Anxiety, HSP, Heart Murmurs – PediaCast 234

It’s time for another news and listener episode! Join Dr Mike in the PediaCast Studio for the latest news on anxious kids, ADHD medications, heart problems, and new small baby guidelines from Nationwide Children’s. We’ll also answer YOUR questions on Henoch-Schonlein Purpura (HSP), toddler speech, and heart murmurs. It’s all happening this week… on PediaCast!

Topics

  • Anxious Kids

  • ADHD Medications and Heart Problems

  • Small Baby Guidelines

  • Henoch-Schonlein Purpura (HSP)

  • Toddler Speech

  • Heart Murmurs

Links

Transcription

Announcer 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!

Mike Patrick: Hello, everyone! And welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. I'd like to welcome everyone to the program. It's Episode 234, 2-3-4 for November 28, 2012.

We're calling this one Anxiety, HSP, and heart murmurs. So, welcome to the show everyone, hope you had a great Thanksgiving. We're back from our holiday break and ready to roll up our sleeves and get back to work.

01:00

We have a great news and listener's show lined up for you today, but before we get to the rundown, just a couple of quick housekeeping items. As you know gifts matter during the holidays. And at Nationwide Children's Hospital we rely on your gifts to continue advancing pediatric research and providing the best pediatric care on the face of the planet.

So to help us help kids, I would simply ask that you consider Nationwide Children's as you think about charitable giving this holiday season. We make it really easy for you, just swing by Nationwidechildren's.org/giving. And I'll put a link to it in the Show notes at 234, Episode 234 at pediacast.org so you can find that easily. But it's one you can probably remember -nationwidechildren's.org/giving.

And again we would just ask that you consider giving to Nationwide Children's this holiday season. If you have money that you're going to be giving to a charitable organization anyway, please think about us and help us help the kids. I also wanted to point out some other ways you can find PediaCast.

Now I say other because you obviously found it, I mean, you're listening right now, you found us somewhere. But did you know that you could listen directly from our Show notes pages?

02:09

We also have a PediaCast player on the website at pediacast.org. You can find us in iTunes -most people know about these options, but there's also the free Apple podcast app for IOS which you can find in the App Store.

And speaking of podcasting apps, you can also listen to PediaCast through such apps as Downcast, Pod Cruncher, iCatcher!, and the Wizzard Media Podcast Box. We're also on Stitcher Radio, and a new addition, PediaCast is now in the Tune In radio directory. TuneIn -T-U-N-E I-N as website mobile app and it's also available on the Sonos Home Audio System.

Stitcher is in Sonos as well. And TuneIn allows you to listen to radio station streams from across the country plus many other shows like PediaCast. So be sure to check us out there.

03:03

The bottom line is we're trying to make this as convenient as possible, so you could listen to pediatric information from a source you trust in many different places. And all of the things I just mentioned will have links to all of those options in the Show notes for episode 234 over at pediacast.org.

OK. Speaking of pediatric information, we better get to that. What are we talking about today? Well as I mentioned it's a news and listeners show, so in the news department we have child anxiety and specifically what's the parent's role in creating anxious children. We got to put the blame somewhere and moms and dads unfortunately in many cases the blame is squarely with you.

We're going to talk about it and let you know what you can do to stop creating anxiety in your kids. ADHD medicines and heart problems, is there a connection? Small baby guidelines, improving outcomes for the tiniest preemies. We're talking like four months early, I mean, that's just like just over half-cooked.

04:00

So we're going to talk about taking care of tiny, tiny micro preemies, that's coming up in the news. And then we're going to answer some of your questions on HSP which is also Henoch-Schonlein purpura, toddler's speech -don't get too excited with that one, I'm just kind of be pointing you in the right direction.

And then we'll have a detailed talk on heart murmurs, sort of a nuts and bolts talk on what is a heart murmur? Why do kids have it? Are they serious? What do you do about them? So that's all coming up. And then at the end of the show, stick around to hear a little shop talk on podcasting.

I don't get a chance to do this often, but sometimes I have to put medicine aside and talk geek. And I know other podcasters listen, and I have had some email in the past where people are asking, "Hey, what kind of programs do you use? Where do you store your files? How do I go about podcasting?" You could do an entire hour show on that, so I'm not going to do that.

But what I do want to do after the show is to share with you some great software including one called the "Levelator", sounds like a superhero. And if you do podcast interviews, trust me, it is a superhero. So what is the levelator and also another one called Amadeus pro which is like the the swiss army knife for audio editing.

05:14

So if you care about the art of podcasting in addition to the art of medicine, stay tuned after the show. All right. I also want to remind you that if there's a topic that you would like us to talk about, it's easy to get a hold of me just head over to pediacast.org and click on the contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S.

Also the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, make sure you 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. And with all that in mind, we're going to take a real quick break and we'll be back with 'News Parents can Use', right after this.

[Music]

06:37

Mike Patrick: Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website, you can visit them online at medicalnewstoday.com.

Parents with social anxiety disorder are more inclined than parents with other forms of anxiety disorders to be haven ways that put their children at a high risk for developing stress of their own, that's according to a new study by researchers at John Hopkins Children's Center.

