up" on exercise.

Good fitting shoes with over the ankle support should be used, especially on anything but flat level terrain. Once injured it is very difficult to regain function and conditioning in the ankle. And if multiply injured it is nearly impossible to regain the "tightness" of the joint.

Now, after all is said and done, always keep in mind that the activity is merely a means to an end. It does take a bit of thought and effort to positively "cajole" and "encourage" children through the difficulties and to know when it has become "nagging" and "pushing." AND to figure out how to "mix it up" and keep it interesting THROUGH their normal lapses in interest.

Younger children usually respond to the attention and model their behavior on what they SEE YOU DO. If they see you warming up-- if they see you rearranging other things so you can keep your appointment with your exercise-- if they see you doing it even when you don't feel like it-- if they see you talking about positive results you feel-- if they see you changing the venue when you get bored instead of quitting-- if they ... (well you know what I mean, don't you?)

As the child gets older they can respond to WHAT YOU SAY. Providing reading and instruction sometimes helps them exceed your own abilities. Rewards can be (and sometimes need to be) more delayed, intermittent and abstract. But it's always wise to point out their internal benefits. Before and after charts and/or photos are very revealing and often helpful.

And, even older still, the adolescent needs to be instructed that IT'S THEIR JOB to take charge and "turn into" a person who can accomplish their goals. They should not be afraid of discovering their own weaknesses and shortcomings so they can ameliorate them. They should realize that they should be making provisions for, and progress in, EVERY area of their life. Social, Education, Vocation AND Health should ALL have a "daily entry" in their student day-planners. To help them, YOU should "interview" them frequently to help them see their progress and direction in all four of the areas- including "health" (i.e. exercise). When they progress from adolescence to adulthood they should be so ingrained with the habit that, although they may not know why, they just feel "bad" or "uneasy" when they haven't "done something" today. (I do go on a bit don't I)

That is the "true" competitive sport- BECOMING! I'm sure other competitions have their place, I'm just not sure what it is.

Hope this helps... a bit anyway... "A shared memory is part of who they are forever"

What an event for a two year old!

I'm assuming, at that age, she probably didn't handle either the injury or the treatment very well. Depending upon how she was treated in the ER, and the doctors office, (and how she took it) it may have changed her behavior. Usually, however, if it is caused by such an event, it makes them more clingy and less adventuresome - at least for awhile. The thought about a headache is reasonable, and you seemed to have treated it well; but, by now (a week or so out) shouldn't be an issue. The "terrible two's" is a REAL phenomenon (whenever, between the time they learn to walk and go to college) it occurs. And it is not uncommon for injuries to increase during that time.

It sounds like you've watched for the usual neurological signs, which have all been negative, so it would be very unlikely that behavioral changes would be due to a neurological phenomenon. That said, the decision to perform an MRI would be based more upon the neurological PHYSICAL EXAMINATION than upon taking a history, no matter how thorough it is given. (The physical examination is, however, driven by what a doctor hears in the history). So, if you believe you have noticed a distinct difference in her behavior - which is troublesome - your physician should perform a thorough exam with that knowledge. He/She will look "more closely" for the subtle signs of neurological trouble.

Although I don't know what articles you've read, any of them which talk about personality changes after a head injury are undoubtedly referring to injuries where there were neurological signs and symptoms to begin with (like unconsciousness, fracture, subdural, anoxia, etc.) It's got to be very rare indeed that such behavioral changes could be blamed upon a head-conk just requiring stitches without any other neurological signs. Like I said, however, if you were a patient of mine, and I was talking to you on the phone, I would say: "bring her on in and let me check her out to see if anything else is needed." [In the majority of cases of toddler head lacerations, without neurological signs, neither an MRI nor a head X-ray is required.]

Hope that helps - although by now you and your doctor have probably already taken care of it.

Of course I wouldn't be able to make treatment advice as a physician as I haven't examined your child.

You didn't mention what training the physician you've been seeing has had. I'm not sure whether you have seen pediatric urologist or a pediatrician; or, if you're still at the family practioner stage.

A very common cause of what is "thought to be UTI" is: pin worms- so common that most pediatrician check for those almost whenever a girl has problems with recurrent UTIs. Also vulvo-vaginitis.

You mentioned she "pats" dry. Usually of much more significance is the direction that she wipes. NEVER wipe from back to front (pulling contamination from the anus); ALWAYS wipe from front to back.

And, of course, sometimes nervousness or other emotional issues causes frequency and urgency- wouldn't be unusual, especially if she is dry through the night. (i.e. has a normal size bladder that can hold through the night)

And, to round out picking my brain, caffeine drinks (and certain other medications) can produce nervousness with frequency and urgency along with certain types of food allergies - I've seen it with milk, and nut allergies... Hope this helps you manage her problem.

