Antibiotics, Co-Sleeping, Hankies – PediaCast 269

Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include antibiotics & ear infections, co-sleeping, breath holding, the American Academy of Pediatrics, tissues vs hankies, the circumcision debate, and moms who try to breastfeed… without success.

Topics

  • Antibiotics & Ear Infections

  • Co-Sleeping

  • Breath Holding

  • American Academy of Pediatrics

  • Tissues vs Hankies

  • Circumcision Comments

  • Breastfeeding Comments

Links

 

Transcription

Announce 1: This is PediaCast.

[Music]

Announcer 2:  Welcome to PediaCast, a pediatric podcast for parents.  And now direct from the campus of Nationwide Children's, here is your host Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast.  It is a pediatric podcast for moms and dads, this is Dr. Mike coming to you from the campus of Nationwide Children's Hospital.  We're in Columbus, Ohio.  It is October 23, 2013, it's PediaCast 269 and we're calling this one antibiotics, co-sleeping, and hankies.  I want to welcome everyone to the program, we have a big listener show lined up for you this week.  The questions have been rolling in, which I really do appreciate lots of good stuff to choose from.

0:01:02.5

Before we get to the complete line up of topics, I have a quick story to share with you which relates to parenting and to perspective.  My son and I recently attended a Halloween event at Kings Island, and for those of you outside of Ohio you might not be familiar with the name.  Kings Island is a local amusement park with the roller coasters and thrill rides.  The place is all decked out for Halloween, the rides are going full speed, there are characters in costume from one side of the park to the other, the place is covered in a man-made mist, the fog hits everywhere, very spooky and it's night time, and there are a dozen or so haunted mazes to traverse with a fake blood, and people jumping out and yelling boo.  Good times especially if you're 16 year old boy, and especially if you are a dad of a 16 year old boy who doesn't mind hanging out with his 40 something Pap, that's a good feeling, and that's the parenting part of the story.

0:01:59.9

Dads make sure that you connect with your teenage sons, something they enjoy doing, might be a little awkward at first but trust me it's worth it.  Now the perspective part, we're there among the ghosts and goblins and we're hip deep in fog and it starts raining hard, really coming down.  So we huddle under the 300 foot tall replica of the Eiffel Tower which is positioned in the center of the park, and we aren't the only ones huddled there, there's a big group and together we watched the rain come down on all four sides, now we're dry but we're also trapped.  There's no let-up in sight and my son is disappointed and you know what, I'm disappointed too.  I brought ponchos but they're in the car and that's a long way off, the ones in the gift shop are much closer.  So I give my son my credit card and I convinced him to brave the elements and return with new ponchos which my wife is going to love because we have about 20 or so of them at home, it's just that ponchos are never around when you need them and then you're going to buy a new set.   

0:03:06.8

Here's the other parenting tip by the way, when you're huddled under cover in bad weather send your teenage son out under the rain, they love that stuff.  So off he runs and I'm watching and he gets about 20 feet or so out into the rain and I see him slow down, he stops, he turns, he shrugs his shoulders, I'm thinking "go, go you're going to get soaked", but then I read his lips as he mouths, "It's not raining."  What?  I mean I can clearly see the rain coming down, he motions for me to join him and I shake my head no, you're not going to fool me, but he seems serious and he mouths it again with a big grin on his face, "It's not raining."  So I go, you know I trust my son, and here's a third parenting tip, sometimes the kid's right and the grown up is wrong, and that's the case here, I go out and sure enough it's not raining.  

0:04:00.1

Despite the empty street and the mass of people huddling under the Eiffel Tower.  You see the rain was the water draining off in down the sides of the tower, it was just making a waterfall along all four sides, but it wasn't really rain, it was tower run off, so off we go.  Now a few others see us and venture out, but most remain under cover for I don't know how long, and the moral of the story in my mind is sometimes, especially when parenting hardship comes our way, which is bound to happen.  Sometimes we get all wigged out and we think we're ruining our kids with messed up decisions, but then when we stepped out of our comfort zone we see things are all right after all, definitely a lesson to be learned there and a lessoned learned while enjoying a night out with my teenage son, doesn't get much better than that. Let's explore our line up this week, antibiotics and ear infections, I have a doctor in training who write at writes in.

0:05:01.3

She was given advice by a nurse practitioner, and the doctor is not sure about the advice and wants my opinion.  The nurse practitioner has a nugget of truth but over all her advice is faulty and I'll explain why and I think this topic will be of interest to my fellow practitioners in the crowd.  So antibiotics and ear infections, do you treat or do you not treat?  Co-sleeping, a mom in Japan has concerns, her family, friends, and neighbors sleep with their babies, she wants to sleep with hers but she has some safety concerns so we'll explore that topic for her.  Breath holding, we talked about this extensively a few episodes back, a mom writes in wanting some clarification, what's the difference between pallid and cyanotic breath holding spells, so I'll clue her and you in.  The American Academy of Pediatrics, so listener wants to know exactly who they are and how in the world do they come up with their recommendations, can we trust them? Are they influenced by outside forces? I'll let you know.