07:01

Earlier studies have shown connections between parental anxiety and anxiety in children, but nobody really knew whether parents with certain anxiety disorders exhibited anxiety-provoking behaviors more frequently than parents without anxiety disorders. This new report, published in the journal Child Psychiatry and Human Development, suggests they do.

The team identified a set of behaviors in parents with social anxiety disorder, the most common form of anxiety, and in doing so cleared up some confusion related to the so called "trickle-down anxiety", frequently seen in children with anxious parents.

Behaviors such as an absence of insufficient warmth and affection, as well as elevated levels of uncertainty and criticism directed towards the child, can heighten anxiety in children, and if they become chronic, can increase the chance for the affected kid to develop an advanced anxiety disorder of their own.

The study's senior investigator Dr. Golda Ginsburg, a child anxiety expert at Johns Hopkins Children's Center and professor of child and adolescent psychiatry at The Johns Hopkins School of Medicine, says, "There is a broad range of anxiety disorders so we home in on social anxiety, and we found that anxiety-provoking parental behaviors may be unique to the parent's diagnosis and not necessarily common to all those people with anxiety."

08:17

The investigators stressed that the study did not specifically examine whether the parents' behaviors caused anxiety in their children, however they say there is some proof they do. The researchers emphasize that health professionals who treat parents with social anxiety should be aware of the possible influence it has on children.

Dr. Ginsburg explains, "Parental social anxiety should be considered a risk factor for childhood anxiety, and physicians who care for parents with this disorder would be wise to discuss that risk with their patients."

Anxiety is the outcome of a detailed interplay between genes and environment. The researchers say that although genetics cannot be controlled, environmental factors can be altered in an attempt to diminish or prevent anxiety in the kids of anxious parents.

09:01

Dr. Ginsburg goes on to say, "Children with an inherited propensity to anxiety do not just become anxious because of their genes, so what we need are ways to prevent the environmental catalysts, in this case, parental behaviors, from unlocking the underlying genetic mechanisms responsible for the disease."

Dr. Ginsberg and team examined interactions between 66 anxious parents and their 66 children, who ranged in age from 7 to 12 years. Among the parents, 21 had already been diagnosed with social anxiety, and 45 had been diagnosed with other anxiety disorders such as generalized anxiety disorder, panic disorder, and obsessive-compulsive disorder.

The parent-child pairs then worked together on two items: duplicating increasingly hard designs using an Etch-a-Sketch, and arranging a speech about themselves. Participants had 5 minutes to complete each task and were observed by video.

The researchers then measured the following factors using a scale of 1 to 5: parental warmth and affection directed at the child, criticism of the child, expression of doubts concerning a child's performance and ability to complete the task, granting of self-rule, and parental over-control.

10:14

The parents diagnosed with social anxiety exhibited less warmth and affection towards their children, criticized them more, and were more likely to express doubts about a child's ability to complete a task. And all that in five minutes, wow.

Prevention of childhood anxiety is important, because anxiety disorders affect one in five U.S. children, many of whom are undiagnosed. These unrecognized disorders can cause depression, poor academic performance during childhood and into adulthood, as well as substance abuse.

So the take home here at least in my mind is first; moms and dads if you have an anxiety disorder, don't brush it under the table. Recognize the problem, don't be ashamed of it, social anxiety is common and suffering from it is not your fault. As it turns out it may be your parent's fault since they passed on their genes to you and raise you in a specific environment.

11:01

But the goal now is not to pass this legacy onto your kids. Now you can't help pass them on the genes, but you can make a difference on your child's environment, right? So first you recognize the problem and get help. Where do you find that help? Start by asking your doctor. OK.

So you recognize and seek help for your own anxiety issue, that's important. What's next? Be intentional about exhibiting warmth and affection toward your child. Now for some of us this comes easy, for others of us, it's difficult, you have to work on it, but it's absolutely worth the effort to exhibit the warmth and affection towards your child.

Next, watch your criticism of your child, build them up rather than pulling them down. Now, you don't have to lie to do this. American Idol auditions are full of people who lie to their kids by telling them they were great singers and on national TV they're proving to us, no, they're not great singers.

So don't necessarily lie, but focus on the things they do well rather than the things they don't do so well. Encourage them in those areas. Also stay humble. You know, just because it isn't your way, doesn't mean it's the wrong way. So take your pride out of the equation when your kids are doing something in a certain way.

12:10

I mean, obviously if it's dangerous, if it's going to get them into trouble, the way that they're doing it because it's something that matters, then obviously you have to step in. But you got to pick your battles, you know, some things are worth fighting for, but really most day to day activities aren't worth the collateral damage like making designs on an Etch-A-Sketch.

Finally, don't express doubts about your child finishing a project even a five-minute one, be the encourager. We've talked about other studies that show persistent children are more likely to succeed. If you express doubt about your child's ability to finish, they're likely to give up and giving up on little projects makes it easier for kids and teens to give up on the big important ones like their education.

And consider this, kids and teens who give up on the big important projects may well turn into adults who give up on big, important things like jobs and marriages. So encourage your child to persist through difficulty and be sure to model that behavior yourself.

