Baby Helmets, Speech Therapy, Picky Eaters – PediaCast 257
Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include pacifiers and ear infections, baby helmets for flat spots, vertigo in toddlers, speech therapy, picky eaters, and headphone safety.
Pacifiers & Ear Infections
Baby Helmets for Flat Spots
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Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is June 26th, 2013, Episode 257. And we're calling this one "Baby Helmets, Speech Therapy, and Picky Eaters."
It is a Listener Question program. We have answers to listeners' questions this week. And we're going to cover more topics, then those three. We have a bunch of stuff lined up for you. The questions have been rolling in and you've really responded to the call. Of course, we still have room for plenty more. So if you have a question, we'll give you details on how to get in touch with me and ask your question coming up here in just a moment.
But what are we talking about today? Let's go to the expanded line-up. Pacifiers — you know, we recently talked about parents who lick their child's pacifier. You know, so the pacifiers falls on the floor. Mom or dad puts it in their mouth or washes it off with their own saliva and sticks it in the baby's mouth. It turns it's not necessarily a bad thing. And if you want to know the details on that — who would've thought, right — Episode 255, we have the details on that.
Today, though, we're going to cover a little bit of a different aspect of pacifiers. How are they related to ear infections and colic? So can pacifier use increase the incidence of ear infections in colic in babies? One listener wanted to know. Stick around and we'll give you the answer.
Baby helmets — flat spots on the back of baby's head — it's a common consequence in the Back-To-Sleep Campaign. While flat spots are better than death by SIDS, they can a be concern for parents. Baby helmets promised to round out a baby's head, but do they work and are they worth the money? That's coming up.
Also, vertigo or dizziness in toddlers, what are the possible causes? How common is it? How do you treat it? We'll explore the answers there.
Then, we have a question about speech therapy. When is it necessary? How young is too young? I'll give you my thoughts on that.
And then, picky eaters — is your child just run-of-the-mill picky eater? Or is there selective eating endangering their health? We'll clue you in on the danger signs for picky eaters and lets you know what you should do if picky eating is a concern in your home.
And then, finally headphones and ear buds — how loud is too loud? How long is too long to listen? We'll explore all those answers together.
And then, after that, we'll have a final word for the diabetics in the crowd and lets you know about a free state-of-the-art online tool that will help you manage insulin doses. So that's coming your way at the end of the program.
Quick reminder, the Autism Speaks 2013 National Conference for Families and Professionals, it's happening Friday, July 26th and Saturday, July 27th at The Hilton at Easton here at Columbus, Ohio. The conference is sponsored by Autism Speaks, Nationwide Children's Hospital, the Ohio State University Wexner Medical Center and the American Academy of Pediatrics.
And as the name of the conference suggests, it is aimed at families and professionals with great information and education aimed at both groups. This year's& focus is treating the whole person with autism, care across the life span. And it will feature sessions and workshops focused on the most current guidelines for addressing medical issues, developing approaches to care that integrate behavioral and medical approaches across the lifespan and helping children and adolescents with autism spectrum disorder to have happy, healthy and successful lives.
Got a couple of great keynote speakers lined up for you for this conference. Dr. Paul Carbone is an associate professor of Pediatrics at the University of Utah and lead pediatrician at the Utah Neurobehavioral H.O.M.E. Program. He's going to be speaking on understanding medical issues from childhood to adulthood as it relates to autism.
And Dr. Steven Shore, an educator and author, also assistant professor of education of Adelphi University in Garden City, New York. He'll be speaking on creating a fulfilling life.
So, if you're dealing with autism at home elsewhere in the family or in the classroom, or if you're a clinician or scientist interested in learning more about autism, I would give a strong vote of confidence for this conference. Autism Speaks held this annual event in Columbus last year. And there's a reason they're returning to Columbus in 2013.
So, definitely give it some thought. Make it a party of your summer plans, and I'll put a handy link in the Show Notes for this Episode Number 257 over at pediacast.org. The link will take you to the conference homepage and you'll find much more information there and a convenient registration page as well.
So, The Autism Speaks 2013 National Conference for Families and Professionals right here in Columbus, Ohio, Friday, July 26th and Saturday, July 27th. Don't miss that and again, details in the Show Notes for 257 over at pediacast.org.
All right, I gave you a little hint that if you had a question for me that you would like answered in the program, it's easy to get in touch. Just head over to pediacast.org. We do have a Contact Dr. Mike link and that will put you right in touch with me and you can ask your question that way.
Also, I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's take a quick break and I'll be back with your questions and some answers, right after this.
All right, first stop is Jocelyn from Newark, Ohio. That's not too far away. "I have a seven-week-old baby who uses a pacifier. My mom mentioned recently that she heard pacifiers should be replaced after a few months of use, as they can cause increased ear infections and stomach troubles. Is this true? I understand it need to be tossed if there's any damage to the nipple. I'm so glad to have found your show. As a new mom and a speech pathologist, I appreciate the evidence-based practice model. Thanks for all you do."
Well, thanks for the question, Jocelyn. Really appreciate you writing in. First, let me say you are right, pacifiers or binkies, soothers, pacies, bubbas, nukes, dummies, whatever you like to call the plastic nipple substitutes that we place in the baby's mouth for his or her sucking pleasure — whatever you call them — yes, you should toss them in the trash if they're working and becomes damaged.
