Auditory Processing, Night Shift, Baby Yoga – PediaCast 248
This week Dr Mike tackles more of your questions! Join us in the PediaCast studio as we cover auditory processing disorder, hemangiopericytoma, working the night shift while pregnant, subgaleal hemorrhage, baby yoga, and listening skills.
Auditory Processing Disorder
Night Shift & Pregnancy
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus from 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 April 10th, 2013. It's Episode 248, and we're calling this one "Auditory Processing, Night Shift and Baby Yoga."
Now, of course, we have more topics than just those three coming your way. It is a Listener edition of the program so we're going to be answering your questions. And I'll get to a complete line-up of the topics here in just a moment.
First, I want to say welcome to the program, all of you. And Spring has sprung here in Ohio. So we're pretty happy about that. The sun is shining, it's a bit warmer outside. You'll notice I have a little bit more jump in my step, a more positive outlook. The Ohio winter grey was really getting to me last week, as you probably surmised by my tone. So spring is here and I'm pretty happy about that.
Spring also means tornado season. And, those of you who are potentially in the paths of the large type tornadoes, so those in the Plains States and here in the Midwest as well. I remember, and I guess this is sort of probably where I don't know if I'd call it a fascination, but sort of my interest in tornado stems from the fact when I was a kid, there was a very large tornado, an F5. Back then, it was just F. Now, it's EF. But anyway, it was the largest type tornado you could have back in 1974. And it hit a town here in Ohio called Xenia. And we live about an hour, an hour and a half, right around there, away from Xenia, in a town called Urbana, Ohio.
And I remember we had debris from the surrounding countryside. We have like dried corn husks. I can vividly remember, they blew into our yard, which is really weird in April. That was dried stuff from a field. But a friend of mine — and this is true story, not kidding you here — had a large ceramic Easter egg land in his yard and it was unbroken and had a family name and said "Xenia, Ohio" on it.
So, it blew, like an hour, hour and a half away, up in the air and landed in my friend's yard. So that was pretty amazing and true. It really did happen. I didn't see it land. Now, I'm sitting here thinking, maybe he made this whole thing up. Maybe he had like an aunt who lived in Xenia and he's like, "Hey, look what fell in my yard." [Chuckle] I think I need to give this guy a call.
Anyway, that's sort of where my interest in tornadoes comes from. But anyway, my point here is since this is a pediatric podcast, we have to kind of wrap this around and make it relevant to pediatrics. We want your family will be safe. And you know, you got little ones at home and it's important that you have a tornado plan. They have one at school, you probably have one where you work, you need one at home, too. And particularly since we've seen pretty big deadly tornadoes in recent years. Back in May 2011, Joplin, Missouri, a 158 deaths.
So even with our improved knowledge of tornadoes and early warning systems, we still see big ones with large death tolls. So it's really important that you are prepared. And to help you do that, I have a couple of links for you in the Show Notes for this Episode 248. If you want to head over to pediacast.org, you'll find them, from the National Oceanic and Atmospheric Administration, otherwise known as NOAA. They have a very nice tornado FAQ and also a tornado safety tips sheet. Really everything that you need for your family to be prepared for tornado season.
What supplies do you need, like a battery-operated radio and flashlight, where do you go at home? If you have a basement, that's a good bet. But the southwest corner idea, as it turn out is a myth and their FAQ talks about that. If you don't have a basement, you know, you want an interior hallway or a bathroom and it really goes into where you need to be and what you need to do. You can take a mattress in with you and cover yourself up, that would be good if you have time. Also if you're out in your car, it's not a good idea, as it turns out, to hide under an overpass. And they explained why that is and what you should do in their FAQ and in their Safety Tips sheet.
So definitely check those out again, Episode 248 in the Show Notes over at pediacast.org.
All right, as I've mentioned, we do have a Listener show coming your way this week. And I recently put out a call for questions. And of course, in usual fashion, you guys responded. But we need more. So if you're sitting out there with a pediatric question in your head, maybe it concerns your child or a grandchild or a niece or nephew, or really any other kid or teenager that you know, or if you have a topic idea or you want to point me in the direction of a new story, if that's the case, head over to pediacast.org, click on the Contact Link and ask away. That's what the five listeners who are featured in this week's program did and you could be next.
So what are we talking about today? What questions did you have? Well, the first is on auditory processing disorder. What is it? What causes it? How do you diagnose and treat it? So that's coming your way.
Also, hemangeopericytoma– OK now, I lost some of you there. But never fear, our listener has a question about a tumor on her child's knee. We'll break down the word, hemangeopericytoma. We'll make it easy to understand and let you know the ins and outs of this sarcoma.
That may not have helped. What is this sarcoma? You've probably heard the word, but what exactly does it mean? We'll clue you in.
And then, working the night shift while pregnant, is it dangerous to the health and well-being of mother and child? We'll give that some thought.
Then, we're going to go on another technical topic. Well, you guys asked some good scientific questions this week. Subgaleal hemorrhage and cephalohematoma — you probably seen a baby born with a giant baggy lump on the back of their head. or you know someone who had a baby with a lump on their head, or maybe your child did. That's usually a cephalohematoma and we'll explain what it is and why some babies get them. And then, we'll also explore their much more dangerous but far less common cousin, a subgaleal hemorrhages.