13:04

I know all these makes sense, but I also know many have difficulty with these stuff, but your kids are worth making the effort definitely. All right let's move on to our next news item.

Children who take Adderall, Ritalin, and other central nervous system stimulant do not have a higher chance of developing serious heart conditions. This finding which confirms research from 2011 came from a study at the University of Florida and was published in the British Medical Journal. The study contributes to a clinical and policy debate of treatment risks for kids with ADHD also known as Attention Deficit Hyperactivity Disorder that's been going on for 10 years.

Lead investigator Dr. Almut Winterstein a pharmacoepidemiologist and professor in pharmaceutical outcomes and policy in the UF College of Pharmacy says, "Stimulant drugs are one of the most common medications prescribed to children." That fact aside, every year, youths have an estimated one in 30,000 risk of experiencing a serious cardiac event, but according to Dr. Winterstein's results, "No relationship exists between these two facts. In other words stimulant drugs did not put kids at a higher risk for serious cardiac events.

14:12

So what are we talking about here? What are serious cardiac events? Well, they include sudden cardiac death, stroke, and heart attack, conditions which normally result from an underlying heart condition and not medication.

This finding confirms previous research which also indicated that central nervous system stimulant drugs taken by kids and adolescents do not cause any severe cardiac events.

Dr. Winterstein conducted her first large population study in 2007 which examined the risk of serious cardiac events in children and teens between the ages of 3 and 20-years who were using CNS stimulant medication. She found a 20% increase in doctor's office visits because of symptoms related to the heart, but she found no increase in death or hospital admissions for severe heart problems.

In other words, parents and children taking these medications may be more sensitive and concerned about what they perceived to be heart symptoms, but these office visits did not translate into real disease.

15:09

Data of over 55,000 children with ADHD who were receiving treatment between 1994 and 2004 were observed in that study. However, Dr. Winterstein explains that population of 55,000 kids was not large enough to decide whether these medications were risky or not. So they decided to enroll more kids.

The latest trial analyzed a much larger population from the United States to the tune of 1.2 million Medicaid eligible children from 28 different regions of the country. Incidentally this study follows another large and unrelated project from 2011 by Dr. William O. Cooper who focused on privately insured patients and that report was published in The New England Journal of Medicine.

Dr. Winterstein says, "We complemented Dr. Cooper's study by utilizing Medicaid patients who are typically more vulnerable and at a higher risk for serious adverse events. This allowed us to examine patients with severe underlying heart conditions who received stimulant medication."

16:03

Results from the investigation showed there are no short-term effects from CNS stimulants. However, the results do not answer any questions on long-term effects. Dr. Winterstein explains, "Neither of the studies was able to answer what happens in the long term. It's an important issue to address, but we won't be able to answer the question until this generation of ADHD children, who began using stimulant drugs in the 1990s, reaches adulthood into their 50s, 60s and 70s."

The experts now want to determine the effects of continuous stimulant medication over the use of a 10 year period or more because the results of even small increases in blood pressure and heart rate over a long continuous amount of time are unexplored.

When people first started questioning stimulant use in children about 10 years ago, doctors were cautious. But now, more kids and ever before are using these medications. Why? Because as the studies emerge showing low risks for severe events, doctors have become more comfortable prescribing them.

17:00

Dr. Regina Bussing a professor in the University of Florida College of Medicine's division of child and adolescent psychiatry says, "Not all parents and doctors are comfortable. Despite these studies many are still concerned about the potential of cardiovascular risks and these concerns result in many kids not receiving ADHD treatment."

Dr. Bussing advises a balanced approach, use stimulants when they're warranted, but continue recommended evaluation practices. Parents should stop medication and take the child to the doctor if any symptoms occur, such as chest pain or shortness of breath. However, she does concede this research should ease the worry of doctors and parents about cardiovascular risks.

Dr. Winterstein also concludes that parents should still continue to see a doctor if any symptoms develop while taking CNS stimulants. She says, there is still some concern regarding the increasing number of kids who are taking them without knowing the long-term risks and advantages.

So what's a parent to do? I mean, that's the question, right? Well, one thing this researchers did not consider but other research studies have is the risks of untreated ADHD, there's a risk in that as well.

18:02

If a child or adult really does have Attention Deficit Hyperactivity Disorder and it goes untreated, we know there is an increased risk of such thing as school dropout, drug use, divorce, and prison time. So moms and dads, you have to weigh all these facts, talk to your doctor, make the decision that's right for you and your family.

All right. Let's move on to our final news story and this one comes from our neck of the woods, Nationwide Children's Hospital. For the last decade, prematurity has been the leading cause of infant mortality in the United States.

As a result of prematurity many infants enter this world too early with a small chance of survival. In order to help these extremely premature infants, physicians at Nationwide Children’s Hospital developed a set of guidelines tailored to meet the needs of these tiny infants, some born up to four months early.

Now, a new study shows that these guidelines are not only improving survival rates for extremely premature infants, but also improving their quality of life.

This study, appears in the Journal of Neonatal-Perinatal Medicine, includes more than 200 so-called 'small babies' to find these infants born less than 27 weeks gestation.

19:04

These kids stayed in the Small Baby Pod inside the Neonatal Intensive Care Unit at Nationwide Children's Hospital. They receive care following the Small Baby Guidelines and were monitored from birth to at least 2 years corrected age.