And the reason for this is simple. You don't want your baby choking or aspirating on a piece of plastic. Aspirating by the way just means sucking it down into the lungs. You don't want that. So damaged pacifiers go in the trash.
Now, with regard to your mother's advice, she sort of has her wires crossed a little bit. There had been some studies that show pacifier use may be associated with an increased risk of ear infections. However, that association is not dependent on the age of the pacifier. So there's no reason to believe a pacifier will cause ear infections because it is an old pacifier.
So what information is your mother referring to? Well, there had been some studies that show babies who suck on pacifiers do have an increased incidents of ear infections. And the more often they use a pacifier, the stronger the association.
So does that mean pacifiers are bad and should parents not be using them because they cause ear infections? Well, not exactly. The study show an association but not a causal relationship. In other words, the research doesn't support the idea that pacifiers cause ear infections. They only show an association or a relationship.
So let me explain. To show pacifiers cause an ear infection, you've had to take two groups of kids, one group who are allowed to suck on binkies or pacifiers, and another group who are not. And then, you would have to expose both of those groups to identical living situations and try to have also a gene pool that's about equal between the two groups. If there's a family history of ear infections in a certain percentage of the kids, you'd want that to be the same in both groups. I mean you really want these groups to be identical as possible with regard to genetics and their environment, so that the only difference between the two groups is whether the baby suck on the pacifier or not.
Then, you would follow them forward and measure the incidents of ear infection. And by the way, you'd have to have doctor look to see if the infection was there and not just going whether mom went to see a doctor. I mean, you'd want someone regularly looking in their ears to see if ear infections occurred. And we'll kind of get to why that is in a minute.
Now, if the pacifier group has a statistically significant higher incidents of ear infections compared to the non-pacifier group and the only difference between the two groups was in the pacifier use, then you can make a convincing case for your hypothesis. But that would be a difficult study to set up. And studies which look at the association are not well-controlled prospective studies set up this way.
In the past, these studies have been retrospective studies where they've taken a group of babies with ear infection and a group of babies without ear infections and asked all the parents about historical pacifier use. And these studies have shown that kids with ear infections are more likely to have used pacifiers in the past.
But now, that's not the same thing as saying a pacifier causes ear infections, is it? Sure, there is an association but we can't say there's a causal relationship. What if babies who have a history of ear infections are more fussy in general? And what do parents tend to do when babies& are fussy? They put a binky in the baby's mouth, right? Now, that doesn't necessarily mean the binky caused the ear infection. Perhaps, fussy babies are just more likely to get a pacifier placed in their mouth.
Something else to consider, how do we know when a child has an ear infection? And I kind of alluded to this a moment ago. We know because mom or dad took the child to see a doctor, right? But keep in mind, ear infections can and often do go away on their own. And while some parents rush their child to see a doctor at the first sign or symptom of an ear infection, others wait a few days. And if a child gets better on his or her own, they avoid the trip to see the doctor. So how many of those kids had an ear infection? An ear infection that didn't get diagnosed and went away on its own.
Now, let's also think about pacifier use in these two sets of parents. Could it be that those parents more likely to rush their baby to the doctor at the first sign of illness are also more likely to give their fussy child a pacifier? These parents are the fixers. While the non-fixers let their babies fuss a bit and give an illness some time to go away. So could differences in parent personality and parenting styles have an impact on the pacifier-ear infection association? Absolutely. So the studies we have on these associations are not tightly controlled and the results are questionable.
Now, what about so-called stomach trouble, as your mother reports? The thought here follow these lines — the more babies suck on pacifiers, the more likely they are to swallow air. The more air they swallow, the more gas they'll have. The more gas they have, the more likely they'll develop "stomach problems" which gets diagnosed as& colic.
But that's the thought that I think a lot of people kind of go down or the thought process that they go down. But as we discussed before in this show, colic isn't thought to be caused by a swallowed air. We don't know if swallowed air really causes a problem or not. We don't know if pacifier using babies actually swallow more air. That's not been studied. And any studies out there that show relationship between pacifier use and colic are really fraught with the same problems as the ear infection studies.
Colicky babies are more fussy than non-colicky babies. That's the definition of colic. Fussy babies are more likely to have a pacifier placed in their mouths. Again, there may be an association but not necessarily a causal relationship. So what's a parent to do? Well, in the absence of an absolute causal relationship between ear infections and pacifiers, and between colic and pacifiers, you just got to look at risk versus benefit. And in the absence of convincing evidence that there's a causal relationship, personally, I'd say use them, especially if they help soothe your baby.
Babies enjoy sucking and if they get calories every time they want to suck, that could be a problem, with regards to obesity down the road. Or you could just let your baby cry a bit, but moms and dads don't want that either. You want your baby to appear happy and you want to keep your sanity by not hearing them cry.
Now, what about babies who do suffer from colic or who do suffer from recurrent ear infections? Does it make some sense to try abandoning the pacifier to see if the ear infection or the colic goes away? You know, yes and no. That plan does makes some sense on the surface and if it works, great. But honestly, and I know this is anecdotal, but I haven't met a parent in 19 years of practicing pediatrics, I've not met a parent who said, "You know what, when I took that binky away, life got better. The ear infections vanished. The colic disappeared." I've never heard that.