0:06:03.9

Tissues versus hankies, a British listener is concerned, she's heard disposable tissues are used in the United States while re-usable hankies are the bomb in the United Kingdom, is this a problem?  We'll talk about it.  And at the same British mom also has a comment on the circumcision debate, she's uncovered a possible conspiracy as apparently more than meets the eye when it comes to making a recommendation on infant circumcision, so we'll explore that issue.  And finally, parents who try to breast feed but can't.  I have a heartfelt final word in the words of parent who tried her best and failed.  Overall I have a great listener show lined up for you this week and it's not me that makes it great, really it's you with some real emotion from our audience members and you'll see what I mean when we get started.  Couple of quick reminders, we can't have this great listener shows if you don't write in great questions and comments.

0:07:01.1

If you have something that you'd like to say or question you'd like to ask just head over to pediacast.org, click on the contact link and ask or comment away, we'll try to get it on the show for you.  Also I want to remind you, the information presented in PediaCast is for general educational purposes only, we do not diagnose medical conditions or formulate treatment plans for specific individuals.  If you have a concern about your child's health, be sure to call your doctor and arrange a face to face interview and hands on physical examination.  Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org.  Let's take a quick break and we will get back with your questions and your comments right after this.

[Music]

0:08:20.1

Dr. Mike Patrick: We are back, first up is Dr. Daniel Boyer from Boardman, Ohio.  Dr. Boyer says, "Hi Dr. Mike, I love the show, just start listening a few months ago but now I'm hooked and going through all the archives.  I'm an intern in my first year of family medicine residency.  While out on my rotations, I heard from a nurse practitioner that antibiotics are no longer recommended for ear infections by the American Academy of Pediatrics and by ear, nose, and throat doctors.  Can you comment on this and go on to more details about the current guidelines, surely there are still some indications for their use, I'm curious what you all have to say on the issue as I know you're more up to date than many other physicians and definitely to your research.  Thank you so much and keep up the good work, Dr. Boyer."

0:09:04.2

Well thank you for the question Dr. Boyer, I always appreciate hearing from fellow physicians in the crowd.  So here's the deal, the nurse practitioner who told you antibiotics are no longer recommended for ear infections by the American Academy of Pediatrics.  This nurse practitioner is making a sweeping generalization one that's easy to remember but not quite true.  Here are the facts as we know them, number one: ear infections are common in children.  Fact number two: most ear infections will go away on their own, given sometime our immune system works.  Fact number three: many ear infections are caused by viruses, antibiotics won't help, but your immune system is up for the job.  Fact number four: many other ear infections are caused by bacteria, antibiotics do help, they don't help instantly but you may get better a little faster compared to your immune system doing the job solo.

0:10:01.1

Fact number five: overuse of antibiotics contributes to the development of drug resistant micro-organisms and may make it more difficult to treat serious infections in the future.  And this is true both on the individual level, so you taken the antibiotic, you kill all the bacteria that that antibiotic kills in the mouth and on the skin and in the intestine and the ones that are left are the ones that that antibiotic doesn't kill, the more resistant ones and then they basically divide and re-grow into the space where the ones that were killed had been, and so now you're colonized with a lot more drug resistant organisms and that's not only true on the individual level, it's also true on the community level, if you're at work or at school and someone who's been on an antibiotic and has more drug resistant organisms now colonizing their body, and they use a telephone or they touch a door knob and then you come along or use the drinking fountain, and so we share micro-organisms even the resistant ones and so this isn't a problem just for individuals it's a problem for communities as well.

0:11:09.1

Fact number six: untreated bacterial ear infections can lead to complications, things like a spread of the infection to the blood stream especially for young children or those with compromised immune systems.  The infection can also spread in nearby bone like mastoiditis, or it can spread to the coverings of the brain, meningitis so not good things.  They're not common but they're possible, untreated ear infections can also lead to ear drum perforation and scarring, and if this happens repeatedly it can lead to hearing loss and significant complications down the road like cholesteatoma which is when skin cells of the ear canal invade through that perforation and make a benign tumor of skin inside the middle ear space and then you have to have surgeries down the road and it can create hearing problems, so there are complications we have to consider.