So that's coming up. And then, we're going to take a look at baby yoga, also known as dynamic gymnastics. There had been some popular YouTube videos surfacing on this practice, but it's dangerous. And in my mind, it amounts to child abuse. Want to know why? Well, stick around and I'll explain.
And then, finally, we're going to wrap up with a final word on listening skills.
So lots of great questions this week from our wonderful audience. And again, if you have a question of your own, we're caught up on questions and I need more. So head over to pediacast.org, click on the Contact link and ask away.
Also, I want to remind you 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.
All right, let's take a quick break and I'll be back with your questions, right after this.
All right, our interlude music there, you'd probably heard that one many times before, especially if you're a regular listener of PediaCast. It has a name. As it turns out, the name of that one is Windy City, which I thought was appropriate given our little talk about tornadoes earlier. I kept this in the back of my mind. A ceramic Easter egg, a big one with a family name and then, it says "Xenia, Ohio". Did that really land in my friend's yard? I believed it all these years. In fact, the only time that doubt ever slipped in was as I'm presenting it to you. And I'm thinking, did that really happened or was he just kidding me? Seriously, I'm friends with him on Facebook. I need to ask and report back to you.
All right, first stop with our listener questions this week is Marcy in Bellmore, New York. Marcy says, "Hi, Dr. Mike. My daughter is five years old. When she started kindergarten, her teacher thought it would be a good idea for her to receive speech therapy, because she was mispronouncing different letters. As part of her assessment for speech therapy, she was required to see an ear, nose and throat doctor. We've already been seeing an ENT because my daughter has a history of frequent ear infections. The ENT doctor suggested that my daughter may have an auditory processing disorder. I was hoping you could explain this a bit more on your show. Thanks. Marcy."
Well, thanks for the question, Marcy.
Auditory processing disorder, also known as central auditory processing disorder. It's another one of those diseases that we don't fully understand. As the name suggest, the underlying problem is how a person processes sounds.
OK, so what does that mean? Well, if you think about the brain as a black box, which sometimes is not very far from the truth. Something goes in and in this case, information from the ears in the form of sounds. And then, something comes out which is our response to those sounds in the form of speech or actions. In this case, the problem is in the black box. So sounds make it in OK. And then, there's nothing wrong with the response to those sounds in and out of themselves. But the response isn't what we would expect, given the sounds that went into the box.
So the response is OK, there's nothing wrong with it, other than that it doesn't quite match up with what went in. So the issue is inside the black box or inside the brain at the location where we interprete sounds and initiate a response to them. So that's what is meant by a processing disorder.
Now, why do we think this is? How do we know it's not a hearing problem. Maybe the ear isn't sending in the correct signal. Well, kids who have an auditory processing disorder do have normal hearing. So, if you sit him down on a quiet sound booth with an audiologist and the audiologist does a sound test with pure tone, they pass the test, no problem. But when you add in background noise and dynamic speech, so when sounds need to be separated and analyzed on the fly, that's when it appears that the trouble starts. Unfortunately, we don't yet understand what the problem is or even where the problem lies inside the black box. And at the end of the day, there probably isn't a single problem. Auditory processing disorder is likely a group of diseases with a common expression and as more becomes known, we'll do a better job of teasing out the differences in the future.
OK, so now that we've defined auditory processing disorder, how common is it, what specific problems do these kids face and how can we help them? Well, it turns out about 5% of school-aged children are affected, so it's pretty common. Five percent of school-aged kids affected by it.
In terms of specific problems that these kids face, the biggest issue is following speech, and particularly, in noisy environments. So, how does this look at home or in the classroom? Well, these kids don't like to be in a noisy environment. So background noise typically aggravates the problem and leads to stress and frustration on the part of the kid. However, when you sit him down in a quiet and focused environment, they'll settle down, they're more comfortable and they perform better.
These kids often and initially present with speech problems. Why? Because they interpret sounds differently and repeat back what they think they heard rather than the actual sounds. So,they may have a problem differentiating similarly sounding phonics. For instance, ch 'cha' and sh 'sha'. So ch and sh, they may have difficulty telling those apart even when the difference is readily apparent to everyone else.
They may also have trouble differentiating words when the endings sound alike. For instance, they may confuse light and sight. And by the time they figured out which of those words make sense in the context of the sentence, you're already through your four sentences downstream and they've lost you.
So these kids have difficulty following speech and sometimes even in quiet environments, they may have trouble following instructions, they may have trouble understanding, they may have trouble learning, because they aren't following you. And because these kids have trouble following, what's the normal response? They give up and stop paying attention. So these kids seem to have an attention problem because they aren't paying attention and they may seem disorganized and forgetful.
And you'll see right away that these symptoms seem an awful lot like another problem we've recently covered, ADHD. And in fact, there are many kids out there diagnosed with attention deficit hyperactivity disorder, treated for ADHD who really have an auditory processing disorder and stimulant medication is not going to help them.
OK, so what does help? Well, the first step is getting the right diagnosis. And this is best accomplished by evaluations. First, from an audiologist to make sure there isn't a hearing problem, because a true hearing problem can cause similar symptoms. And then, an evaluation by a speech pathologist who has the tools and knowledge to make the right diagnosis.
Now, I do want to point this out — kids with auditory processing disorder may have other issues going on at the same time, like ADHD or autism or anxiety or depression. So comprehensive medical and behavioral examination is still important. And your child might benefit from medications for their other problems, if those exist.