Hygiene is always a concern in urinary tract infections. Most common cause in girls is wiping from back to front. "Holding it" also can precipitate a urinary tract infection due to concentrated urine and lack of proper "flow." This could have been the case in a 9 year old who feels "inconvenienced" or "uneasy" with temporary toileting facilities.

A specific culture to find out which of many bacteria is causing the UTI (urinary tract infection) does, in fact, take approximately 3 days unless the doctor performs the test in his office. HOWEVER, the diagnosis of a girl having a UTI can be immediate or within a few hours and temporary treatment begun without waiting for 3 days.

If this is a girls FIRST UTI then the above mentioned two reasons are so common that most pediatricians feel further diagnostic workup (beyond treatment to resolution) is not necessary. If a second infection occurs (while the girl has been aware and avoiding the above mentioned causes) [or first in a boy] then further diagnostic workup is most often warranted with x-rays, or cystoscopy.

Because subsequent UTIs are frequently "silent" (without symptoms) in a girl most pediatricians will place her on a "routine culture follow-up" per a routine that they develop.

This general medical information hopefully is of some benefit in ascertaining quality of medical care but obviously not designed to give specific treatment advice for any one patient.

On May 19, 2005 you wrote that you were "very disheartened" to see that one of my articles mentioned Lindane as a treatment for scabies. Somehow I missed being notified of it's presence and just today stumbled upon it in the archives.

The internet is such an effective tool but with it's impersonality sometimes, even without intention, rudeness happens. Which I believe is, without question, what entrapped you without your knowledge.

It hasn't been too long ago that the information, as it was written in the article, was precisely true. I am happy to say that, thanks to your comment, today it has become so again- as you can quickly ascertain: http://rrjmd.home.att.net/illnesses/scabies.htm

I write new articles in response to questions and comments, try to review old articles occasionally, and always value well meaning criticisms. If you find any other areas which have slipped out of date, I would appreciate another Email.

I would assume that if you were searching for information about Scabies in my site it means that you have a child who might have the affliction. I hope that it has been resolved to everyone's satisfaction.

Please excuse an old man's, well-meaningly blunt, observation that most of us are much more readily polite to strangers than those persons most meaningful to us. And, as I'm sure you will agree, "tact" is a true skill that is: un-endingly learned, pleasantly experienced, difficultly exhibited and only methodically, consciously, and exhaustively "taught" to our children.

Glad to be of help ... actually leg cramps and foot pain is the second most frequently asked question that I get from viewers of my website - second only to Tonsillectomy.

The more I research the topic for all the questions I'm asked the more I realize just how UNDER-diagnosed the problem is in children and teens; and just what an amazingly wide range of skill level and treatment patterns the doctors who treat children have.

Unfortunately, I hear all to commonly that a child's doctor has just been "watchfully ignoring" the problem. Then when they are "forced" to face it the treatment is frequently not complete. Most often children have experienced the pain for so long that they "think it is normal!" Then when they obtain even just a little help it seems adequate.

There are many "styles" of orthotics; from those "naturally" inside cowboy boots, to "Dr Scholl's", to hard pieces of bent plastic, to good flexible-but firm polymer with a substantial arch (Theta) angle. [Do a Google search for Theta Orthotics - to see what I mean - www.theta-orthotics.com/ ] They are not inexpensive - so be sure and get the best ones from the beginning... thanks again for your kind words.

Yes there most definitely is a problem, and one that could create even substantial lifestyle impairment. There are, however, definite ways parents and grandparents can help.

You didn't mention how old your grandson is or what type of training the doctor he visited had (i.e. family doctor or certified Pediatrician etc); but when pediatricians see a child with leg pain the first thing they think of (also the first things people expect them to think of) are metabolic and other myelophthisic problems - which, although uncommon are pretty bad.

Probably, when he says "there's nothing wrong" he means there is nothing that he/she considers "serious" wrong- a good thing.

Most likely "pes valgo planus" or what most people call "flat feet" is the issue. The motion dynamics in the feet are so out of balance that compensating muscle groups are overused just to maintain normal posture and balance. When they are further stressed by sports or other activities they are very painful. In "flat feet" the muscles do get "stronger" but only so far and usually not enough to erase the pain.

You may have already gotten some hints in the way he behaves and his preferences. Does he prefer to go without shoes - or does at least "some support" help? Does he try to run but gives the impression he's frustrated that he can't without discomfort? Does he rub his feet or legs from being sore? Does he awaken in the night with cramps or pain in his legs and feel relief when they are massaged? Do you notice him starting to shy away from "active" play using lower extremities - even prefer being "indoors" and sitting? Does he feel he can't keep up with others or isn't as "good" as they are?