So it boils down again to risk before benefit. And I think the benefit of using the pacifier is clear to most parents with babies at home. The risk, I'm not convinced they really exists, except in the case of a damage to the working end and in that case that risk is clear. Choking or aspirating on a torn piece of plastic, that's not something you want to deal with. So you do toss the damaged binkies in the trash.
So I hope that brings a bit of clarity for you, Jocelyn, and again, thanks for the question.
All right, next stop is Jolene in Northwood, New Hampshire. "Hello, my seven-month-old has a flat spot on his head. We got a helmet to fix the problem. My question is, how do babies get this flat spots and how well do the helmets work? Thanks so much. Jolene"
Well, thanks for the question, Jolene. It's another good one. First, let me say, I don't know what cause the flat spot on your child's head. I didn't examine your child and I don't know where the flat spot is located. And I can't obtain a good history by asking you follow-up questions.
Now, having said that, we can talk about flat spots in general and the role baby helmets play in treating them. The most common flat spots are seen at the back of the head, also known as the occiput and the most common cause is from kids spending time on their backs, or these little babies spending time on their backs.
And this, of course, is a by-product of the so-called Back-To-Sleep Campaign of the early 90's when we started telling moms and dads to put babies to bed on their backs. Not, their tummies, not their sides, always on their back. And we handed out this advice to decrease the risk of sudden infant death syndrome or SIDs and it worked. Parents heeded the advice and the occurrence rate of SIDs dropped dramatically.
But as a by-product of kids sleeping on their backs, we begin seeing infants with flat spots on the backs of their heads. Of course, we'd rather see kids with flat spots in the backs of their heads than those same infants dead from SIDs, right? I mean, you can live with a flat spot. So still, the risk of getting a flat spot still outweighs the benefits of not dying from SIDs.
Now, as it turns out, not all children who sleeps on their backs develop flat spots. And the difference between kids, so those who develop these flat spots and those who don't is the amount of time they spend lying on their backs and the plasticity of their skull. In other words, how easily do their skulls change shape? And this is thought to have a genetic basis with some babies just being more prone to getting flat spots than others because of their genes.
Now, the first variable, the amount of time a baby spends on her back, that's something you can control to a degree. The second, the genetics, you can't control that. So let's talk about the variable you can control — time spent on the back.
So how can this be controlled if we're saying put your baby to bed on their back? Well, the Back-To-Sleep Campaign covers unsupervised sleep. But there are plenty of times when babies are horizontal, when they're not sleeping. They may be on the floor, on the pack and play, hanging out with you. You may have an eye on him but also watching TV and sprawled out with a book — or sprawled out with a book. And so, it's at these times when babies are supervised that we advocate tummy time. Have your child spend some time on their tummies when they aren't engaged in unsupervised sleep. If by themselves sleeping, babies should be on their backs.
Now, let me take a quick tangent here, because a lot of parents have this question — how long do we keep our babies on their back? And I think the safest answer for that is you put them to bed on their back, pretty much throughout their entire infancy, up to one year of age. Now, there's going to come a time when they're able to consistently roll themselves over from their back to their front. Now, if it just happens once and it's an outlier — it happened and it was kind of weird that they got themselves over — I would go ahead and put them back on their back in that case.
But if they're consistently getting themselves from their back to their front, let them be. And you don't have to keep rearranging them on their back once they get themselves off of their back consistently. Because that would just be a losing battle of wills, right? You put them on their back, they go on their belly. You put them on their back, they're going on their belly.
So once they have the muscle tone and strength to be able to get themselves from their back to their front on a consistent basis, it's usually safe to leave them. And that's going to be usually when they're usually closer to six months of age. So between four and six months is usually pretty good. But I would still just put them on their back. And then, if they get themselves on to their belly again, that's going to be OK as long as they have the strength and the tone to do it on a consistent basis.
Now, I would also point out right from the get-go and even after babies can wiggle into other positions, you don't want anything in the crib which could end up blocking your child's airways. So no pillows, blanket, stuffed animals, bumper pads. Just a flat fitted sheet and clothing appropriate for the room's temperature.
OK, so those are the rules. We've covered the reason for the rules to avoid SIDs and suffocation and the consequence of the rules, the possibility of a flat spot on the back of the scalp, which by the way is called plagiocephaly. We've also established that flat spots are better than dying from SIDs and that you can lower the risk of flat spots by incorporating tummy time.
But even with the best efforts, flat spots can still occur, especially in babies who have a genetic tendency for a plastic skull. So when it changes, it shapes early. So here's where the good news comes in. Plastic skulls easily become flat but that means they can also easily become round again. They're moldable.
And often, when the flat spots appear, by incorporating more tummy time when your child is awake and getting them upright immediately after sleeping in naps and when your child begins to wiggle into different positions, we see a natural tendency for the shape of the skull to become roundish again. Maybe not perfectly round, but let's face us, few of us have perfectly round skulls, anyway.
Now, having said all these, there are a small number of kids even with the best efforts who will still have significant flattening that doesn't appear to be improving.
I should out point out too, there are some problems with skull development that can cause a misshaped skull. So if you're concerned with about your child's head, it really is important to see your doctor to make sure that it's a positional problem and not a developmental problem.
And that, Jolene, really, is why I made a point of saying I don't know the cause of your child's misshaped skull. I mean, the flat spot could be positional or could be something else. You really need to see your doctor and let them do a good history and physical.