0:12:02.9

Fact number seven: lots of school and work are missed due to ear infections and the longer it takes the infection to go away, the bigger the loss in productivity and for some jobs or even school, missing is unacceptable.  We have lots of things to consider, some of them would lean us toward being pro antibiotic use for ear infections and some would lean us toward being anti-antibiotic use to ear infections, right?  Now as physicians and nurse practitioners we have to evaluate each patient in light of the exact situation he or she is in.  We cannot practice cookie cutter medicine, and in essence that's what your nurse practitioner friend is doing, it's easier to make that sweeping statement "Kids with ear infections should not get antibiotics, don't believe me, ask the American Academy of Pediatrics and the Ear, Nose and Throat doctors."  Now unfortunately when we try to apply something like this to all patients, we're going to do some of them a disservice.  We have to strike a balance and that is what the American Academy of Pediatrics is trying to do with their practice guidelines for the diagnosis and management of acute otitis media.

0:13:13.3  

What we don't want to over use the antibiotics and make it more difficult to treat ear infections down the road, yet we don't want to cause undue suffering from eliminating the use of antibiotics completely.  And to highlight this goal of the guidelines, the American Academy of Pediatrics says in its introduction to the guidelines and I quote, "This clinical practice guideline is not intended as a sole source of guidance in the management of children with acute otitis media, rather it is intended to assist primary care clinicians by providing a frame work for clinical decision making.  It is not intended to replace clinical judgement or establish a protocol for all children with this condition.  These recommendations may not provide the only appropriate approach to the management of this problem."  

0:14:09.0

If the guidelines do not say, "Completely eliminate antibiotics for all children with acute otitis media, also known as middle ear infections…, if they don't say they completely stop using antibiotics what do they say?  Well if you really want to know, and as practitioner you should, and your nurse practitioner friend should want to know as well, don't just believe everything you hear even if it comes from a so called expert, check it out for yourself.  If you really want to know what the AAP says about treating ear infections with antibiotics, my advice would be to read the clinical practice guidelines, and by doing so you won't nearly get a flow chart or recipe for treating ear infections, you're also going to get the rational which is just as important for deciding how you as an individual practitioner will incorporate the guidelines into your practice.  And the guidelines are presented concisely, but they also consider the myriad of circumstances that you're likely to encounter.

0:15:04.5

So Dr. Boyer to help you out, I'll put a link in the show notes for episode 269, that's this one, over at pediacast.org so you can read the guidelines for yourself, evaluate their merits and fit them into your own practice.  And please do share that link with your nurse practitioner friend as well, you'll be doing her more of a favor than cheated you.  I do appreciate your writing in, and thank you too for not believing everything you hear, always important to check it out for yourself.  Next up is Sayaka from Osaka Japan. Sayaka says, "Thank you very much for your show especially the transcripts since I'm a non-native English speaker.  I have a question related to co-sleeping, according to your show co-sleeping is a dangerous thing and I was quite surprised since co-sleeping with baby is usually recommended in Japan.  I didn't share the mattress with my new born since I didn't have the confidence not to roll over and squash the little guy, but this winter I was thinking about co-sleeping because one, it's warmer for both of us and two, he's much older and stronger."

0:16:07.5

"My baby is now nine months old and he's capable of moving everywhere and crying out loud when he needs to.  At what age does co-sleeping become safe?  I know adults and children don't normally co-sleep in western countries so it sounds odd but please discuss just from a safety point.   FYI, if I let my baby or little child sleep alone in another room it seems really odd or even neglecting in my culture, I really appreciate you telling me when we can start co-sleeping without danger. Thank you, Sayaka."

Dr. Mike Patrick: Well thank you for the question Sayaka in Osaka, I appreciate your support of the program from half a world away.  This really boils down to your risk tolerance level and I would be a fool to give you a concrete age when co-sleeping becomes absolutely safe.  There's always a chance you could roll over and suffocate your child even if your child is three years old, that becomes much less likely as your child gets older but the risk is probably never eliminated completely.

0:17:06.0

I could roll on top of my wife and suffocate her especially if she were doped up on three different sleep aids and I was an all over the bed deep sleeper.  Now this scenario is extremely unlikely particularly since neither the conditions I presented are true, but it is possible.  If it happen that you did roll over and suffocate your nine month old which is much more likely than me accidentally suffocating my wife in her sleep, if it did happen to you and your child whatever the age I'd feel pretty bad having told you it was safe.  With that said, what sort of numbers are we looking at?  I mean that can help us take a realistic look at the risk right?  Let's put it into perspective.  According to the US Consumer Product Safety Commission, and these are the latest numbers we have available on this and unfortunately they're kind of old.  

0:17:55.5

Between 1990 and 1997, 515 deaths of children under the age of two occurred in the United States while the child was sleeping on an adult bed.  Of those, 121 were attributed to a parent, caregiver, or sibling rolling on top of or against the child, and more that 75% of these were infants younger than three months, that's what we have folks, old numbers in the United States.  Based on those numbers what would I do, given my own personal risk tolerance level?  Well I would absolutely not sleep in the same bed as a baby under three months, OK 75% of these deaths were in that category, so I would absolutely not sleep in the same bed as a baby under three months.  The same room in their own crib, that's fine and Sayaka I think you see the sense in that because that's your story, you did not feel comfortable sleeping in the same bed as your new born regardless of what your culture dictated and I think that was a smart move on your part.