OK, so let's say your child has all of these evaluations done and a speech pathologist diagnoses an auditory processing disorder. What then? What do you do about it? Well, working on a regular basis with a speech therapist is in order. And there are some practical things you can do to help your child. For instance, reducing background noise. Have your child look at you when you're speaking. Talk slowly. Use simple sentences. Write down instructions rather than relying on your child remembering what you say.
To help with school work, you want to make sure that the school is providing a quiet, distraction-free study space and that you are providing that at home, as well. And also, teach your child organizational strategies that rely on written words.
And of course, the school does need to be dialed in to the problem. They can provide a distraction for your learning devoid of background noise. These kids should be sitting in the front of the classroom. They benefit from written supplements to the lesson, rather than solely relying on spoken lectures. Also, having lectures recorded or in podcast form, so they can review and re-listen, that may be helpful as well.
Unfortunately, a lot of these kids get placed in a special education classrooms, which is good in terms of the learning environment, but these kids don't have a problem with intelligence. And you do run the risk of dumbing down the material they're working on in special classrooms, which can affect standardized test scores in the college admissions.
It's also important to point out that with the right diagnosis and support structure in place, these kids usually do not have a problem with academic success. But again, you need the right diagnosis and the right support strategy.
You know, this is one of those things, too. If you have a kid with ADHD, that's what their diagnosis is and they're on stimulant medication, and they're doing great, then great! You probably have the right diagnosis. But do keep in mind, if you have a kid who's been diagnosed with ADHD and they've tried this medicine and that medicine and this dose and that dose, and nothing seems to be working, then maybe it's time to explore some other things and auditory processing disorder would be one of those.
In terms of long-term outlook, many of these kids either outgrow the problem or dramatically improves by the time they reach adulthood. There are others who don't see as much improvement and auditory processing problems can persist into adulthood. But again, with proper recognition and appropriate strategies for learning and work environments, adults with auditory processing disorder can also lead successful and rewarding lives.
So hope that helps, Marcy. And, again, thanks for the question.
All right, let's move on to our next one. This one comes from Deb in Green Rapids, Michigan.
"Hi, Dr. Mike. I've been listening to your podcast for several years and have sent in a couple of questions before. Thank you for doing such a wonderful job of bringing answers, news and information to all of us, parents. I have another question I'm hoping you can help me with. Last Fall, we noticed a growth on our ten-year-old daughter's knee, which was biopsied and then removed in January. Three separate pathology reports all agreed that it was an infantile hemangeopericytoma. We've been to four different doctors. Our pediatrician initially referred us to a dermatologist, who referred us to a pediatric surgeon, who referred us to a pediatric oncologist. Each time, we've gotten a little more information about the problem and we're comfortable with the course of treatment that's being recommended after an MRI, a CT-scan and bone scan. A second surgery would do a wide re-section of the tumor area, which is now mostly scar tissue. But they don't feel chemotherapy or radiation is necessary at this time.
I know that hemangeopericytoma is a form of sarcoma and that it's a rare type of tumor so that not much research is available. And that's a lot of the reason why we've had multiple doctors and varying treatment options. I'm wondering if you might be able to explain more about sarcomas and how it's determined as to whether tumors are benign and malignant, and if there's anything specifically out there about hemangeopericytoma as well. The oncologist explained that when they occur in anyone under 18, they're classified as infantile but that's misleading since these tumors do behave differently in infants than in kids or adults. I try to find information online but there's not much out there and I don't understand most of what I do find.
Anything you can explain or describe in layman's terms would be incredibly helpful. I know this is a rare tumor and most likely other listeners will never need to know about it. But in talking to other parents since this whole thing begin, I've heard of other kids with various types of sarcomas, so even knowing more about them in general might help someone else. I've written about our experience with this on my blog at momstakeonthings.com. Most recent post starting with the one in January called 'That Funky Looking Thing on Hannah's Knee'. Thank you — Deb."
Well thanks for the question, Deb, and thanks for your long-time loyalty to the show. Really appreciate that as well.
So, let's begin with the benign versus malignant tumors and then we'll move on to a definition of sarcoma and we'll wrap with some detail of hemangeopericytoma.
Actually, before we begin, and I don't think we've really covered cancer on PediaCast much. So let's define what cancer and tumors are. Cancer is really just out-of-control cell division. Now, obviously cell division is importan for growing and for replacing damaged tissue. But when cells grow in an uncontrolled fashion, they can impede on surrounding tissues. They can spread to other areas of the body and then leash havoc. They can cause dysfunction and damage and ultimately lead to death.
So , what causes cells to start dividing out of control? What causes cancer? We know genes are involved, so DNA, genetics, genes. And we know environmental factors which alter those genes play a role, things like chemicals and radiation and viruses. A tumor by definition is a massive cell that have divided in abnormal fashion. A benign tumor is one which may get larger but it's not expected to spread aggressively. So there's potential for encroachment on surrounding tissue and for that reason, it may need to be removed, but there isn't fear of aggressive growth or distant spread. On the other hand, a malignant tumor grows and spreads to distant sites in an aggressive manner and without intervention can lead to organ system dysfunction failure and death.
So what determines if a tumor would be benign or malignant? Well, that depends on the source cell. So the cell that started the out-of-control process and certain characteristics of that source cell.