OK, so let's say we established the flat spot is positional. The flat spot is significant and it's not getting better with time. What then? Actually, we have to back up and define significant now, don't we? What is significant? That's going to vary from family to family. What's your tolerance for flat versus round?
Ok, so let's say, in your opinion, it's too flat. You want to help round it back out. Well, here again, most of the time, we have good news. This skull again became flat because it has plastic tendencies and we can help round it back out because it has plastic tendencies. And here's where helmets come into play. So by wearing a custom-made helmet, we can encourage positional flat spots to round back out. And we do have studies showing this& treatment work and that it is safe.
But there are some issues. Number one, this custom helmets can be expensive, in the neighborhood of $500 to a $1000 and insurance doesn't always cover them.
Number two, there's potential for abuse — clinicians telling parents their child needs a helmet and then custom-crafting one for a large sum of money. In my mind, the person who prescribes the helmet should not be the person making money from the helmet. Does that make sense? I mean, it just opens the door for inappropriate prescribing.
Number three, yes, the helmets work and are safe. But how do they stack up with allowing the skull to naturally mold itself back to round once a baby is moving around and not always on their back? In other words, if the flatness will improve on its own, why hurry the process with an expensive helmet that must be worn 20 or more hours a day?
And by the way, a search at PubMed… So this is sort of national repository; really, an international repository for medical research. So, a search at PubMed with the terms plagiocephaly — which is flat spot on the back of the head — and helmets reveal lots of recent research in this area. And many of these studies again show helmet treatment for plagiocephaly is safe and effective.
But other studies suggest we are over-treating this condition. For instance, a 2012 study from the University of Minnesota looked at skull shape in teenager who had been born after the Back-To-Sleep Campaign started and who had not been treated with helmet therapy. So they found flat spots in these kids, in the back of the head of these teenagers, in only 1% of teenagers. Yet, in other studies, the prevalence of plagiocephaly in infants who had been sleeping on their back has been shown to be in the 20% to 40% range. So if 20% to 40% of infants have flat spots, but only 1% of teenagers have them with no intervention between the infant and teenage years, then that says something for the ability of the skull to reshape itself over time.
Now granted, these studies aren't on the same kids. There has not, to my knowledge, been a study that look at kids prospectively to see what percentage of infants with plagiocephaly grow up to be teenagers without it. But I still think the fact that only 1% of teenagers born after the Back-to-Sleep campaign begin, only 1% has flat spots of kids who have never had helmets. To me, that's significant.
So what about you, the parent? What should you do? Well, that really depends. It depends on your definition of significant. It depends on your definition of normal skull shape. It depends on your willingness to wait and your risk tolerance for the possibility of the condition not improving. It also depends on your financial situation sometimes.
So lots of your variables to sort through and what's right for one family may not be right for another. Here's what I would avoid. I'd avoid buying an expensive helmet from the person who says you need one. In that situation, I might get another opinion. That's me. I'd also watch out for the fear mongers who may point you to research that shows misshapened heads are associated with developmental problems and "You better get your child a helmet ASAP to avoid autism later. And by the way, I'll be requiring a $500 deposit today in cash."
Remember, an association does not mean one thing caused the other. Yes, there are studies showing severely misshaped heads are associated with developmental delay in autism. But look folks, we aren't talking run-of-the-mill positional flat spots here. We're talking severely misshaped heads, ones that are more than likely associated with an underlying developmental problem which caused the abnormal shape and the brain dysfunction. And there's no evidence that correcting the shape of the head fixes brain dysfunction. So don't be fooled by hucksters throwing you that line, especially if they stand to gain financially by selling you the helmet.
All right, thanks for the question, Jolene. I hope I didn't confuse you more. It's quite possible I have. There's good reason for that. It's because the right thing to do is not completely clear.
All right, let's move on to our next question. This one comes from Anna Maria in Cleveland. "Hi, Dr. Mike. Love the show. Thanks for your hard work on it. I don't think my topic has been covered in previous podcast. My question is about benign paroxysmal positional vertigo."
Let's break that down really quick. Benign means it's not serious. Paroxysmal means it just happens sometimes and we don't really understand why. Positional means it's related to the position of the body, and vertigo is dizziness. So this not serious dizziness that comes and goes and appears to be related to a body position.
OK, "So when my son was 13 months old, he had an episode where he could not stand up straight and fell to the ground unable to walk. Because he had been walking since nine months of age and because he was great at walking, this episode was alarming. I called 911, but by the time they arrived, he was around as usual, of course. Anyway, after working diagnosis of breath holding spells, he went on with life as usual.
Then, he had several more episodes and we went down to rule our seizures or chiari malformation path with an EEG and an MRI. Then, we captured an episode on video, showed the neurologist and left with a diagnosis of benign paroxysmal positional vertigo. The neurologist basically said this is a harmless condition and only needs treatment if he has several daily episodes that interfere with quality of life. This has been fine for us. He's now three years old and only occasionally has these dizzy episodes. They are upsetting to my son but we remain calm and reassure him it's OK and he should tell an adult and sit down when he has them.
Now, it seems that our 13-month-old has had her first episode. She began walking at nine months and is a great walker but she recently stumbled and could not stand up. She did something slightly different than my son did. Her head sort of moved around and her eyes looked like they were having trouble focusing. She looked as if she felt dizzy. She was upset and clingy and then took a nap. I should have add here that the nap didn't seem particularly unusual because she had been fighting a virus since the previous week.