0:19:05.4

Now, over the age of two years, no the risk is not zero, but you know driving your child around in a car even when properly restrained, that does not have a zero risk either yet we do it.  Now between the ages of three months and two years, this is more of a grey zone, now 25% of those roll over suffocation deaths were still over the age of three months, that's still a lot of deaths.  What about between three months and six months, you know me personally I wouldn't do it, I still think they're just too much risk.  Over 12 months, personally for my own personal risk tolerance, I'd feel better about it, I'm pretty sure I did it when my kids were sick or scared, is it 100% absolutely safe?  No, but it's anything 100% absolutely safe.  

0:20:02.5

What about between six months and 12 months, which is where Sayaka finds herself.  You know how deeply your child sleeps and how much you move, and this is a serious grey zone.  I'm not sure I would do it, there is risk involved, is the risk great enough to justify against the potential consequence of your baby dying?  You have to make that decision, I'd be foolish to decide for you, you have to make the call and be willing to live with the consequences.  Now you'll likely find what you want to hear somewhere.  Someone will be willing to tell you that co-sleeping with a nine month old is absolutely safe, that would make you feel pretty good right?  Someone said that, but just because an expert says it doesn't make it true.  Nothing in life is 100% absolutely safe, not even bubble wrap. I mean we joke, you can't wrap kids in bubble wrap to protect them, well you could but they might suffocate.  I'm hoping this makes sense to you Sayaka, I know you're not a native English speaker and I guess I'm a little worried that translation's not going to come out very well here with using words like grey zone.

0:21:07.2

You have to make a choice based on all the pros and cons, the risks, the benefits, and then go with it and don't look back and that's the hard thing about parenting, this little day to day decisions and I know most doctors give advice on what decisions you should make.  I'd rather give you advice on how to make the decision for yourself, alright let's move on.  Beth in Seattle, Washington says, "Hi Dr. Mike, thank you for answering my question about dry erase markers a few months ago, now I've got a question about my younger son Max who is 15 months old.  I'd gotten behind in my podcast listening so I had missed the August 21 episode where you address breath holding spells.  Well low and behold, yesterday my son had a breath holding spell and I started doing research on it.  We've already talked to his pediatricians since this was his third episode, the puzzling thing is he does not turn blue."

0:21:58.6

"I found some references to pallid breath holding spells, and I was wondering if you could address the differences between pallid and cyanotic breath holding spells, Beth."

Dr. Mike Patrick: Well thank you for the question Beth, the answer to this one is pretty easy.  Let's just define some terms here first real quick, pallid just means pale, the skin turns pale, and cyanotic is a reference to blueness, the skin turns a blue color.  So the answer's pretty easy here, breath holding spells are breath holding spells, it doesn't matter the exact color of the skin, a child holds their breath because they're upset, they briefly pass out, they start breathing again and then they recover, that's it and for those of you who would like to know more about this, do check out PediaCast 262 over at pediacast.org.  So what gives?  Why do some kids turn pale or pallid while others turn a little blue?  Well there are a few different possibilities here, one is the degree of de-oxygenation, so when you hold your breath oxygen gets used up but it isn't being replaced.

0:23:01.9

As the blood de-oxygenates, as oxygen leaves and is not replaced, you go from pink, to pale, to blue and when along that continuum your brain says, "I don't have enough oxygen, I'm shutting down now."  That point may be a little different from kid to kid, some brains are little more sensitive to oxygen loss than others, so the actual loss of consciousness point is going to be a little bit further along down that continuum of pink, to pale, to blue, so that's one explanation.  Another possibility is skin pigment, the less skin pigment the more pronounced the blue color's going to be.  More skin pigment can make the blue a little bit more difficult to appreciate. A third explanation is mechanism, some kids pass out because they went out of oxygen which is more likely to result in the blueness, while other kids may actually be having a vasovagal spell when they have their breath holding episode.

0:24:00.4

And we've talked about this issue on PediaCast before, extreme emotion may cause the vagal nerve to fire, it's one of the cranial nerves, and this through a several different mechanisms can result in a loss of blood pressure which results in less blood flow to the brain, the brain loses its oxygen and glucose supply not because there's not enough oxygen in the blood but because not as much blood is getting to the brain and you briefly pass out.  And again in this case the blood doesn't have to de-oxygenate before you pass out and your skin looks pale for a different reason.  If their body is shunting blood from the skin to your core body to try to get more blood to your brain and your core organs because they aren't getting enough blood because of the loss of blood pressure.  So the mechanism may differ a bit from one child to another, but at the end of the day a breath holding spell, is a breath holding spell, is a breath holding spell, unlike many things in medicine there can be different presentations for the same problem.  I do want to take this opportunity for an important safety reminder, it's the one I made when we talked more completely about breath holding spells back in episode 262.