Now, admittedly, I'm simplifying this a bit because I have five to seven minutes to explain cancer, which is no easy task. So, depending on the source cell and characteristics of the source cell, we can make predictions on how the tumor will behave based on past observations and our knowledge of that specific type of cancer or tumor. As it turns out, the source cell and it's characteristics also determine what word we use to describe the type of cancer we are dealing with. So if the source cell is a malignant epithelial cell which are cells that line tissues and make up glands, then we call the cancer a carcinoma. If the source is a malignant mesenchymal or mesenchymal cell, which are cells that make up connective tissue, things like bone, cartilage, fat, muscles, blood vessels, then we call the cancer a sarcoma.
So, what then is a hemangeopericytoma? Let's break down the word and that will help us to understand. So hemangeo, that let us know a blood vessel is involved. Pericyte — that lets us know that a specific cell, a pericyte cell is involved. Now, it's not a parasite like the micro-organism, but a pericyte. But the micro-organism parasite, P-A-R-A-S-I-T-E, this is P-E-R-I-C-Y-T-E. So a pericyte is a type of blood vessel cell. So what are these cells? What are pericytes? Well, they are cells that make up the deep portion of the inside lining of various small blood vessels like capillaries. The oma at the end of the name, hemangeopericytoma, that lets us know that this is a sarcoma. So it's a malignant cell of mesenchymal cells. So putting it all together, mangeopericytoma is a malignant tumor that arises from cells which make up a portion of the deep lining inside the capillary wall.
OK, so what do you do about it and how do you treat it and why are there differing opinions among your doctors? Well, here's the deal, in the world of cancer treatment, things aren't always black and white. In fact, I think they're seldom black and white. Treatment protocols for specific cancers are fluid. They're changing to reflect new knowledge and success and failure in the treatment of similar tumors at different institutions.
So as long as your cancer team is being managed in that approach, as a team, and that includes oncologists and surgeons who discuss the case and make individualized treatment decisions based on your specific disease and taking into account up-to-date research, up-to-date experiences, up-to-date treatment protocols, and the team has experience and access to appropriate resources for that particular cancer, then you're in good shape.
Now, how do you know for sure that your team is up to date, has the right resources and is doing the right thing? Well, in my opinion — so this is my kid we're talking about — I make sure that I'm at a dedicated pediatric institution with a solid reputation for cancer treatment. And by the way, I do want to point out, at Nationwide Children's Hospital, we do have a world-class cancer team that is happy to see kids from outside the State of Ohio, whether that be for primary treatment or for a second opinion.
Now, I'm not suggesting you do this, Deb. You may be in very good hands in Grand Rapids. But I do want to make sure that everyone out there is aware of our outstanding cancer programs. It's recently ranked as one of the best in the nation by both US News and by Parents Magazine. And I'll put a link in the Show Notes, again, Episode 248 over at pediacast.org. And you'll also find a link to our exclusive contact form so you can easily reach out to one of our cancer specialists with any concerns affecting your child.
So, thanks again for your question Deb and thanks, too, for sticking with us through the years, really appreciate your trust and loyalty. The rest of you out there, if you'd like to read more about Deb's journey with, in her words, "the funky looking thing on Hannah's knee", I'll put a link to her blog, momstakeonthings.com, again on the Show Notes for Episode 248 over at pediacast.org.
All right, let's move on to question number three. This one comes from Sarah in Nebraska.
"This might not be a question you're interested in answering because it deals with pregnancy instead of pediatrics but I trust you to provide quality information, so I thought I'd ask. What kind of information is available about working in overnight shift, 10pm to 7am, for example, while pregnant. I've done some Google-ing but it's either anecdotal information or somewhat scary article about miscarriage or something. I love your show and I'm hoping you'll be interested in talking about this topic."
Well, thanks for the question, Sarah. I think it's interesting you mentioned the 10pm to 7am shift, because that just happens to be a shift that I am acquainted with, working in the Emergency Department. And I am happy to talk about staying healthy during pregnancy as well.
Now, we know a mother's health does affect baby development in pregnancy outcomes. But what about working in the night shift specifically? Well, I did a little research and there really has not been any extensive study of this issue. So we have to fall back on what we know. I'd personally take a practical approach to this. Some people tolerate the night shift just fine. They've been doing it for years. It's like they were made to work nights. They're happy and healthy and really wouldn't have it any other way. There are people like that.
For others, they tolerate the night shift, it's not their favorite, but they deal with it. They sleep fine when they go home. They feel well rested when they wake up. They eat healthy and exercise. They take care of their bodies. It's not their favorite thing in the world but it agrees with them OK.
Then, there are those of us that pretty much go kicking and screaming into the night shift. You know what I mean. Or even worse, those of us who work erratic schedules, switching back and forth between nights and days. And that's my life, when I work shifts in the ER. For us, it's not so easy. We don't sleep well after working all night. We feel tired, we use caffeine as an eye opener at all hours and some folks even resort to other drugs to manage sleep-wake cycles when they're living in that kind of situation.
Now, the first two groups I described are likely fine during pregnancy. Again, I don't have any research supporting my assessment but it makes sense given what we know. And without research in a given area, that's all we have to go on.