Results from this study showed by following these guidelines, the survival rate of these small babies increased over time. Dr. Edward Shepherd chief of Neonatology at Nationwide Children’s and coauthor of the study explains, "Our approach was to standardize the level of care, ensuring that every baby received the same care. The idea being that if we do everything the same, for each of these infants, our results should be better."

Before these guidelines were instituted, there were very few survivors of babies born less than 27 weeks gestation. In fact, many families and medical professionals viewed these kids as having the predestined conclusion of not making it through the first few days of life. However, the findings from this study show that patients who received care following these Small Baby Guidelines, do very well compared to normal children.

20:00

Dr. Shepherd says, "The challenge is to convince families and our peers that these kids while they have many challenges, can ultimately lead a normal life. If you treat small babies as if they do not have a chance for survival, they don't do as well as they could. Our approach was that each and every one of these infants has enormous potential for a normal outcome and for a satisfying life."

In addition to improving survival rates, this study showed that treating babies with this unique approach leads to shorter hospital stays. While small babies often go on to develop infections, necrotizing enterocolitis and/or bronchopulmonary dysplasia, by following these guidelines, babies can recover from these conditions and see improved developmental outcomes which leads to an earlier discharge. Dr. Shepherd adds, "This is a real win-win; a shorter stay means parents get to take their child home sooner and it saves an enormous amount of resources."

Part of the success of the Small Baby Guidelines is due to the multidisciplinary approach to treating these infants. The specialized care team includes everyone from physicians and nurses to cardiologists and nutritionists. The goal of this multidisciplinary approach is that every member of the team should understand the goals, the expectations and the gold standard of care so this can be achieved in each patient.

21:08

While there is still a need for new approaches to prevent the many illnesses premature infants face when entering the world too soon, physicians and researchers at Nationwide Children's continue to study ways to prevent complications seen in small babies as well as the cause of prematurity.

All right. As I'm going through that I got the material from a press release here at Nationwide Children's, and as I'm going through that I'm thinking, I find some of you who are physicians may have caught this as well. They mentioned a multi-disciplinary team and they say everyone from physicians and nurses, to cardiologist and nutritionist -just cardiologist or physicians I don't know.

For some reason I didn't catch that on my first -when I first went through the material, but then as I'm going it through with you, I realized that we kind of made the point that maybe cardiologist aren't physicians, they are folks. Cardiologist are physicians.

22:03

All right. I'm really off track here. We're going to take a quick break, we do have your questions on HSP and heart murmurs, that's all coming up, it's going to be right on the other side of this break.

[Music]

Mike Patrick: All right. We are back and I think I got myself back together here. So I will try to stay on track.

23:00

First stop we have a thanks from Rebecca in Augusta, Georgia. "Dr. Mike, I just wanted to say thank you for your podcast. I'm a fourth-year medical student, currently interviewing in pediatrics and I'm a mom of a two-year-old little boy. I love listening to your podcast while I travel, I keep them on my iPad and I listen whenever I have the time. Thank you. "Thanks for the kind words Rebecca. And if you end up doing your residency here at Nationwide Children's, be sure to look me up.

Next is Judy in Doha, Qatar, "A couple of years ago on a family vacation, my son, nine-years-old at that time began complaining when he went on a walks, he said his legs hurts. A day or two later he began vomiting through the night, we were away from home and figured he had food poisoning.

A few days later after we returned home, he developed a strange rash on his legs and then one of his legs began to swell. I took him to our pediatrician and immediately she said he had HSP or Henoch-Schonlein purpura. In a nutshell, she said we shouldn't worry and that it would go away on its own.

After this happened, I tried to read what I could find on the disease, but the more I read, the more confused I became. That's all in the past, but my curiosity exist. I enjoy listening to your program and thought that maybe you could shed some light on this disease. Thanks, Judy."

24:11

Well, thanks for the question, Judy. So HSP which is short for Henoch-Schonlein purpura is an interesting disorder and while it's not exactly common, it's not all that rare either. So it's definitely something I think many other parents in the audience have faced or will face at some point.

So what exactly is HSP? Well, it's a type of vasculitis, so it's an inflammation of blood vessels and it affects capillaries which are very small vessels primarily in the skin as where there affected capillaries are going to be and joints. However, capillaries in the kidneys and GI tract can also be affected.

The inflammation of these capillaries causes defects in the blood vessel wall which results in bleeding into adjacent skin, joints, and then possibly kidneys, and GI tract. So why does this happen? Actually before we get to why it happens, let's cover the name. Why is it called Henoch-Schonlein purpura?

25:06

Well, hold on the purpura, we're going to get to what purpura means. So where do Henoch-Schonlein come from? Well, Eduard Heinrich Henoch

was a German pediatrician and his professor was Johann Lukas Schönlein and they together described this condition in the 1860's. So that's how we have Henoch-Schonlein, it's the German pediatrician and his professor, it's named after them.

Now there's actually controversy over this -yes we have medical controversy. There's controversy because William Heberden, an English physician and Robert Willan a dermatologist, they had previously described the disease around 1805.