0:25:07.2

Breath holding spells is not a diagnosis you make yourself at home, if your child passes out seek medical attention.  Breath holding spells need to be diagnosed by a doctor, why?  Because there are other things, serious things, life threatening things that can cause children to pass out.  Thank you again for the question Beth, always appreciate it.  Next up we have Tiffany in Grants Pass, Oregon, "Hello, I have a question that I've been thinking about for quite some time, it is somewhat multi-faceted.  We have all heard of the American Academy of Pediatrics, I saw if I'm correct that you are a member.  Here are my questions, one: what is the American Academy of Pediatrics?  Two: how does a physician become a member?  Three: how does the AAP decide on what it will recommend or not recommend, does someone or some company pose a topic or suggest a product and then all the members get a vote?"

0:26:02.2

"Number four: what prompts the AAP to take a stands on one thing and not another?  When I asked these questions, the stuff I am thinking of is like what age to start solids?  Pacifiers, nipple confusion, back to bed, circumcisions, vaccines, fluoride, car seats, front and rear facing, and pretty much all the other topics that your listeners present to you.  So I hope I didn't completely destroy this question, I just thought it would be interesting to know where and how the safety suggestions and guidelines are born.  As always, your Oregon fan, Tiffany."

Dr Mike: Well thank you for the question Tiffany, you always post good ones, and I'm sure many moms and dads out there have wondered the same thing, so what is the American Academy of Pediatrics?  And yes I am a member.  The American Academy of Pediatrics is an organization of pediatric primary care physicians and pediatric specialists, how does a physician become a member?  Well there are different levels of membership, in order to be a full pledge fellow of the American Academy of Pediatrics which grants you voting rights and some other privileges.

0:27:04.5

In order to be a fellow of the AAP, you have to complete a three year pediatric residency following medical school and you have to pass an examination from the American Board of Pediatrics which is different from the American Academy of Pediatrics.  And one must maintain certification with the American Board of Pediatrics to remain a full pledge voting fellow.  Now of course one must pay lots of money for the privilege of taking exams, maintaining board certification, and remaining a member of the AAP.  So I'm going to add this question, if you have to pay all this money, why do you do it?  I mean after all you don't have to be a member to practice medicine that only requires a state license?  Well maintaining board certification is required for some physicians especially academic physicians and of hospital privileges are desired.

0:27:58.3

Board certification and AAP membership are sometimes required for your job, if they're not they do give consumers some confidence.  You know, my doctor knows what he's doing, or as at least wise enough to know when he doesn't know so he or she can educate himself or herself and know.  In other words it identifies us as a trustworthy professional, that's why we join.  Next, how does the AAP decide upon what topics it will take a stands and when topics are decided, how do recommendations get made?  Well to appreciate the answer to this question you have to understand how the AAP's organizational structure works, the Academy is divided into sections, committees, and councils and members join the various sections, committees, and councils based on their specialty and their interest.  For instance, I am a member of the section on emergency medicine and the council on communications and media.  Other examples include the committee on infectious disease, the committee on pediatric education, the section on breast feeding, the section on adolescent health, the council on children with disabilities, and the council on school health.

0:29:07.5

There's literally a hundred or more of these committees, sections, and councils that you can get involved with and some of these are open for any member to join, you simply need to have an interest in that topic and some require that you have completed a fellowship after residency and are board certified in a particular pediatric sub-specialty.  And it is through this committees, sections, and councils that recommendations get made.  Now each committee, section, or council has its own set of rules by which that group functions.  But one thing they have in common is that each of these groups has an executive committee whose members are determined by the rules of that group and by the votes of that group's individual member.  So for instance the council on communications and media has an executive committee and if I want to serve a term on that committee then I must meet all of the qualifications that that council has for being on the executive committee, and I have to run and get votes from other members of the council.

0:30:09.7

Now it is within these executive committees where topics are decided upon, recommendations get made and policy statements are born.  Now of course there's a power check in place, the AAP is a whole, doesn't want a rouge committee putting something crazy out there, so in the spirit of one voice there's an over reaching executive committee of the entire academy which is shared by the president of the American Academy of Pediatrics who is elected by the entire membership of fellows and this over reaching executive committee has final say on policy statements and practice guidelines.  Each council, committee or section needs topic approval from the overreaching executive committee and needs that committee's final stamp of approval before policy statements and practice guidelines become official and public.