The third group however, for them, there are concerns — concerns for the effects of chronic stress and fatigue, concerns for drug use including caffeine, alcohol, nicotine and other sleep aids, and concerns for relationships and social problems that might stem from working the night shift. And sure, these things may contribute to problems with fetal development and pregnancy complications and outcomes.
So what about your case, Sarah? Well, I think you have to ask yourself how well do you handle nights. Are you getting rest and good nutrition and appropriate exercise? Are you exposing your baby to chemicals that help you sleep and wake up? What's your stress level? How about your relationships?
And of course, with the balances with your need to work and possibly support your family — if nights are a problem, what are your alternatives? Can you switch shifts? Can you switch jobs? Or, if the problem is child care when you get home for other kids in the house — and that's leading to lack of sleep and stress and fatigue and drug use — can you make other child care arrangements, so that you can get some rest when you do get home after the night shift?
So I guess, Sarah, you really have to reflect on the specifics of your unique situation. If life is good, great! There's no evidence out there to suggest that nigh shifts in and out of themselves are a problem. But, if night shifts are leading to other issues like fatigue and stress and nutritional problems and chemical use and relationship issues, then you'll be best served by making any adjustments that are within your control. Now, having said that, I realize some adjustments are not within your control but others are, and you have to identify and adjust those accordingly.
So hope that helps, Sarah. And again, thanks for the question.
All right, we're going to move now to Austin in Bountiful, Utah. Austin says, "Hello. I recently begin listening to your podcast and so far had found them useful. My 11-week-old daughter has a subgaleal fluid collection on her head. She acquired it at about five weeks of age and our pediatrician at the University of Utah Hospital knows little to nothing about it. Our pediatrician think it is from the difficult labor which included three hours of pushing in the posterior position followed by a C-section. The fluid collection recently increased in volume as to make the skin tight around it and then, receded back to about two-thirds capacity of the skin. Do you have any information about subgaleal fluid collections or a podcast that touches on it? Thanks – Austin."
Well, thanks for the question, Austin. We have not covered this issue before which sort of surprises me, because these things aren't necessarily uncommon, especially in the newborn period. So, Austin, you describe the situation as a subgaleal fluid collection.
First, let's define subgaleal. The outside surface of the skull — OK, got to think deep here a minute — is lined with the membrane called the periosteum. And the skin of the scalp is attached to a connective tissue layer called the galea aponeurosis. Now, between these two layers is something that we call a potential space. So the two layers, the periosteum which is sitting on top of the bone and the galea, the deep part of the scalp, these two layers are sitting on top of each other. They're not connected to one another, so there is potential for fluid to accumulate between the two layers. So when you say a subgaleal fluid collection, we are talking about a collection of fluid, under the scalp beneath the galea aponeurosis and on top of the periosteum of the scalp. So between those two layers which is the subgaleal space,
Now, what sort of fluid are we talking about? Well, the most likely fluid is blood. OK, why? Well, there's some veins that went through this area that are called the emissary veins. And they're very large veins and they're prone to rupture when exposed to traumatic forces and such traumatic forces can occur with difficult and prolonged labors and particularly, when vacuum suction is used to assist a vaginal delivery.
That's the most common scenario where we would see rupture of the vein that would lead to bleeding into the subgaleal space. So if an emissary vein ruptures, a large amount of blood can spill out of the vein and into that potential space and that's then what we call a subgaleal hemorrhage.
Now, I want to pause for a moment and contrast this with a more common problem called cephalohematoma. Again, let's break down the word, cephalo means head, hematoma means collection of blood. So this is a collection of blood in the head, around the head. This is a similar issue but in the case of a cephalohematoma, the bleeding occurs between the skull bone and the periosteum, rather than between the periosteum and the galea aponeurosis.
Now, the reason that this is a important distinction to make, as it turns out, the periosteum — that's the covering right on top of the bone — it dives down between sutures of the skull. So think about a baby's head. They have the soft spot, right? So, basically, the skull is made up of plates of bone that sort of all come together. And the reason that they do this is because they grow around the margins. And so, by having the skull made up of a bunch of different plates, it can grow effectively. And so, if the periosteum covers the top of the bone and then dives down in between all these suture lines, that means that any potential space between the bone and periosteum is smaller because it only covers a portion of the skull, one of those plates not the entire scalp.
So the potential space between the bone and the periosteum, it won't hold as much blood. And you can tell the difference between a cephalohematoma and a subgaleal hemorrhage by looking at the location of the bulge or the bogginess on the scalp. So if it is confined to a specific portion of the skull and doesn't cross the midline or any other suture line, then you're probably dealing with a cephalohematoma. But if the swelling involves a larger portion of the scalp and perhaps crosses the midline or crosses other suture lines, so it involves more than one plate next to each other, then you're more likely dealing with a sub-galeal hemorrhage.
So why is it important even to distinguish between these things? Well, cephalohematomas are usually not dangerous. They look terrible. They can take a long time to go away. But the blood is confined to a relatively small area and there's usually sufficient pressure from the presence of all that blood in that small area to occlude any tear in the blood vessel which results in clotting and healing. Again, it can take sometimes weeks to months for the blood to go away as the body digest it and gets rid of it, but it's not really particularly dangerous or life-threatening.