So they found it first, then it was called Heberden-Willan disease, but today the English description has fallen out of use and the Germans retained naming rights and so we call it Henoch-Schonlein purpura. OK. Enough history. What is HSP as commonly call it today?

26:02

Well, thanks to Sir William Osler a Canadian physician and his work in the early 1900's we have an answer. I know I said enough about history, but I couldn't resist. All right. So let's move on to the cause, well, HSP is an auto immune disorder, so that means the body's immune system is attacking some portion of the body and in this case it's attacking small blood vessels or capillaries in the skin and joints, and possibly in the kidneys and the GI tract.

So why does this happen? Well, we don't know for sure. This auto-immune attack is usually initiated by a trigger. Now most commonly the triggers is going to be a viral upper respiratory infection, but other viral infections in the body and bacterial infection such as streptro can also be triggers. So the infective organisms stimulates the immune system which fights the infection, but then the immune system overreacts and fights those small blood vessels as well.

Now there are other triggers that are possible including certain medications including antibiotics, and antihistamines, also insect bites, and immunizations including those for measles, typhoid, yellow fever and cholera.

27:04

Cold weather has also been implicated as a trigger and environmental exposure to certain chemicals may be a trigger as well. Now, these things aren't triggers for everyone obviously because otherwise everybody would be walking around with HSP all the time. And they aren't necessarily triggers every time the infection or exposures encountered by the same individual.

We also know HSP is more common in children and young adults than it is in older adults. And there appears to be a genetic component with HSP meaning it can run in families, but having said that most people diagnosed with HSP don't have a known family history. So there's lots of complicated factors at play and we still don't know all the specifics.

But the bottom line is this; you have a trigger, most often a viral upper respiratory infection, this revs up your immune system which kills the virus, but then your immune system over reacts and begins to attack small blood vessels or capillaries in the skin and joints also possibly in the kidneys and GI tract, and this results in inflammation of those blood vessels with the walls of the blood vessel breaking down and bleeding into adjacent areas occurs.

28:10

So from a signs and symptoms standpoint, what is this looked like? Well in the skin, you see a purplish rash and these are the equivalent of bruises. See if they're bleeding in the capillary into the skin, that's a bruise. So you get a purplish bruise, that's where the purpura comes in. So that's what we call purpura is a bruise in the skin.

And it most commonly occurs in the lower extremities, the buttocks, the perenium or the private area ad the lower trunk. The rash is the hallmark of the disease, so it's present in 100% of cases, you can't have HSP without having the rash. The purpura appear in crops with new crops appearing in waves, and these waves lasts an average of three weeks.

So over a three-week period you're going to get new bruises and then what happens is the immune system over reaction slows down and stops, so there are no new waves of purpura appearing, but like bruises it takes a while for the lesions to fade away.

29:04

So that's what we see on the skin. What about the joints? Well the joints are involved in about 75% of patients with HSP and in 25%t, joints symptoms actually precede the rash. Large joints are most frequently involved especially the knees and ankles, and the affected joints have pain and swelling and can even interfere with walking.

The joint symptoms last several days, but no permanent damage is done, so the joint symptoms like the rash go away on their own. Now, unfortunately that's not always the case when the kidneys are involved. Kidney involvement can lead to permanent damage to these organs, but the good news is permanent damage of the kidneys is not common.

Now we see kidney involvement to some degree in 30-50% of patients with HSP. And it's not uncommon to see kidney issues last for as long as six months after the onset of the rash and joint pains. So when the kidneys are involved, they tend to be involved for a while.

30:01

So what do we see in the kidneys? Well most often we just see mild hematuria and proteinuria. So little bit of blood and little bit of protein in the urine. And it's maybe microscopic, so you may not actually be able to see it, so checking the urine with urinalysis is part of the work-up for HSP.

Now most often the hematuria and proteinuria are mild and they stay mild for a while, could be up to six months, and then they go away, end of the story. But sometimes they're severe and can lead to what we call nephritic and nephrotic syndromes, and when these are severe we can see kidney insufficiency, and high blood pressure, and in most severe cases this progresses into permanent damage and full blown kidney failure. But the good news is this occurs in less than 0.1% of all cases of HSP.

So it's rare, but it can definitely be serious so it's something that we watch for in all kids with HSP. OK. What about the GI tract? Well, GI symptoms occur in about 85% of the cases, but they are also usually mild and include abdominal pain, nausea, and vomiting. Sometimes the GI symptoms are more severe, sometimes blood appears in the stool, and very rarely a child could have a life threatening GI bleed or a type of bowel obstruction which is also potentially life threatening called intussusception.

31:16

So that's how HSP typically presents. Now, what about the differential diagnosis? Well, there's a long list of things that can cause similar symptoms. So the differential diagnosis of HSP especially its more severe forms is quite extensive and it include things like blood infection, septic shock, a type of meningitis caused by an organism called meningococcus, bleeding disorders, Kawasaki disease, Rocky Mountain spotted fever, lupus, and even child abuse.

These are serious conditions and HSP can be a serious condition. Now, fortunately in most cases the kids do find and everything resolves on its own, but it's very important that you see a doctor for any of these symptoms right away so you can get the correct diagnosis and the correct work-up, and the correct treatment for whatever the diagnosis turns out to be.

