Colic, Underage Drinking, Mercury Exposure – PediaCast 202

We have lots of great information coming your way today! Topics include recalls of Infant Tylenol and Tumblekins, colic and its possible relationship to migraines and nicotine, lingering symptoms of concussion, underage drinking, ideas to lessen the stress of moving to a new city, ear infections and ear tubes, and reactive airway disease. Plus Dr Marcel Casavant, Medical Director of the Central Ohio Poison Center, drops by the PediaCast Studio to talk about mercury exposure from a broken compact fluorescent lightbulb.

Topics

  • Infant Tylenol Recall

  • Tumblekins Recall

  • Colic and Migraines

  • Colic and Nicotine

  • Lingering Symptoms of Concussion

  • Underage Drinking

  • Moving to a New Home

  • Mercury Exposure from CFL Bulbs

  • Ear Infections and Ear Tubes

  • Reactive Airway Disease

Guest

Dr Marcel Casavant
Medical Director
Central Ohio Poison Center

Links

Transcription

Announcer 1: This is PediaCast.

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

Mike Patrick: Hello, everyone, and welcome once again to our little show. It is PediaCast episode 202. Yes that means we've done 202 episodes. And this is for March 7th 2012, and were calling this one Colic, underage drinking, and mercury exposure.

Of course we'll have lots more topics coming your way and we'll get to exactly what it is we're going to talk about in just a couple of minutes. Fist we have some housekeeping items though. As most of you know who listen to the program regularly, we sort of have two general types of programs that we do.

01:04

This would be one of our news and listener programs. And then we also do interview shows, and the interview shows we kind of cut to the chase and get right to the topic without a lot of chitchat at the beginning. And the reason for that simple, we have a lot of folks who do Google search on a specific topic come across the show and they want their information.

And so we present it to them, and that way they can get what they need quickly. But then that lives us with these news and listener shows which tend to go on a little longer. And we do a little more chit chat at the beginning. And so, that brings us to some housekeeping matters that I want to catch up on.

The first is, we are back on Stitcher, so PediaCast used to be on Stitcher. Stitcher for those of you who don't know is kind of a way to put all of your listening things into one application. So, if you have a Stitcher account you can collect podcasts, you can listen to mainstream media shows.

02:06

It's just a place where audio can live in the form of an App on your iPhones, iPads, through Sonos which is a home audio system. Lots of ways that you can interact with Stitcher by having an account that's free of course. And for more information on that, you can visit them online.

But we were on Stitcher and we got booted off, and it was not because of a problem with our material, it was really more of what we weren't doing. And they were sending me emails, that I needed to complete a specific application or some form, and said, you've got until this deadline date to get it done, and I kept putting it off and putting it off.

And next thing you know we were off of Stitcher and it didn't take long for some of you to let me know about it. And so, I got myself in gear and did what I needed to do, and within 24 hours we were back on Stitchers. So, we are there again.

03:03

And I want to bring it up now because there was actually a new version of Stitcher for iPhones and iPads. So, if you are a Stitcher user, make sure that you get the newest version because this is kind of cool, and now integrates with Facebook so that you can set it up whenever you're listening to Stitcher and automatically post to your account and let's your community of friends and family know what you're listening to.

And the cool thing for that with regard to us is that it's press the word automatically about PediaCast it goes out as a status update all your family and friends that you are listening, that you're really cool because you're listening to the show. But it has helped us spread the word.

If you don't want those things on you Facebook, you can turn it off in the Stitcher App. And I'm not sure if the default is that it's on or if it's off, you have to check that out. But it's something cool, and if you aren't using Stitcher to listen to PediaCast perhaps you should consider using it or at least trying it out.

04:05

All right. Also want to remind you that speaking of social media, we're not only on Facebook, we're also on Twitter, and we're on Google+ as one out too. So if you are a Google+ user, make sure that you look for PediaCast and add us to your circle of friends and we can hang out there together.