Of course, I left a message at her pediatrician's office and I feel confident they will give me sound advice. But I wanted to hear your perspective on a few questions I have about vertigo. Also, I realize we're not definitely sure this is my daughter's diagnosis, but I'm still curious."
Dr. Mike Patrick: See, I had& you guys trained well. You know I can't make a diagnosis and give specific advice for a specific kid. So you say, "Hey, talk to me about vertigo in a general sense." I love it.
All right, so what is Anna Maria's questions? And I'm just going to answer them as we go. "Number one, is vertigo in young children relatively common and is it really harmless? It is unsettling to watch your child walk perfectly one moment, then stumble to the ground the next. When do children typically outgrow this?"
Dr. Mike Patrick: So question number one is actually several questions. Nice job there, Anna Maria. No, I wouldn't say vertigo in children is common but it does happen. Really, whether something is common or not common, that distinction is only helpful when your child doesn't have something. So you may be worried they might get it. If it's uncommon, then you feel better about it. It's unlikely to happen to your child.& But at the point your child has the problem, it doesn't really matter whether it's uncommon or not. You have no choice but to deal with it. I mean, for you, it is now very common and part of everyday life.
Is it really harmless? Well, this is sort of a trick question. If the cause of the vertigo is truly benign paroxysmal positional vertigo, then yes, it really is harmless. Unless, of course, your child is in a dangerous situation when he suddenly becomes dizzy like in a swimming pool without an adult nearby or high up on monkey bars, that sort of thing.
However, there are& other causes of dizziness which may be harmful which is why your child had an EEG and an MRI. So for other parents out there whose children are having dizzy spells, you don't want to assume that the problem is benign paroxysmal positional vertigo, you want to get them checked out.
Question number two, "Since both children and their grandparent as an adult seem to have vertigo, is it inherited? We're told no. But I'm wonder if you have differing information." So, the underlying cause of benign paroxysmal positional vertigo is thought to be the occasional& presence of calcium carbonate crystals — so once it come and go within the semi-circular canals in the inner ear. There's no known genetic basis for these crystals coming and going but your family sure makes me thing there could be a genetic basis, in some cases.
The genetics of benign paroxysmal positional vertigo haven't really been studied extensively. So the doctors you talked to are correct, The condition is not known to be inherited. But maybe, in some cases, it is. Keep in mind a lot of the diseases that we are now beginning to understand that there is a genetic component to them, it's really just been recently that they were beginning to understand that. So there are plenty of diseases that we would have said ten years ago, "No, that's not inherited" and now we say, "Yeah, there is a genetic component to it." So it's possible.
Number three, "If we are sent down to rule out seizures route, I'm concerned about additional radiation exposure from an MRI. My daughter has urinary reflux and has already had two VCUGs at her young age. I'm trying to avoid radiation exposure as much as possible."
So easy answer here, Anna Maria. There is no radiation exposure with an MRI. MRIs use magnets, not radiation. Now, your 13-month-old would likely need sedation, so that refers in a small risk. And she might need contrast material, so there's another small risk. But there's no risk of radiation exposure. Also, again, looking at risks versus benefit, when you have kids with unexplained episodes like this, this kind of diagnostics studies probably the benefit outweighs any risk. But talk to you doctor about that.
Question number four, "And finally, I know vertigo is related to position. But for my kids, it seems like episodes occur more often when they are sick or run-down. I have not found any scientific evidence for this association. What do you think? Could there be a link between illness and vertigo episodes?"
So that's another tough one, Anna Maria. Could illness somehow make calcium carbonate crystals appear in this semi-circular canals by some unknown mechanism? Perhaps. It's also likely that kids with benign paroxysmal positional vertigo act sick and run-down around the time of their episodes because they are feeling motion sick. Vertigo makes you feel sick and run-down. So, maybe their illnesses aren't really an illness but rather the first sign of the episode. Something to think about.
OK, Anna Maria concludes by saying… Whew, whew, that was a lot especially for something benign. I tried to say whew and I don't know my voice cracked. "I hope you are able to provide some insight. Thanks again for the great podcast. It's a wonderful resource for curious parents."
Well, thank you for the questions, Anna Maria and the kind words. I, too, hope I was able to offer some insight. Benign conditions are only benign on the medical side of things. They aren't always benign on the family side. You know what I mean? If it's disrupting life at home, it's not completely benign and your questions are well-placed.
All right, let's move on to Tiffanny in Grants Pass, Oregon. I have to pause and chuckle here because Tiffanny writes in often and I've actually had to force my spellchecker to learn how to spell her name. Because she uses two F's and two N's to spell Tiffanny. But I keep including your questions in the show because they're always good ones.
This week, Tiffanny says "Hi, Dr. Mike. My son is three years old. He will be four in August and can speak what I consider very well. I do notice though he has slight lisp when he says the S sounds. So when he says 'socks', it comes out 'fox'. Is this something children generally outgrow or should I consider some sort of speech therapy? Thank you so much for your podcast."
So a great question, as always, from Tiffanny. And you know, it's one many parents ask the doctor — will speech therapy help and when is the best time to do it?& Let me preface this by saying, "I love speech therapists." OK, I'm just going to get that off my chest right now, I love speech therapists. They're great.