Has changing shoes helped somewhat? for example does he have less or more pain when wearing "Sunday shoes" (firm leather support with an arch support); or "good" sport shoes with a substantial arch support; or cowboy boots (which usually have the better arch support.) None of these have enough of an arch to "correct" the problem but a little usually helps some.

Many "children's doctors" (and even some certified Pediatricians) stop after the workup for the "bad" things and may even call it "growing pains".

Fortunately, most parents don't need a physician to diagnose "flat feet" - when looking at the bare feet the arch seems to "collapse" toward the floor and the toes turn ("splay") outward. [It's not always possible to compare the child's feet with their parents or siblings because they are frequently flat also];

But, unfortunately, most often another consultation with a podiatrist foot specialist is needed in order to have them made. [I have referred a few others to a site on the internet where you can obtain them by mail using measurements from an easy molding kit at substantially less cost]

The amount of pain relief seems to be related to the arch angle built into the orthotic - called the "Theta" angle. When I was in private practice I was often disappointed with results when I referred them to orthopods and podiatrists and found that there was a huge difference in the skill and expertise of the various foot specialists in my town. I finally resorted to referring to only a couple which had decent results.

We now realize that the material with which the orthotics are made AND the "Theta" angle built in to them are the two most significant factors in their comfort, compliance, use and pain resolution.

I hope that this has helped a bit -- Please let me know if I can help further or you would like any further references.

In order to respond I'll need to know a few more details.
1) What were the baby's symptoms at 2 days that prompted the ER visit; and, what was the temperature and how was it taken?

Also, a "migraine" headache is different than a "spinal leak" headache and doesn't respond to a blood patch. What you describe in your sister seems to be a "spinal leak" headache which is not common but a known side effect of spinal taps especially in adults. When it occurs, most of the time it heals itself over time - but unfortunately, there is the somewhat unusual case that needs a blood patch - which is usually performed by an anesthesiologist or pain specialist.

Crying and fussiness from colic can occur randomly, usually lasts under 1 hour, frequently develops a "pattern" that the parents can spot. Fussiness from gas, food, environmental and other issues usually show's itself over time and can be corrected. Fussiness from colic always goes away within 2 -3 months; fussiness from temperament - usually does not.

Hope this helps, that you can find and establish a good relationship with a knowledgeable pediatrician, and that the problem can be resolved.

It is not uncommon for a physician to measure an "opening and closing pressure" when performing a spinal tap. If an elevated pressure is found then a more definitive MRI is performed to look for cysts, tumors etc. MRIs will frequently show results of increased pressure if any.

It is not uncommon for children w/ neurological problems to also show subtle behavioral/cognitive symptoms which are vague and difficult to delineate. This "hyperactivity" or "impulsivity" is "worked up" and treated separately (or in addition to) the neurological. Some neurologists work this problem up, most refer to a pediatrician or psychiatrist for evaluation and treatment... I have given basic clinical information - not specific to any one person. I hope this helps, a little.

I'm not sure what you mean by "bad breath and dental issues" but would be rare for any of the things you list to be related to adenoid tissue. Mouth breathing, could be- IF the adenoid tissue mass was excessively extensive. Perhaps you have an ENT specialist that you trust (and a child who might cooperate by being sleepy) so a good exam of the adenoid tissue can be made in the office. If the nasal choanae are completely obstructed by tissue it either could be removed, or you could wait until the child's passages grow and lymph tissue shrinks. [As an incidental note: there have been studies which have shown that T&A's (removal of tonsils and adenoids) do NOT reduce snoring. And, it's not a good idea for a parent to go into the surgery- even if you want special treatment for being medically associated. Still further, if you have to "wonder" if the place will be "clean" you should go to a different hospital.]

To be honest, in all my years of hearing about infants difficulties, this is the first time I've heard about this specific issue. My guess is that, were you to visit a board certified pediatrician whom you trust he/she would be able to give you assurances that "it was nothing to be concerned about" but tell you to wean her off the pacifier (two is a bit old for the thing anyway- much longer and you may run into dental issues.) Most individuals begin to salivate immediately when something is placed into their mouth, that's normal and expected. Most individuals drool in the night- just look at the pillowcase. So... drooling in the hours of sleep would be expected, especially if something is in the mouth. Braces, bite guards and other dental appliances usually don't produce hyper-salivation even at night.

Before you were told that however, your doctor should examine the baby's neck, gums and mouth for sign's of congenital salivary or swallowing problems or other duct's, cysts, "lumps" or "bumps" that "hadn't oughta be there."