And they do have a hang out feature at Google+, and I think we need to do that, not necessarily doing the show live in the curse of a hang out. But you know, schedule on a time and we can all get together and kind of chit chat on Google, and I can answer some of your questions there as well.

So something to think about in the future, but first you have to find us on Google+ and add us, and then we can do a cool hangout in the future. One other thing for the runners out there, the Columbus Marathon is now the Nationwide Children's Hospital Columbus Marathon, it's going to be run on Sunday October the 21st 2012 starting early in the morning.

05:05

And the race has been run since 1980. So, this is the 33rd running of the Columbus Marathon. They do a marathon, a half marathon, walkers are also welcome. And it's a popular marathon for folks looking to qualify for the Boston Marathon because the course is relatively flat, we are in Central Ohio after all.

And so, it's suitable for obtaining good times. And as it turns out thousands of runners travel to Columbus each fall and about 20% of those who come are rewarded for their effort by qualifying for Boston. In fact that makes Columbus one of the leading marathons when it comes to the percentage of runners who obtained a qualifying time.

So, it's a flat, fast course. And this year is the first year for our partnership between Nationwide Children's Hospital and the Columbus Marathon, in fact it's such a strong partnership, the event has a new name, the Nationwide Children's Hospital Columbus Marathon. And to celebrate that, they're doing really something cool.

06:00

Each mile of the marathon will feature a patient champion. And these are kids and families whose lives have been touched in some way by nationwide Children's. And I bring this up because right now they are searching for these patient champions.

And to be considered, you just have to write in and tell us your story. It's easy to do and we'll put a link in the show notes, so you know exactly which site you need to go to to tell us your story and then maybe you'll be chosen as one of our, you or child will be chosen as one of our patient champions.

Again, we'll have one those for each mile of the marathon. And for the runners out there, this is an opportunity for you to become a children's champion and do a little fund raising not only for our patient champions, but for all the kids whose lives are touched by Nationwide Children's.

And for more details on being a Children's champion and help raising funds for the hospital. I'll put a link in the show notes to that as well. We'll also have a link to main Nationwide Children's Hospital Columbus Marathon page. So, if you want to register and come to Columbus to run, you can get all the details and get yourself registered.

07:05

You do want to hurry with that though because it does sellout every year, and so you want to get in and get yourself registered. We'll put all three links in the show notes for episode 202 over at pediacast.org.

And also if you're planning on coming to Columbus to run in the marathon in October, let me know that you're coming through the contact page over at pediacast.org, and perhaps we can arrange a PediaCast family gathering for all the participants while you're in town.

You know a little carb loading dinner or something to that nature. Maybe a little tour of the hospital too. Anyway, So what are we covering today, we have some recall information for it's pretty important with regard to infant Tylenol.

And I'm going to explain exactly what's going on with that and why it was recalled after -it hit then off the market for quite sometime and came back, and now it's off the market again. We're going to talk about why that is. Also there's a recall on Tumblekins, so if you have any Tumblekins in your home, we're going to tell you why those are not safe and what you should do about it.

08:08

Also colic and this is something that really affects lots of new parents who have young, young babies at home. We're going to talk about colic and its potential relationship to migraines. and to nicotine also the lingering symptoms of concussion.

Concussion symptoms may last a whole lot lower than we have previously thought. And could be the reason that your child is doing poorly in school even months after they've had a head injury, so we'll talk about that.

Also, underage drinking, hospitalization, and the injury toll of it. And also what you -the parent can do to prevent your underage child from reaching for the bottle. We've talked about moving in the past, we do have a listener question specifically about moving to a new city and how you can alleviate the stress of that on your kids.

And as it turns out I'm a bit of an expert at uprooting your family and moving thousands of miles, you know more than once.

09:06

And so, we'll talk about how to prepare your kids from moving to a new city. Also, Dr. Marcel Casavant is scheduled to stop by the studio here soon, and we're going to discuss mercury exposure.