32:02

OK. Speaking of treatment, what is that looked like? Well, uncomplicated HSP -again the good news is the symptoms usually just go away on their own without the need for any specific medical treatment other than rest, fluids, and pain control.

The bad news is, the symptoms lasts several weeks, however when complications set in like significant kidney complications or severe abdominal pain and vomiting, or GI bleeds, or bowel obstructions, then kids often need to be hospitalized and treated under the guidance of a pediatric nephrologist. or a kidney doctor.

If kidney issues are significant and are involved, pediatric gastroenterologist that's the GI guy -if significant GI symptoms are present and sometimes the pediatric surgeon if bowel obstruction becomes an issue. Also a child might need to be hospitalized to rule out some of the other conditions I mentioned in the differential diagnosis depending on how a child presents or the results of their initial work up.

33:00

So what about the prognosis for HSP? Well, again the vast majority of kids have no lasting effects, everything resolves on its own after a few weeks. Unfortunately up to 50% of kids will have at least one recurrence and as many as 15% may have long terms renal insufficiency of some degree, but less than 1% will wind up with end stage renal disease.

Also pregnant women who had HSP as a child have an increased risk of developing hypertension and proteinuria also known as pre-eclampsia. So again the prognosis for most kids with HSP is good, but there is potential for problems down the road. So that's HSP in a nutshell. It's definitely an interesting disease, and if you're interested in learning more about HSP, we'll have some links in the Show notes for you over at pediacast.org, just look for episode 234.

We'll have HSP the Nationwide Children's Hospital health library has an article on it, and we have a great article from Medscape Reference on HSP if you want to know more and again I'll put a link to that in the Show notes for episode 234 over at pediacast.org.

34:07

Thanks, Judy for bringing it to our attention. Like I said HSP is definitely an interesting disease -Henoch-Schonlein purpura. All right. Next stop Juliet in Texas says, "Can you point me to any specific podcast you have that discuss delays in toddler's speech." I can do that Juliet. We talked about toddler's speech back in episode 4, 158, and 173, and I'll put links to all of those in the Show notes for episode 234 -this episode at pediacast.org.

So in PediaCast 4, way back when, we had a general discussion on toddler's speech development. It's an old one recorded back in 2006. But I took a look at the content and it's still up to date, so be sure to check that out. Pediacast 158 we answered a listener question about a two and a half-year-old son with ear tubes in place.

He had hearing problems prior to the tubes, the hearing problems resolved after placement of the tube, but he was having speech delay and the mom was wanting to know how should speech develop, when should they be putting two words together? When do they need to see a speech pathologist? What's the influence of a second child and in particular an older brother, what effect could that have on speech development?

35:20

So we answer all those questions and that is in PediaCast158. And then in PediaCast 173, we covered a new story about a research project in Australia that looked at the association between late talkers and behavioral problems. So that's another one you may be interested in checking out. And again I'll put links to all those shows in the Show notes for this episode 234 at pediacast.org so you can find them easily.

Hope that helps Juliet and thanks for writing in. OK. And our final question this week comes from Tatiana in Washington, DC. "Dear Dr. Mike. I've been listening to PediaCast since the Birdhouse Studio days episode 5. Well, you see, you just missed the toddler's speech episode Tatiana.

36:02

So she started listening to episode five and I found you'd be a wonderful resource for parenting my two girls who are now ages five years and two months. My two month old was recently diagnosed with heart murmur and I immediately came to PediaCast to see if I could find one of your well balanced and thoughtful discussions on the topic.

I was surprised to find that does not appear as if you have addressed the topic of heart murmurs yet and I was wondering if you could dedicate part of the show to the condition particularly helping parents like me understand why murmurs occur, when the condition is a cause for concern, why a murmur might appear and/or disappear, plus any other information that you might think is important for a parent to know.

Thankfully in our case the heart murmur appears to be innocent and our pediatrician simply plans to monitor it for a few months before deciding if a cardiology consult is necessary, but I'm still interested in understanding more about heart murmurs. Thanks again for your work on PediaCast and the Nationwide Children's for allowing your wonderful work to continue, Tatiana."

Well, thanks for the question, Tatiana. So let's talk about heart murmurs. This is actually an easy topic because we all know the heart makes noise, right? lub dub, lub dub, lub dub.

37:09

Let's talk first about what these normal heart sounds are. the heart has four chambers and four valves which serve to keep blood flowing in the right direction. So when we think about the normal lub dub sounds, and by the way doctors don't actually call it lub and dub, we call them S1 and S2, sound 1, sound 2.

So S1 is the lub, and that's the sound associated with the closure of the atrial ventricular valves. So there are valves, there's a valve between the right atrium and the right ventricle called the tricuspid valve, and another valve between the left atrium and the left ventricle called the Mitral valve. And when those two valves close, that makes S1 or the lub.

S2 is the dub, and that is the sound associated with the closure of the aortic valve or blood leaves the left ventricle and the pulmonary valve where blood leaves the right ventricle.