0:31:00.6

That's the machine in a nut shell Tiffany, it's a complicated process for sure, but one that I believe results in evidence based recommendations and guidelines that you can trust.  Alright let's move on, next up is Phipa in Suri, United Kingdom.  Phipa has a question and a comment, so first the question, "Hi Dr. Mike, thank you for your continuing efforts in producing your wonderful podcast although sometimes your perspectives highlight how the British National Health Service and the American system are vastly different.  I have a rather light hearted question, my daughter's school insist that children carry a named hankie at all times".  Phipa says, "I find the prospect of my child wiping her nose in a saggy, crusted piece of cloth rather gross, plus I'm not looking forward to retrieving and washing said items.  Is there any evidence that tissues are more hygienic than hankies, please yours hopefully, Phipa."

0:32:10.9

Dr. Mike Patrick: Phipa by the way is a molecular bio chemist, so she's a smart cookie and she knows darn good and well with the answer to this question is, but she wrote it and I had to include it if for no other reason than to get the word hanky under the program.  So a pub med search for the word hanky, well it only turned up investigators with that last name, I couldn't find any research on cloth hankies, but really do we need it?  I mean I'm all for evidence based medicine but you heard the description, saggy and crusted hankies, what's causing the sagginess and the crustiness, it's not, it's nasal mucus we're talking about here and what is in snot lots of micro-organisms.  I definitely think disposable tissues are the way to go.  Now I know Phipa there are differences between the British way and the American way, but on the issue of disposable tissues versus hankies, I think there's a clear winner and it's on my side of the pond.

0:33:08.4

I mentioned that Phipa also has a comment which she by the way tries to turn into a question, but I'm not going to take the bait on this one, I'll allow her argument to stand as is.  She says, "I listened to episode 265 with interest as with all your wonderful episodes, keep up the good work, but disbelief at the cultural gulf that exists between the United Kingdom and the United States on the topic of infant circumcision.

So apparently hankies aren't the only thing that separates the Yankees from the Redcoats.  Do parents in the state really agonize over this decision?  Here in the UK, we don't because unless you are a Jewish family or there is a clear and immediate clinical need, we don't circumcise male infants in our society, it's just not on our radar, full stop….

0:34:01.5

"Now, out of interest I had looked at the AAP recommendations you had mentioned on your podcast and I felt a slightly panicked that although I don't have sons, British men as a society are doomed to higher rates of HIV, HPV, penal cancer and other genital nasties as well as being saddled with the body part that is hard to care for.  But then I looked at our own British Medical Associations web site and found polar opposite recommendations.  Our policy statement advices that, "The medical harms or benefits have not been unequivocally proven, but there are clear risks of harm if the procedure is done inexpertly."  Running that through your risk benefit filter would come down on the side of do nothing unless there is a clear immediate medical indication.  Furthermore the policy states, "Male circumcision that is perform for any reason other than physical, clinical need is termed non therapeutic or sometimes ritual circumcision."

0:35:00.7

"So from a British view point, medical not religious circumcision of American male infants looks like a cultural tradition.  Do our respective professional associations view the evidence with cultural bias?  Could our health care systems and their different financial origins served to promote an income generator in the United States and withdraw it as another cost in the United Kingdom?   What is going on Dr. Mike?  Same evidence?   Different interpretations I'm interested to see what you think….  So you know Phipa is trying to draw me in folks, see how she's doing that?  She says, "So American doctors who published our recommendations want paid to perform circumcisions and the British government who is responsible for your recommendations don't want to pay for them….  And I'll admit as a potentially modifying factor you may be on to something there Phipa, but the argument of the British Medical Association regarding their concern for harm if the procedure is done inexpertly as they put it.

0:36:03.3

The problem with that argument and this might also be a difference between our two countries.  The problem with that argument is that here in the States circumcisions are performed by experts. Seriously though Phipa you raise some good points and I appreciate you listening and taking the time to write in.  Speaking of taking the time to write in, again this listener programs are really how good they are is based on your participation, so if you do have a question or a comment, or you want to point me in the direction of a new story, please write in and let me know.  It's easy to do, just head over to pediacast.org click on the contact link and ask or comment away, we really love hearing from you.  We're going to take a quick break and I will be back with a final word, it's a very heart felt final word from a listener, it involves breast feeding when it doesn't go so well, so stick around, I'll share that with you, it's coming up right after this.

0:37:08.3

[Music]

Dr. Mike Patrick: Welcome back, this is the point in the program where I usually provide a final word and I'm going to do that this week but rather than it being my final word I thought I'd let Lee from Burlington, New Hampshire have the honors.  She says, "Hi Dr. Mike, first I want to thank you for such a great podcast I look forward to your show every week and feel that your insight and advice are well balanced.  I'm writing today about a recent show where you shared good news with us specifically the information about breast feeding and the many benefits that it can provide a mother and a child."  