There are however a few practical considerations that I think we have to keep in mind here. In a perfect world, a child of any age would see a speech therapist or speech pathologist, a language pathologist, and come away with normal speech. But we don't live in a perfect world. And there is your child's maturity and cooperative ability to consider. There are also financial considerations.
So if you have any concerns about your child's speech the first thing I would do is talk to your pediatrician. And if he or she thinks a speech therapy referral is indicated, I would do it, regardless of the child's age. If your doctor think it's the right thing to do, then just do it.
Now, having said that, if you're paying out of pocket — and even if you aren't paying out of pocket, remember somebody is paying, medical services aren't free — so when you consider the cost, if your child doesn't have the maturity to cooperate and get something out of the therapy, then does the benefit justify the cost? And that's something that you the parent has to decide.
Now, some late three and early four-year-olds will do fine with speech therapy. They'll cooperate and they'll improve. Others won't and giving those kids sometime to mature is not always a harmful idea.
Now, I realize there are speech therapists out there right now cringing. "Doesn't he know there are studies showing the earlier we get our hands on the kid, the better they're going to do?" Yes, those studies exist. But as with our last discussion on baby helmets… Well, I guess it was a couple of discussions ago now. But when we talk about baby helmets to treat flat spots in the& back of the head, we know we have to be careful in interpreting the data. What is the incidence of improper phonation or pronunciation, or sound-making skills in teenagers who had never had speech therapy compared to improper phonation in late three and early four-year-olds? It's going to be much lower in the teenage groups.
Like flat spots on the back of the head, problems with making sounds do tend to correct themselves over time. Now, will speech therapy fix them faster? Absolutely. And is it being fixed faster going to make a child better at communicating and so that will improve their development? Absolutely. But does that mean it's& a 100% mandatory when a child is uncooperative and the therapy is breaking the bank? Moms and dads, you have to decide.
And by the way, I realize my analysis is not always politically correct. I get that and I get some flak for that. But at the end of the day, I insist on a practical approach and I do have the best interest of you, the PediaCast listener, in mind and not the members of the medical establishment who like to skew data and use scare tactics to drum up business.
Yes, there's a time for baby helmets. Yes, there's a time for speech therapy. But these things are not universally required. And your best advocate for deciding if and when is your friendly neighborhood pediatrician, the one who's taking care of your kiddo since the day he or she& was born, the one you know and trust.
So talk to your doctor, Tiffanny, and elicit that opinion first.& And then, if you and your doctor agree it's a good idea, have the speech evaluation done. Listen to the opinion of the therapist, consider the nature of the problem, consider your child's maturity level, consider your finances and then make a decision.
So I hope that helps Tiffanny and as always, thanks for the question. Keep sending me good ones.
All right, we have one more listener question lined up which is actually another multi-question question. This one comes from Linda in Wister Ohio. "Dear Dr. Mike, I'm a new listener of PediaCast. I really like that you cover topics of interest to parents and kids of all ages, not just babies and toddlers.
The first episode I listened is the one on eating disorders. At the beginning of the podcast, the doctor you were interviewing mentioned that the eating disorder clinic has patients who are very selective eaters. I have a very selective eater who's nearly 15 years old and at this point, I don't think it's something she's going to outgrow. I would like to hear some more information on selective eating. How do you know when it's a problem and needs to be addressed?
I also have an unrelated question about headphone use. Kids, mine included, seem to be using headphones a lot. What effect do headphones have on hearing? Should kids be limited and how long they use headphones each day? How much is too much? Thank you for your time."
Well, thanks for the questions, Linda. So let's talk selective eating first — also known as picky eaters.& Now, the world of mental health has a large book. It's called the Diagnostic and Statistical Manual for Mental Disorders. And it describes diagnostic criteria for every officially recognized mental disorder including eating disorders. The latest edition called the DSM 5 was published just last month, May of 2013, and it currently recognizes three major eating disorders — anorexia nervosa, bulimia nervosa and binge eating disorder. And we cover these topics in significant detail back in PediaCast Episode 249.
Now, selective eating is not a recognized mental health disorder, although extreme forms of selective eating would fit under the diagnosis of avoidant restrictive food intake disorder. So, what is that? Well, avoidant restrictive food intake disorder includes children who eat only a very narrow range of foods. And that range has to be so narrow that it interferes with their physical or emotional health.
So, by definition, avoidant or restrictive food intake disorder is a persistent disturbance in eating that leads to significant, clinical consequences such as weight loss or inadequate growth, a significant nutritional deficiency, dependence on tube feeding or nutritional supplements to sustain adequate intake and/or impaired psychosocial functioning such as inability to eat with others.
So, run-of-the-mill picky eaters don't really fit this definition. In other words, picky eaters were growing well and healthy without any signs of nutritional deficiencies and who were able to eat with family and friends. They're just picky eaters. And you can and should encourage them to try new things but at the end of the day, their diet is not impacting their physical or mental health. And you know, in some cases, the manner in which parents approach this problem is a bigger problem than the picky eating itself.
Now, I'm not suggesting that's the case in your home, Linda. But you know, sometimes as parents, we need to major in the majors and minor in the minors or lay off of the minors. If the child's growing well and healthy and your doctor can help you determine this, then stepping away from the food battle, often in time, resolve the situation.
Now, if your child is losing weight or not growing adequately, or showing signs of a nutritional deficiency, or the selective eating is significantly interfering with his or her mental health or is associated with a distorted body image, then that's a problem.