On the other hand, the subgaleal potential space is much larger. Remember, across the suture lines and is beneath the entire scalp, so it can hold much more blood. And not as much pressure is generated so you don't get as great of occlusion of the damaged blood vessel. Now, couple this with the newborn's often inefficient blood-clotting system — which is why vitamin K shots are given in the delivery room — or at a baby with a genetic bleeding disorder, then you can have a serious situation. And as it turns out, the subgaleal space can hold up to 50% of a baby's blood volume. So this can lead to hemorrhagic shock which can be life threatening.
Now, once these things occur, cephalohematomas and subgaleal hemorrhages, how do you treat them? Do you drain the blood? No, and there's couple of reasons for this. If you drain the blood, you would just increase the potential space again and bleeding could resume. So if you drain the blood, right, now, you got an empty space, it can fill back up. So you worry about continued bleeding if you drain it.
The other thing that you worry about is introducing infection to the area. It's really not a good place you would want to get infected, next to the skull, which could then lead to an infection of the skull bone itself and could also lead to meningitis. So, it's important that you keep this infection-free.
So what do you instead? Well, you allow the body to break the blood down on its own. And again, that can take weeks or more likely several months. And in the meantime, in the case of subgaleal hemorrhage, you watch for signs of shock, of hemorrhagic shock, which is most likely during the acute event — not weeks down the road when the body is breaking down the blood — but when it first happens, that's the really dangerous time when the baby could lose a lot of blood in this area. If too much bleeding or hemorrhagic shock is a concern, then we give replacement fluids or blood products, so that we fix the loss of blood volume with more volume to get the blood pressure and their oxygen delivery where it should be.
Also, if it's determined that a child has a clotting disorder as part of the problem, then you deal with that as well. And another issue that may pop up is prolonged jaundice. As the body breaks down all that spilt blood, bilirubin is a by-product of red blood cell digestion and too much bilirubin leads to jaundice. So that can become an issue as well.
Now, having said all of these, all of that, in the back of our minds, none of it sounds like Austin's case, right? There was no vacuum delivery, there was no acute bleed beneath the scalp following birth, there's no mention of jaundice. And the scalp swelling wasn't even noticed until five weeks of age. So what's the deal?
Well, I can't say with any certainty because I don't know all the details and we don't practice medicine in the form of a podcast. But here is a possible scenario that would fit that situation. You can have a rough labor and delivery that results in a tiny tear of a blood vessel in the subgaleal space. So a tiny tear. So it's just going to leak a little bit of blood. Or, maybe, there's a blood vessel with a structural abnormality or malformation in that location. Perhaps there's also a mild clotting problem. And all of these things allow for a very slow bleed over time. And if the bleeding is slow enough, you might not notice it for a few weeks as that blood slowly accumulates in such a large space.
Now, most of the time, this is a rapid bleed shortly after birth. But slow bleeds over time are possible as well. And when that happens, there is more concern for an underlying malformation of the blood vessel with that location or an underlying clotting problem. Again, not to say that this is the situation for your child, Austin, but certainly, possibilities.
And by the way, if I were a general pediatrician seeing a kid with a subgaleal hemorrhage and I had any concerns about how to manage it — what to do, what to watch for — I'd probably touch base with a neonatologist and/or a pediatric hematologist. Neonatologist, being a baby doctor, baby specialist and a hematologist, being a blood specialist, to help me with the management. But that's me.
So thanks for the question, Austin, and welcome to the Pediacast family.
All right, let's move on to our final question this week which is really more of a comment. This one comes from Andy in Manila. Andy says, "Hi. Can you give your thoughts regarding baby yoga? I came across this very disturbing video on YouTube and I just find it dangerous and torturing for the baby. Thanks." And she provides a link to a specific YouTube video.
So thanks for pointing me in the direction of this video, Andy. And for those of you unaware of this so called 'baby yoga' phenomenon. Well, first, it's really not yoga at all. Another term it sometimes goes by is dynamic gymnastics. But it's really not gymnastics either. What it amounts to really is just swinging your baby by his or her arms or legs in a very dangerous fashion. And I couldn't be more empathic in condemning this activity.
It's not smart, it's not safe and really it does amount, as I mentioned in the introduction of the program, in my mind it really does amount to child abuse. And in fact, if I had a suspicion that a child I was seeing had been exposed to this behavior, I'd have an obligation to make sure the baby was in a safe environment and to report the incident either to a local law enforcement or to Child Protective Services.
Now, I realize these are strong words. But if you're familiar with this so called baby yoga, you'll understand where I'm coming from. If you have no clue what I'm talking about. In the picture in your mind is mom sitting with her legs crossed and a baby in her lap doing a little baby yoga, that's not the case. Make sure you check out the YouTube video that Andy is referring to. And I'll put a link to it over in the Show Notes for Episode 248 at pediacast.org. I mean, this video really is a mom grabbing this kid by the arms and just swinging him around ever which way.
Now, with all of that as background, I do want to make some comments specific to the video in question and then wrap up with why I would consider this child abuse. First, the video, even though it's in the context of a local news story — so this isn't just a video that someone put up on the Internet, on YouTube that they made themselves at home. This is actually a news story from a local news station and a news reporter. And even though this video is in the context of a local news story and supposedly verified as authentic by a Time Magazine reporter, despite those assurances, I just don't believe it. I really think the video is a hoax.