0:38:07.7

"I realize you were simply reporting the results of a recent study on the numbers of women who are breast feeding and how the numbers are increasing with regard to the length of time a mother continues to breast feed.  I don't argue the benefits but I do wish that you could have mentioned that while breast feeding is indeed quite wonderful, sometimes it does not just boil down to a choice to breast feed.  When I was pregnant with my daughter I planned on breast feeding her, went to a class beforehand and had a good group of friends who had breast fed their children seemingly without any trouble.  I had every confidence that I would be able to breast feed, and while I knew that baby and I would have a learning curve, we would soon be in happy mommy, baby breast feeding wonderland.  Sadly that was not how things played out, instead of having a vaginal birth and having my daughter immediately on my chest after her birth, I was having a C-section that went a bit sour and caused me to have to be put under general anesthesia."  

0:39:04.8

"When my daughter and I could have been sharing skin to skin time, she was in the nursery and I was in surgical recovery for over two hours.  As soon as I was able, I placed her on my chest and hold her skin to skin and try to introduce her to the breast.  We were both exhausted and soon fell asleep, we stayed on the hospital for two days and during that time the lactation nurses would come in to help me when they could but knowing how busy they were I felt badly asking for help.  At one point a nurse told me I needed to give my daughter an ounce of formula because she was very hungry.  As a new mother hearing that I needed to do this to help my daughter was all I needed to hear, I also trusted the nurse, she must know what she was doing.  Of course then we all started to enjoy the immediate satisfaction of a bottle of formula.  We were sent home with a small bag of formula and really not much information of any on breast feeding.  I got home and started to panic, I did not want to give up on the breast feeding, I knew it was best for my daughter but it was going so badly."

0:40:02.0

"I called the lactation nurses and they had me come back for a hospital grade breast pump and help me pump a small amount of colostrum from my breast, I felt so proud and happy that I could give my baby this liquid gold.   I went home with a pumping schedule, a finger feeding system and instructions to purchase herbal supplements and to set my alarm to wake up every two hours to pump even if the baby was sleeping.  I tried, I did but sheer exhaustion went out and slowly the amount of formula she got increased.  I went to a new parents support group that mainly focused on breast feeding, most of the moms sat around in a circle with their babies snuggled in and nursing.  I did a bit of nursing and then pulled out a small bottle of formula, another mother pulled out a small bottle, and I said, "Oh, I think we have something in common, is that formula?"  And she gasped, "No, this is pumped breast milk."  I felt ashamed.  It is so hard to make friends with new moms even though we all have a very big common denominator, regardless I still attended the weekly meeting."

0:41:01.0

"I met with more nurses and with my daughters' pediatrician I use nipple shields and pumped and pumped and pumped.  My body produced barely an ounce each day, actual breast feeding was very difficult.  My daughter only like nursing in a football holds on my left side and would not latch at all to my right.  At five months old I was barely producing any milk, I threw in the towel, I was done.  One friend, when she found out that I'd stop breast feeding actually said she could not be friends with me any longer because of our differences in parenting.  So now I have written far more than I had planned, but this topic really gets to me, mostly because I'm still so sad that breast feeding was never beautiful or wonderful for me and to illustrate that it is not so simple or cut in dry this decision to breast feed.  As you can read from my letter and hopefully agree I did the best that I could, I can only hope this small amounts of breast milk my daughter drink did her some good."

0:42:00.8

"And I also hope that the world would be more understanding someday down the road when my daughter may try to breast feed her child.  I realized you were only sharing the facts of the report that day and I do still love your show I just wanted to share my side and ask that maybe you throw in there that we're still good parents even if we don't breast feed, thank you for all you do, I will still continue to share your podcast with my friends, sincerely, Lee, mom to a happy, healthy, wonderful little six year old girl."

Dr. Mike Patrick: Well thank you for sharing that Lee, I could not have said it any better and I do think that sometimes we get caught up, and yes breast feeding is best but we do have to be realistic as well and I think that the more that we focus only on that, the more that we do ratchet up the guilt and it's not right and I think that your comments, Lee are really something that many other moms and dads out there needed to hear as well, so I will let your comment stand as this episodes' final word, they're good ones, they're good, wise words.

0:43:02.8

I do want to thank each and every one of you for listening to the program and especially those who participate by writing in, I really appreciate your questions and your comments.  Don't forget, PediaCast and our single topic short format episodes, they're called PediaBytes.  They're available on iHeart Radio Talk as our the full length episodes, you'll find those on the web at iheart.com and the iHeart radio app for mobile devices.  Reviews and comments on iHeart radio and in iTunes would be most helpful as our links mentions, shares, re-tweets, re-pens, all those things we're on all the different social media sites.  PediaCast is on Facebook, Twitter, Google Plus and Pinterest, also be sure to tell your family, friends, neighbors and co-workers about the program and most of all tell your child's doctor.  Next time you're in for a sick office visit or a well-child check-up or an ADHD re-check, whatever it is, you're going for flu shot clinic, just mention, "Hey, there's and evidence based pediatric podcast aimed at moms and dads, easy to understand, great information, please share it with your other patients."    