Now, the next question becomes, so for kids who have selective eating and it's not really causing physical or mental problems at this time, are there certain behaviors associated with this selective eating that have a higher risk of resulting in consequences to physical and emotional health down the road.
And there are some behaviors you do want to watch out for that you do worry about a little more in terms of this becoming a real problem. Here's some examples: avoidance of large groups of food based on certain sensory qualities, like texture, color or temperature. So if there's certain textures that they just avoid all the food with that texture, or with that color, or at a certain temperature, that's a concern.
Avoidance of food that requires chewing and reluctance to swallow. And we see this sometimes in kids who have a history of choking. They suddenly avoid foods that require chewing and purposeful swallowing and they transition to a very softer liquid diet. Their caloric and nutrient consumption drops and they begun to lose weight or no longer gain weight, as you would expect them to.
These are kids who are going to need help and the best place to get that initial help is your child's doctor who can assess if a mental health referral is& necessary in one of the best resources in your community if a referral is needed.
So I hope that helps, Linda. Bottom-line, picky eating that does not lead to physical or emotional problems and does not result from physical or emotional problems, that sort of picky eating is not a recognized disease. Of course, if you're still concerned, talk to you doctor. If the picky eating seems extreme to you but not quite the level of an eating disorder, your doctor may have some strategies for getting your child to try new things. Or here, she may refer you to a psychologist or other behavioral specialists who might have some helpful tips on dealing with the pickiness.
In some cases, though, it may be time to back away and worry about something else. All right,& the best first person again to ask about all this, really, is your friendly neighborhood primary care physician.
All right, let's move on to the headphone question. What effect do headphones have on hearing? Should kids be limited and how long they use headphones each day and how much is too much? So good questions, Linda.
There are no current recommendations on specific lengths of time or specific degrees of loudness when using headphones or in the ear buds. However, there are some things we do know which can guide parents on appropriate use. First, we know that loud noise damages hearing. So what is loud? Noise remember is measured in decibels. And I think it's useful just to kind of go through a little chart or a meter here to give you an idea of what kind of decibels equals what sort of sounds.
So, if we start with a soft whisper, that's going to be 30 decibels. Normal conversation is 60 decibels. Vacuum cleaner or washing machine is 70. A noisy restaurant is 80. A power mower is 90. A symphony orchestra is a 100. Rock concerts are a 110 decibels. An ambulance siren is 120. A jack hammer is a 130. A jet engine, 140.& Firecracker, 150. Shotgun blast, 160. Rocket launch, 180. OK, so soft whisper 30, rocket launch 180. So we're talking in that range with about a 100, which is a symphony orchestra concert, being in sort of medium-loud.
So where do portable music systems rank? Well, each system is different. But with ear buds which are the most commonly used today, a low-medium volume is going to be about 95 decibels, a medium volume is a 100 decibels. So again, that's about the symphony orchestra range. High-medium is going to be a little bit more like a rock concert at a 105 decibels. Loud volume is going to be like a heavy metal rock concert, about a 110 decibels. And then, very loud, a 115 decibels.
Now we're talking rock concert to ambulance siren. And actually, a lot of portable music systems will go up to extremely loud at a 120 decibels. And now we're up to ambulance siren or jackhammer kind of range.
Why is it important to know what these decibels are? Well, the ability of noise to damage hearing depends not only on the loudness of the sound, but the length of exposure and also how often exposure occurs. And, finally, the length of exposure that can result in damage is related back to volume. So these things, volume and length of exposure are really intertwined together.
So at 95 decibels — this is going to be like low-medium — damage can occur after about four hours of daily exposure. A 100 decibels — so medium orchestra concert — damage can occur after about two hours of daily exposure. One orchestra concert is not going to do it. But if you went to the orchestra for two hours every single day, for I don't know how long, a couple of weeks let's say, hey, you can start having problems.
A 105 decibels, so high-medium, damage can occur after about one hour of daily exposure. A 110 decibels, so loud volume rock concert, damage can occur after about 30 minutes of daily exposure. So if your kid's listening with the headphones and it's as loud as a rock concert in those headphones, 30 minutes of daily exposure can start to result in damage. A 115 decibels — so we're now very loud volume — damage can occur after about 15 minutes of daily exposure. A 120 plus decibels, so extremely loud, damage can occur almost immediately.
So how long is too long depends on the volume and how much volume is too much volume depends on how long and how often your child listens. OK, I'm not sure that's helpful. The bottom-line is this, lower volumes are better and shorter duration is better.
There are some things you can do to minimize the risk of damage. One, by noise-isolating ear buds that make a good seal in the ear canal. So volume doesn't have to be as loud if the background noise is cancelled out. You can also buy ear buds that support a maximum volume of 80 to 85 decibels. So that's something that you can do.
And these volume-limited ear buds and headphones, and the noise-isolating ear buds and headphones, they're more expensive. But if your child likes to crank the volume or listen for long periods, it may be worth the extra expense to save on their hearing. &
One other thing to keep in mind, the more time your child spends with the ear buds in the ears, the less time they're spending interacting with the family. So limiting headphones for the sake of family relationships is certainly another important consideration.
So I hope that helps, Linda. And again, thanks for the question, they are always appreciated.