We had a listener who dropped a compact fluorescent light bulb on the floor and had a little mercury incident in the house. And so, we're going to talk about what you should do if that happens in your home.

Also, ear tubes, ear infections, reactive airway disease, wheezing, these are questions from listeners. It must be winter, when we get the onslaught of ear infection and wheezing reactive airway disease type of questions.

I do want to remind you if there's a topic that you would like us to talk about, it's really easy to get a hold of me, just head over to pediacast.org, and click on the contact link. You can also email PediaCast@gmail.com.

And again the voice lines are available for you if you want to call and leave a message that way. In fact one of our listener question coming up is from the voice line. And that number is 347-404-KIDS, again 347-404-K-I-D-S.

10:07

Also 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, be sure to call your doctor and arrange a face to face interview and hands on physical examination. Also, your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org.

And with all that in mind, we will be back with the News Parents Can Use, right after this break.

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11:08

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

We'll begin with a couple of recalls you should know about. Just when you thought it was safe to go back in the water, we have another recall from the makers of infant Tylenol. Johnson & Johnson has recalled its entire US supply of grape flavored one ounce bottles of infant Tylenol.

Which is just great because in a previous episode of PediaCast, I touted the product highly and recommended parents should run out and grab some. So, here's the deal, and the reason that pretty much everyone in the pediatric world thought this was a great thing.

As you recalled the old infant Tylenol was dispensed by a dropper. And the concentration was 80 milligrams in .8ml. Parents out there who've had kids for a while, you know what I'm talking about. It's got the dropper, it's got a .4 and a .8 milliliter on it. And so, you dose the infant Tylenol that way.

12:08

Well, the problem was it's a different concentration than the children's Tylenol which is 160 milligrams per teaspoon. And so there could be dosing confusion if the doctor told you how much Tylenol to give if you're not using the right product, the concentration is different.

And so, there was this concern that all the liquid Tylenol product should be the same concentration which I still say is important, I mean, we really need one uniform concentration for all liquid Tylenol products.

And so, this new infant Tylenol came out which was a 160 milligrams per teaspoon, just like the children's Tylenol, except that instead of coming with a cup to those, that it came with a syringe. To make it easy just to pull up the right amount and squirt it in your baby's mouth.

And another good thing about that is that it's less concentrated than the infant drops where it actually taste a little bit better because there's less medicine and more flavoring in a given amount.

13:02

So, we said this which was a good thing, and that you should throw out your bottles of the old stuff, and really jump on board with the new infant Tylenol. And so, now those have all been recalled, so all grape flavored, one ounce bottles of infant Tylenol, which I think is what all of it was. I don't think there was any flavor other than the grape.

And they all come in one ounce bottle. So, they say all grape flavored one ounce bottles. I think it's all bottles of infant Tylenol, if I'm wrong about that write in and let me know, and we'll correct it, but I'm pretty sure it's pretty much all of it.

Over half a million bottles in al and the problem though this time it's not with the medicine, it's not that the concentration was wrong, or there were impurities, nothing like that, like was the issue in the past. But with this one, the medicine delivery system was the problem.

And as it turns out there's a cap on the top of the bottle with the small hole in it. So, you open up the top, and the top of the bottle is capped with a small hole.

14:01

And then the package also comes with the plastic syringe. and the idea here is that you insert the tip of the syringe into that hole, no needle of course just plastic on plastic, but you insert the tip of the syringe into that hole, turn the bottle upside down, and draw the appropriate dose of medicine into the syringe.

And this makes it easy to drop the medicine, it prevents the outside of the syringe from getting sticky, it minimizes the risk of spills, and it reduces the flow of medicine out of the bottle in case a kid gets the top off and attempts to guzzle it down.

There's a flow restrictor there because it's just a small hole. So, this new system was well thought out as a convenient and safe design. So, what's the problem? If parents insert the tip of the syringe and push that top cap is prone to falling into coming apart and falling into the medicine.