0:44:11.7

I really appreciate that word of mouth, really would.  We do have posters available under the resources tab at pediacast.org.  If you like to get in touch with the program with your own question or comment, just head over to pediacast.org and click on the contact link.  We also have a connect with a pediatric specialist link, not just to help you with referrals and appointments here at Nationwide Children's.  Again thank you for dropping by and until next time, this is Dr. Mike saying stay safe, stay healthy , and stay involve with your kids.  So long everybody.

[Music]

Announce 2: This program is a production of Nationwide Children's, thank you for listening.  We'll see you next time on PediaCast.

0:45:06.5

2 thoughts on “Antibiotics, Co-Sleeping, Hankies – PediaCast 269

  1. Hi Dr Mike,
    This is Sayaka from Osaka Japan.

    At first, thank you so very much for your picking my question of co-sleep up at episode 269.
    It was really helpful not only for the co-sleeping, but also for the choices that I as a mother have to choose for my son in the future.

    And thank you for your great educational show. Unlike reading medical books, your podcast is easy to understand and fun to listen to. I really appreciate your consuming precious time to this show.

    On episode 269, I really felt sympathy toward Ms Lee, and I was almost in tears listening how hard she tried to breastfeed. I breastfed my son Kousei, but I am totally on her side. I strongly believe that giving formula sure has a benefit that breastfeed can’t easily get, and giving either breast milk or formula doesn’t matter to be a good mother AT ALL.
    Here, I would like to share my experience about breastfeeding, hopefully to help some new moms who are also struggling of breastfeeding.
    “BREASTFEEDING IS THE BEST.” I’ve heard so many times when I was pregnant, and nobody really explained the troubles that moms may encounter. So I planned to breastfeed without any question. As my baby gets bigger and drinks more, I felt stronger eye strain, knee joint pain, dizziness and exhaustion. Eye strain was so severe that I could hardly read any magazine more than 3 mins. Knee joint pain makes me difficult to hold my baby. Exhaustion deprives me of motivation to do anything. On top of those, breastfeeding every 3 hours at midnight drove me crazy – I lost my temper several times.I was heavily stressed. Breastfeeding didn’t let my weight less at all. With sleep deprivation and highly stressed out, I couldn’t help eating sweets and my weight didn’t lose. I was unhealthy. Also, my baby was a biter – he bites, pulls and screw the nipple occasionally and it really hurt. Every time I breastfed, I tensed up and scared of his biting. With all difficulties, I couldn’t stop breastfeeding because of the pressure of the voice,”BREASTFEEDING IS THE BEST.” When my baby was 6 months, I got mycoplasma pneumonia, then food poisoning , then mycoplasma pneumonia again. Finally I have an excuse to escape from breastfeeding exclusively. After my supply dropped down dramatically, I felt so healthier, happier and lost weights. In conclusion, breastfeeding deprive me of some of meaningful lovely huggy time with my baby, and confidence as a mom. (Lost confidence as a good mom since I was overtired to do anything good for baby and keep the house neat, and lost my temper for my crying baby sometimes.)
    By the way, did suffer-full-breastfeeding give my baby some advantages? I hope so. Here is a story after I stopped breastfeeding. Switched to formula, my baby really disliked. So hated that he known as a super stubborn baby decided not to drink any formula at 7 months. We as parents, teachers at daycare and our pediatrician were upset, but no one could let him drink any formula. We decided to feed solid food four times a day. Although he was really hungry especially at midnight and woke up so many times, he declined drinking any formula. I was so worried, and so stressed out.
    At the bottom line, is breastfeeding really best for all the moms? I certainly think that breastfeeding could be wonderful and best for some of moms, and I envy those who have no or little problem. But I hope everybody knows that breastfeeding sure could have disadvantages like I mentioned, and when you as a mom feel that disadvantage overweight the advantage of breastfeeding, you can choose to give formula as a better choice for you and your baby, I think.
    Hopefully my story might help for some of new moms. In my case, choosing formula might have been a better choice. Ms Lee, I am very sorry and upset to hear that some of breastfeeding moms aren’t nice to you. At least, I’m not. I respect all your effort toward your daughter so deeply. Either breastfed or bottle fed, we as moms support each other. Ms Lee, you are a great mom. And all the moms who survived the sleep deprivation, pees, poops, nose water,vomiting and so on are doing great job! I respect all the moms who survived.

    Thank you for reading such a long personal story/opinion. I hope it helps.
    And thank you again for the amazing show, Dr Mike.

    Sayaka and Kousei at Osaka Japan

  2. Pingback: Got a Cough? Hold the Antibiotics!

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