Don't forget, if you have a question, it's really easy to get in touch with me, just head over to pediacast.org. You'll find the Contact Dr. Mike link and just click that. There's a submission form and I read every one of those that come through. So you can ask your question that way, get in touch and we'll try to get it on the show for you.
All right, we're going to take another break. I promised that the diabetics in the crowd that I would have some interesting information for them. So hang around, we'll get to that right after this.
Dr. Mike Patrick: All right, in the introduction to the program to this week, I mentioned the diabetics in the crowd should stick around for the end of the show because I have some exciting news about a free state-of-the-art online tool which parents and teens dealing with diabetes can use to simplify the calculation of insulin doses. And the good folks at Nationwide Children's Hospital recently developed this online resource, not only for the diabetics who receive their care here in Central Ohio but for pediatric diabetic patients everywhere.
It's called the Diabetes Calculator for Kids and it's a first of its kind electronic tool geared toward the pediatric patient, allowing parents, caregivers and the adolescent patient themselves the opportunity to create an individualized chart which calculates the correct insulin dosage that should be given prior to eating.
Diabetes affects nearly one in every 400 children and adolescents in the United States and is a disease characterized by a high blood& sugar or glucose level. Managing diabetes requires the proper balance between insulin dose, food and activity on a daily basis. It's important to keep the diabetic child's blood sugars within a target range which is accomplished by insulin therapy. This involves administering rapid acting insulin before each meal and adjusting the dose based on the current blood glucose level and how much food the child is expected to eat.
The Diabetes Calculator for Kids is available for any patient who uses insulin. It creates an individualized chart for rapid acting insulin doses in five easy steps. After the parent or patient completes those steps online, a customized chart is produced that can be emailed or printed off, providing the parent, caregiver or patient& an easy way to look up the correct insulin dosage based on current blood glucose without having to do the math each time.
Dr. David Repaske, Chief of the Endocrinology, Metabolism and Diabetes at Nationwide Children's Hospital — he's also been a guest in this program before — he says the goal is to provide an additional tool to empower families to successfully manage their child's diabetes at home in order to provide as normal a life as possible for that child.
The chart can also be printed out and then taken to school or given to a sitter to ensure accurate insulin dosing without the need to learn the formula and do the math for each dose. Nationwide Children's always recommends that parents consult with their child's physician first with any question related to their child's individual diabetes management plan.
The Diabetes Calculator for Kids is free and it's available by visiting nationwidechildrens.org/diabetes-calculator-for-kids. So hyphens between the words, nationwidechildrens.org/diabetes-calculator-for-kids. Hyphens between the words. If you can't remember that, just head over the Show Notes for Episode 257 over at pediacast.org and I'll include a handy link.
So the Nationwide Children's Diabetes Calculator for Kids, if you care for a child with diabetes or you are a teenager with a diabetes, be sure to check it out. And that's my final word.
Also, once again, for those dealing with autism at home, be sure to check out the Autism Speaks 2013 National Conference for Families and Professionals, Friday July 26th, Saturday July 27th right here in Columbus, Ohio. And you'll find link with more information in the conference and an easy way to register again in the Show Notes for Episode 257 at pediacast.org.
All right, I want to thank all of you for taking time out of your day to make PediaCast a part of it. As always, it's very much appreciated. iTunes reviews are also helpful as are links, mentions, shares, retweets, repins on all those social media sites. PediaCast is on Facebook, Twitter, Google Plus and Pinterest.
We've been getting a lot of people repinning our episodes. So if you go Pinterest, look up PediaCast, we have an Episodes board. If you repin those, they start to get some movements. We have seen that and I appreciate those of you who had been sharing on Pinterest. Please continue to that. And if you are on Pinterest and you haven't done it, make a Podcast board and pin them there so your friends can find them.
Also, sharing our episodes on Facebook, Twitter and Google Plus is always appreciated. Really, we don't have a big advertising and marketing budget here, even though I'm part of the marketing department. We don't have it. So if you could be so kind as to let your friends, family, neighbors, co-workers and all your social media friends know about PediaCast, it would be appreciated.
Also, be sure to tell your child's doctor. So the next time you're in for a well checkup or a sick office visit, sports, physical, whatever the case, just say, "Hey, doc, I know about this evidence-based pediatric podcast you really have to listen to and share with your patients." And the posters are available under the Resources tab at pediacast.org.
Once again, we have a contact link that says Contact Dr. Mike at PediaCast. It's actually at the top of the page and also in every Show Notes from this episode moving forward. At the bottom of the Show Notes, you'll also find a Contact Dr. Mike link to ask your questions, provide comments, suggest your topics, all that business.
And then, you'll find a link below that that says "Connect with a Pediatric Specialist from Nationwide Children's". And this is for referrals and appointments. So if you want to connect directly with one of our specialty clinics — maybe you want a second opinion, maybe you just want your child to be seen, their care to be taken over by Nationwide Children's, maybe your local children's hospital doesn't offer a particular service — we're here for you and we want to make getting you connected with our specialists as easy as possible.
Now, sometimes, that does mean that you have to go back to your regular doctor and say, "Hey, I need referral for insurance purposes." But we want you to be able to easily make that connection, and you can do that. There's a link that says, Connect with a Pediatric Specialist from Nationwide Children's. And again, that is at the bottom of each Show Notes page — at least beginning with this one moving forward.
All right, again, thanks for your time. Really appreciate it. And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.
So long, everybody!