And the baby that's being spun and twisted and turned every which way is billed as a two-week-old infant. But if the baby was real, it's way too big for a two-week-old. It has too much muscle tone. The head has way more head control that I'd expect. Its knees are always flexed in the exact same rigid position. To me, it looks like a plastic doll. Also, from a mechanical standpoint, I just cannot imagine a baby's body withstanding those kind of forces without resulting fracture or dislocation.
But let's just say for the sake of argument that even though I don't believe it and I think it's a hoax, let's say it is real. Let's say the mother is holding a real baby and that the local news reporter is right and this has all been verified. In that case, this is nothing short of extremely dangerous. And even though according to this news story, the baby fared well, I would not expect other babies to be so lucky.
Now, let's explain why. Well, first I mentioned I'd be worried about fractures and dislocations. Look, folks, injuries of the extremities easily occur with difficult childbirth. We've talked about the fragile nature of baby hips on this show before, as well as brachial plexus injuries in the upper extremity. So this risk is real.
I'm also worried about dropping my baby while doing this, which could result in head trauma, spine trauma, abdominal trauma, not to mention further risk of extremity fracture and dislocation. And finally, and perhaps, most significantly, I would worry about shaken baby syndrome, with retinal hemorrhages potentially leading to blindness and brain bleeds which may lead to all sorts of nastiness.
So I agree with you, Andy. So called baby yoga or dynamic gymnastics is bad. Just don't do it. And as Andy points out it is extremely dangerous and it's a form of child abuse.
So thanks for writing in from Manila. I really appreciate you, Andy, contributing to the program. For the rest of you, if you're still scratching your head and trying to form a visual of this YouTube video that we are referencing, again, head on over to pediacast.org, find the Show Notes for Episode 248 and click the YouTube link and take a peek of the video for yourself.
All right, so that wraps up our answers to listeners' questions this week. As a reminder, if you have a question that you would like to ask on the program… And actually I put out just over the last couple of weeks, put out a call for questions and, boom, right away, I got these five, we included them on the show. I think I have one more in the tank left to do on our next listener show. But we have four more spaces and we'll do more listener shows after that.
So if you do have a question in mind, this is a great time to ask. Just head over to pediacast.org, click on the Contact link and ask away. We also welcome any of your comments or show suggestions for topic ideas or our interview show if you have a topic idea, that sort of thing, let us know. Again, pediacast.org, click on the Contact link.
All right, we are going to take a quick break and I will be back with a final word on listening skills. That's coming up right after this.
So, my friend who told me this ceramic Easter egg story, see, it's been at the back of my mind now. He's a pastor now at a church. So I think he's going to be upfront with me when I confront him and ask him if his ceramic Easter egg story is true. So, I'll have to let you know about this. I'm going to get back to you on it.
All right, this is an appropriate final word for you this week. Because for my final word, I want to get a little transparent with all of you. Have you ever had one of those things in your life that just keeps coming up over and over a short period of time? And pretty soon, you feel like it's batting you upside the head and telling you to get with the program.
I've actually had that happened several times in my life. But my most recent experience with it has involved listening skills. So I participated in a team building experience here at the hospital. And you know the sort I'm talking about. Team building, you know, you kind of roll your eyes before you have to go, but then you walk out and you're glad you went and took away something valuable. Well, for me, what really stuck out in my mind was the presentation on listening skills.
And then, a couple of weeks later, the same topic comes up, completely independent of the first during a faculty development seminar that I had to attend. Another role that I served with the Ohio State University College of Medicine, I'm an academic adviser for a group of medical students. And in part of our training, to be better advisers, we talked about, you guess it, listening skills.
And then a couple of weeks after that, as part of the church group, guess what comes up in the discussion? Again, listening skills. So here's the deal and the bottom line from pretty much all three presentations, which, again, were independent of each other but it just happened that all three occur in my life in a very short period of time — when we listen, we usually default in into one of four modes.
We either tune out. You're not really listening, you're just kind of planning your exit from the conversation.
Or we 'listen to tell my story' where I'm formulating my own agenda, usually on an unrelated topic as we converse. So I'm listening to you but I'm figuring out what I'm going to say next and it doesn't even have anything to do with what you're saying right now. So that's 'listening to tell my story'.
I can 'listen to respond' where I start out listening, but rather quickly, I start coming up with my response and mostly tune out the remainder of what you have to say, because I'm concentrating on what I'm going to say when you're done, which is in response to what you're saying. So that's 'listening to respond'.
And then, finally, we can 'listen to understand' where I reflect on the context of what you were saying and I really try to understand it from your perspective, before I formulate a response. Now, I may still have an opposing view. I may still respond with my own two cents. But I'm really focused, I'm trying to understand what you were saying before I respond.
So here's where the convicting part comes in and I think many of you would be convicted on this as well. Not because we're bad people but because it's human nature. And as I reflect on my own default style of listening, I realize I don't spend much time listening to understand. I do a lot of tuning out and listening to tell my story and listening to respond, but I have a lot of work to do on listening to understand.
Then, I think, how much better would my relationships be with my children — got to say that first, it's a pediatric podcast, we want to relate this to your family and your kids. But, you know, how much better would my relationship with my kids be, with my spouse, with other members of my family, with my friends, with my co-workers if I really tried to understand what they're saying in the context of their lives, from their point of view, before I analyze the situation with my own filter?