38:03

So why the noise? Well, you're hearing the sound the valve makes as it closes and the turbulence of blood flow due to the closing of the valve. So these noises combined a far more normal lub dub. Now a heart murmur is an abnormal sound associated with the normal lub dubs. So instead of lub dub, lub dub, you may hear lubsh dub, lubsh dub, lubsh dub that's one example, there are others.

So basically any sound outside of the normal lub dub we're going to call that a heart murmur. So what is making the extra sound? Well, it maybe nothing, it may just be turbulent blood flow through a normal structure and the reason murmurs may come and go is because the structures change over time as a child grows and because the force of blood flow can change depending on our heart rate.

So when kids are exercising or they're anxious from setting in their underwear waiting to see the doctor, or when they have a fever, the heart rate increases which increases flow which may augment normal turbulence which can create an extra sound during the cardiac cycle.

39:13

And we call this a normal flow murmurs which tends to come and go, we call them innocent murmurs or flow murmurs. Now, not all murmurs are innocent. Murmurs can also be caused by such things as abnormal heart valves, holes between heart chambers, or blood is getting squeezed through an opening that shouldn't be there.

For instance Atrial Septal Defects or AST when the abnormal opening is between the two upper chambers or ventricular septal defects or VST when the abnormal opening is between the two bottom pumping chambers. Sometimes kids will have an abnormal persistence of a blood vessel that used to bypass the lungs when they were inside mom and getting oxygen by way of the placenta and it need to send blood to the lungs for oxygenation.

So there's a blood vessel that bypasses the lungs called the doctus arteriosus and that's supposed to close after birth. Sometimes it doesn't and we call this a patent doctus and the blood flowing through it can cause a murmur.

40:11

There may be other anatomical abnormalities that create abnormal sounds as blood flows over and through them things like aortic stenosis or narrowing at the aortic valve, coarctation of the aorta or narrowing out pass the aortic valve or pulmonary stenosis which is narrowing at the pulmonary valve.

And there are lots of others sometimes complicated developmental disorders of the heart plumbing which results in all sorts of abnormal sounds. So the next question becomes, how does a doctor decide if a murmur is innocent or caused by a problem? Well, that's what medical school is for and residency.

So we think about the character of the sound, its quality, its loudness, its duration, its location in the normal lub dub cycle. We also consider vital signs and other aspects of the physical exam. And we use all of these information to come up with a plan is this a murmur that we can safely watch or does your child need to see a pediatric cardiologist for a further work-up.

41:10

That's the question and it's best answered by your child's regular doctor who has the proper training and the experience of hearing lots of little hearts to make the right call. So hope that answers your questions, Tatiana. And thanks for writing in.

Don't forget if you have a question that you would like to ask, or you have a show topic idea or want to direct us to a new story, it's easy to get a hold of me just go to pediacast.org and click on the contact link

You can also email pediacast@gmail.com, or call the voice line at 347-404- KIDS, that's 347-404-K-I-D-S. All right. That wraps up our listener portion of the program. We're going to take a quick break and I'll be back to wrap up the show and talk some Shop Talk on podcasting. That's coming up right after this.

[Music]

42:23

All right. We are back and to really just wrap up the show, although those of you who are still with me, I'm going to assume that you are the -or the techie geek part of the audience because I didn't want to do a little shop talk here.

And I use that term with the admiration toward Paul Harvey who you know, when he would do any story that had to do with journalism he would call a shop talk. So I guess in that tradition, if we're going to talk about podcasting we'd better call that.

Before we get to that though, I do want to remind you one more time; if you would please consider helping us help the kids this holiday season with a gift to Nationwide Children's Hospital.

43:03

And as I mentioned in the intro to the show, it's easy to do that, just head over to nationwidechildrens.org/giving, and there also be a link to it in the Show notes for this episode which is 234.

All right. So time for little shop talk on podcasting rather than medical steps. So get ready to get geeked out. So I've been asked in the past like, "Hey, what kind of stuff do you use when you do the podcast? What's your studio like? And so we have three Heil PR-40 studio mics connected to a Mackie Onyx 1220i mixer, and we record directly off the board on a Marantz solid state recorder, ad then the audio also goes into a Mac from the mixer board via FireWire.

So we record it in two places on the solid state recorder directly off the board and then also on the computer. And we do that in case one goes wrong.

44:02

I've been in a middle of an interview before and I've had software crash which is just not good, you know, when you're dealing with a busy specialist and they've taken time out of their schedule to come and do the interview you really hate to have to start over. And I've never had to do that because I read some wise words ones, so that's good to have a back up plan.

And so the Marantz has definitely saved me on more than one occasion. But I probably could just use the Marantz, but then again I've never had a problem with that. But there's always that possibility, and so we do record it in two places.

Now in terms of software, I've tried many programs along the way because I love trying new things, you know sometimes the tech process is as much fun as creating the content. And I've used garage band and I still do for mixing multiple audio tracks.

I've tried Pro Logic on Audition, I mean, these are the big boys in audio processing, but often they're more than you need and somewhat complicated to learn and use. So I found in terms of mixing stuff GarageBand works just fine.

45:04

Now, I do have a few gems in my audio toolbox that I wanted to mention. Programs that I keep going back to, and I don't leave them because I like them so much, I mean, I try other things because I have that 'Let's try something shiny and new mentality', you know what I mean, but these are the ones I go back to.