So, if parents use the mechanism as it was designed, this wasn't likely to happen and it makes sense to those of us in the medical field, it's just like drawing up any medicine into a syringe, you know, you insert it, turn the bottle upside down, draw up the medicine.

15:07

But most parents don't get that which is understandable. They put the tip in and just try to drop the medicine, but of course when the levels starts to drop no medicine comes into the syringe any longer.

And as if turning it upside down to get the medicine out, parents were just pushing harder and that's our natural instinct, right is to push harder. It's locked up, it's not working. Unfortunately this results in the top breaking and falling into the medicines.

So, now you have a new obstruction to getting the medicine out. You're more likely to make a sticky mass and we have a greater risk for accidental ingestion and overdose if the kid opens the broken bottle.

More information on this recall, you can head over to the infant Tylenol recall site and we'll have a link to that in the show notes over PediaCast.org for episode 202.

Hopefully they'll get this fixed, redesign the bottle, and get it back on the market because it's a great idea and theory, they just need to work out the nuts and bolts a little bit.

16:05

And another recall we want to tell you about, this one will affect fewer of you, but I think it's another important one to point out. International Playthings is recalling 31,000 Tumblekins.

Because the wooden toys can break into small pieces with sharp points which are then a chocking hazards and put your child at risk for skin lacerations or cuts. The toys are manufactured by China's Lishui Treetoys Trading Company and distributed by International Playthings.

All tumble can toys are affected by the recall and that includes the farm play set, the fire station, police car, roadster, off loader, fire truck, and school bus. And for more information about the Tumblekins recall, we'll also provide the show note a link in the show notes at pediacast.org.

All right. Let's move on to a couple of stories related to infant colic. A study of mothers and their young babies by neurologist at the University of California San Francisco has shown that mothers who suffer migraine headaches are more than twice as likely to have babies with colic, than mothers without a history of migraines.

17:08

The work races the question of whether colic maybe an early symptom of migraine and therefore whether reducing stimulation may help just as reducing a light and noise can only alleviate migraine pain in children, teens, and adults.

This is significant because excessive crying is one of the most common triggers for shaken baby syndrome which can cause death, brain damage, and severe disability. If we can understand what is making the babies cry, we may be able to protect them from these very dangerous outcomes.

As Dr. Amy Gelfand a child neurologist with the Headache Center at UCSF who will present the findings at the American Academy of Neurologist, 64th annual meeting which takes place in New Orleans this April.

Colic or excessive crying in an otherwise healthy infant has long been associated with gastrointestinal problems presumably caused by something the baby ate. However despite more than 50 years of research, no definitive link has been proven between infant colic and gastrointestinal problems.

18:05

Babies who are fed solely breast milk are just as likely to have colic as those fed formula and giving colicky baby's medicine for gas, does not appear to help. Dr. Gelfand says, "We've known about colic for a really long time, but despite this fact and no one really knows why these babies are crying.

I want to pause here and point out, it's easy to kind of blame stomach problems or to blame colic on stomach problems because when babies cry what do they do? They kind of ball up their belly and bear down as they are crying. And so, their belly gets kind of hard and you just kind of assume that they're having a belly ache.

But really they may be crying for some other reason and it's natural when you cry, and when you're really upset that you bear down and tighten up your belly so that just because their belly gets tighten hard, doesn't mean that that's the cause of the crime.

19:02

Also what happens when you get really upset and you bear down and you tighten up your belly, you stinker, you can. And so, babies oftentimes pass gas when they're crying and colicky, and so then that kind of reinforces.

And some parents might say, 'oh they just pass gas and now they're not crying anymore', gas must have been the problem. But now we're really thinking that it's not related, and in fact when I trained many, many years ago, even back then it was not you know in the pediatric field.