And I'm also working on an area in my life where I wish to improve. And that's how we grow. Ler me tell you, when you humble yourself to your family and you let them know you recognize your shortcomings and you share with them your plan to do better, you not only affect those around you by growing as a person, but you also are modeling healthy behavior to your kids.
So, not only for me to say, "OK, I want to start listening to understand and that's going to improve my relationship with my kids." That's one side of the coin. The other side of the coin is setting your kids down and saying, "You know what, I've not been doing a very good job listening to what you have to say. It doesn't mean that I'm going to agree with everything you have to say but I really do want to understand everything from your point of view." And when you sit him down and kind of humble yourself and say, "Look, I've not been doing a good job, I want to do better," you really are modeling that behavior. And your kids are going to carry that. They're going remember that. They're going to carry that example with them into their own adult lives. And that's something really that you can give to your kids, it's something special.
So, I sort of hope that like me, many of you out there kind of rolled your eyes when I first mentioned listening skills. But I also hope that many of you are like, "Yeah, that describes me too." And if so, if that describes you someone who needs to work on listening to understand rather than just hauling off and responding like I do, if that's you, then let's work on this together. And in a few weeks, so write in, and let me know how listening to understand is affecting your relationships, with your kids and with everyone else that you connect with.
Sometimes, it results in awkward pauses in the conversation, I have learned that, as you synthesize information. But in the end, listening to understand does make an impact and a difference. And that is my final word.
All right, I'd like to thank all of you for joining in to PediaCast and being a part of the program. Particular thanks to those of you who wrote in with your own questions that we included in the show here. I really appreciate that.
Also, I want to remind you iTunes reviews are helpful, we have not had a new iTunes review now for several weeks. And the reason those are helpful is the more reviews that we have and the more recent reviews that we have, it helps to propel us into sort of the What's Hot category in the Kids and Family section of the iTunes podcast directory. That's important because if you're a mom out there and you're looking for a podcast to listen to, you head over to Kids and Family to see what's available and we want PediaCast to be one of the shows that's bang, right there in front of their eyes. And so, by having lots of recent reviews, it just helps to propel us into a position where we will be found.
And we don't have a big marketing budget here on PediaCast. We really rely on word of mouth and people discovering the program and so, that's why it's important.
And we want more parents to know about it because we think what we're offering here is something you can trust. It's evidence-based, you can ask a question and get an answer from a real board-certified pediatrician — moi.
All right, I also would like to remind you that links, mentions, shares, retweets, repins on your websites, on your blogs, and all the different social media sites, that also helps to spread the word. We are on Facebook, Twitter, Google Plus and Pinterest. And so, if you're on in any of those places, make sure you connect with us and share our stuff. We'd really appreciate that.
And then, make sure you tell your family, friends, neighbors and co-workers about the program and of course, your child's doctor. So the next time you go in for a well check-up or a sick office visit with one of your kids, just say, "Hey doc, I got this great evidence-based podcast that's aimed to parents that I'd like you to check out and consider sharing with your other patients." So that will be helpful as well, and posters are available in the Resources tab at pediacast.org.
Also, I want to remind you, we have new link on the Show Notes now. If you go there, with any of our shows moving forward that says "Connect Now With A Pediatric Specialist", and this will take you to a unique form, for PediaCast listeners, where you can ask a question to one of our pediatric specialist that does pertain to your specific child. This is not a question that will be shared on the show. It's just between and our specialist. And it's particularly aimed if you're looking for a second opinion or you're willing to travel to Columbus to see one of our specialist to get a second opinion.
Or maybe you just want to know, is your insurance covered? How do you go about getting an appointment? You know, or this is what your kid's diagnosis is, this is the treatment protocol. Are you doing the right thing? Is there something different we could be doing? Those sort of questions that you would have for a pediatric specialist. We're really opening up an avenue for you to be able to ask a specialist on a very personal level and kind of remove barriers.
So that's what that's for. So connect now with a pediatric specialist and you'll find that in the Show Notes over at pediacast.org.
All right, I want to thank all of you for being a part of the audience and for helping spread the word and for participating in all of those things.
And remember, to tornado safety, make sure that you and your family has a plan no matter where you are, whether you're at home, whether you're driving somewhere. You know, if the family is separated because mom and the kids and dad and another kid somewhere else, there could be potentially be a communications problem, just really do a pow-wow and figure out what your emergency plan is as it relates to severe weather, and in particular, tornadoes. So, where are you going to go, what are you going to do, how are you going to communicate — that way, if the situation arises, you already got it down, you know what you're going to do. There's no question, there's no "Oh, what do we do?" Panic. "What am I supposed to have?"
So you want to be prepared. And we know that as we move in to April and into May and then to early June, this is the time of the year when we're going to be hearing in the news about severe weather heading in the direction of some of you out there right now, particularly those in the Plains States — Texas, Oklahoma, Nebraska, that way — and then, into the Midwest and down into t he southeast. This is where we see the most severe, the largest tornadoes. And some of you who are listening to me right now are going to find yourself in a path of a tornado coming up in the next few weeks.
So make sure you're prepared. If it does happen, share your story with us and let us know how you prepared and how that worked for you.
All right, that does conclude this week's show . Until next time, this is Dr. Mike, saying stay safe, stay healthy and stay involved with your kids.
So long, everybody!
Announcer 2: This program is a production of Nationwide Children's. Thank for listening. We'll see you next time on PediaCast.