So highly recommended for fellow podcasters using the Apple platform. And the first one is a free program called the 'Levelator' from the Conversations Network and I'll put a link to it in the Show notes. This thing is really nice because you know, I used to do -when I'm working with studio guests, not everyone has the best microphone technique, and so they kind of fade away from the microphone a little bit and get kind of softer, they go right up on it and they get loud.

And so we want to try as we're doing the interview to have everybody's voices at the same level, and so I used up multi-track recorder on the computer like directly in the GarageBand, or Pro Logic, or Audition or something to that nature.

46:06

And then you can tweak the volume up and down in the individual track, but that's a lot of work post editing. So I found the Levelator, and basically you just record the interview as one track and yet raw audio goes into this thing and perfectly leveled multi-voice audio comes out. So basically raises the voices that are too low, lowers the voices that are too loud, and you get this equal level in the interview.

It's quick and it just saves a ton of time for manually adjusting sound levels in a multi-track recorder. Now the downside is you can't mix in music as you're doing the show because if you put music through the Levelator, you know, music is dynamic and so the soft parts of the song will be loud and a lot of parts will be softened and the end result does not sound very good.

So it's only for voices and you have to mix the music in a little bit later. In terms of an audio editor, I love Amadeus. And they have a free version that's Amadeus like Lite and then they have a Pro version the Amadeus Pro which is what I use. And I mean, this thing is like the Swiss Army knife of audio processing.

47:12

And I use that to clip the ends off the files so the file starts when I say, "Hello everyone", you know, the dead air space before and after I clip those off. You can control the game, you can normalize the audio, at artwork metadata/tags, and then compress the file into an mp3.

So all of that -all of the nuts and bolts of audio processing, I always fall back on Amadeus Pro. And I know other audio editors will do the same thing, there's even free ones out there like Audacity and they all have strengths and weaknesses, but Amadeus Pro really excels every level of the production process in my mind, and it's elegant, it's easy to use, and the compressed mp3's that it makes. So the technique that it uses to compress the mp3 it just is pristine.

48:04

And I've had other editors out there that kind of create distortions and pops, or clicks, and when you're rendering uncompressed audio into an mp3, that kind of loses more quality than in ought to, but not with Amadeus Pro and I love that I've used it for many years.

And again, I'm not trying to put a shameless plug in here, these products that I just really use in a lot on a day to day basis when I'm doing this thing. And so many of you out there have really over the past couple of years, I've had people, "Hey, what do you use?" And so I thought, you know, I have to feature the stuff.

And I always respond to those emails personally and I've never really put them on the show, but I just thought you know, this is the time for little geek talk with those in the audience who are interested in this kind of thing. Amadeus Pro is put out there by HairerSoft.com and like I said if you head over to the Show notes for episode 234, we'll have a link so you can find them easily.

49:05

And then finally, I use a little free Mac utility called MacMP3Gain. And this is the very last bit of the processing I do on PediaCast files. And this just sets the gain of every file to 89 decibels.

Now why 89 decibels? Well, why then said it to begin with? And the volume -you want the volume to be the same from episode to episode, so someone when they're listening to one episode to another, you don't have to play with the volume when a new show starts. And really if everybody use 89 decibels as a standard, then you would never have to adjust the audio from one program to another, or from one station to another.

And 89 decibels, that's the standard for radio streams and albums. So if you've ever switch from one song to another, or from one podcast to another, or even from one radio station to another and you have to turn the volume up or down, then someone wasn't setting their gain to the standard 89 decibels.

50:01

The easiest way that I found to do that is with the MacMP3Gain all one word, it's free, and I'll put a link to that on the Show notes as well. So the biggest software tools in the PediaCast toolbox, the ones I recommend to fellow podcasters, Levelator, Amadeus Pro, MP3Gain, and I always fallback to GarageBand for multi-track mixing.

And we'll have links to all that stuff again in the Show notes for at 234. So again no shameless plugs there, just want to use them, just being transparent and trying to help out some fellow podcasters who I know to be in the audience. All right. I want to thank all of you for staying tuned in an listening to PediaCast and coming back week after week and joining our audience, really appreciate that.

Also want to remind you that iTunes reviews are helpful as our links on your web pages and mentions in your blogs, on Facebook, and your tweets, and your Google +. Be sure to join our community by liking PediaCast on Facebook. You can also follow us on Twitter, hang out with us at Google +, and stopping by our Pinterest boards and re-pinning your favorite episodes and news stories.

51:05

You can also swing by the Show notes at pediacast.org to add your comments on today's show. We also appreciate you telling your family, friends, and neighbors about the program.

And don't forget to talk us up with your child's doctor at your next well check-up or sick office visit. And we do have posters you can download and hang up wherever moms and dads hang out. And you can find them under the resources tab at pediacast.org.

Once again, if there is a topic you'd like us to talk about or you have a question for the show, just go to pediacast.org click on the contact link. You can also email pediacast@gmail.com, or call the voice line at 347-404- KIDS, that's 347-404-K-I-D-S. And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids. So long everybody.

[Music]

52:02

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

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