We didn't think that it was a gastrointestinal problem, we really did think that it was more of a neurological issue. And so, now we have little more proof of that. So, Dr. Gelfand again says, "We've known about colic for a really long time, but despite this fact, no one really knows why these babies are crying.

She and her colleagues surveyed 154 mothers with two month old babies, they picked this age because two months is when the symptoms of colic typically peak. The mothers were asked about their baby's crying patterns, and the mother's own history of migraine.

20:00

Researcher analyzed the responses to make sure the reported crying did indeed fit the clinical definition of colic. A mother who suffered migraines were found to be two and a half times more likely to have colicky babies.

Overall 29% of infants whose mothers have migraines had colic compared to 11% of babies whose mothers did not suffer from migraines. Dr.Gelfand believes colic may be an early manifestation of a set of conditions known as childhood periodic syndromes believed to be precursors to migraine headaches later in life.

Babies with colic may be more sensitive to stimuli in their environment, just like migraine sufferers. They may have more difficulty coping with the onslaught of new stimuli after birth as their thrust from the dark warm muffled life inside the womb and into a world that is bright, cold, noisy, and field with touchy hands and bouncy knees.

The UCSF team's next plans to study a group of colicky babies over the course of their childhood to see if they developed other childhood periodic syndrome such as migraine headaches, cyclic vomiting, and abdominal migraine.

21:01

And in another study related to infant colic, maternal smoking or the use of nicotine replacement therapy like the nicotine patch during pregnancy, appears to also increase the risk of infantile colic. That's according to a report published on that is recently been published online on the online version of the Journal Pediatrics.

This research comes from the Herning Regional Hospital in Denmark, where investigators looked at over 63,000 infants. Mother's nicotine exposure whether by smoking or by nicotine patch during pregnancy was compared to the incidents of colic in their babies.

The result; researcher's report there is a statistically significant positive association between these two events, meaning moms who smoke or use the nicotine patch while baby is inside the womb have an increased risk of dealing with colic once the infant is outside the womb.

The authors report that the mechanism responsible for the association between prenatal exposure to nicotine and infantile colicker are known. They say their study does not warrant a contraindication for using nicotine replacement therapy for woman who cannot stop smoking while pregnant.

22:07

And they call for more studies to investigate the relationship. So, here's an idea and admittedly it's my own idea. Maybe these babies are addicted to nicotine when they're born. And what we are calling colic is really a baby battle with the symptoms of nicotine withdrawal. Something to think about.

Let's move on from colic to concussions. Now, I know we've covered concussions often, and the reason is simple; they're common, they're debilitating, and the symptoms can last a long time. In fact longer than we may have previously been aware.

Also recurrent concussions can be dangerous. So, it's important that parents know the signs of concussion and what to do when their child has one. Again, today we're highlighting the lingering nature of concussion symptoms.

This information comes from a study conducted here at Nationwide Children's Hospital, and Rainbow Babies, and Children's Hospital in Cleveland. And it was recently published in the archives of pediatric and adolescent medicine.

23:03

This was a prospective longitudinal study which means researchers identified kids with concussions and followed them long term to see what symptoms they have and how long the symptoms last.

Now, you remember a couple of weeks ago we highlighted the difference in concussion symptoms when you look at boys versus girls. And this week we're concentrating on how long those symptoms last. So, what did the investigators do? Well, they identified children between eight and 15 years of age who presented to the emergency department with head injury and concussion.

They interviewed parents and asked about any pre-injury symptoms their children may have experienced, and this makes sense because you don't want to blame symptoms on a concussion if the child was experiencing those symptoms before a head injury occurred, right?

Then they interviewed parents again at three months and 12 months post injury, to see what post concussion symptoms persisted at those time frames. The study also included a control group, kids who presented to the emergency department with orthopedic injuries rather than head injuries.

24:05

Dr.Keith Yeates, Director of Behavior Health Services at Nationwide Children's Hospital, and one of the study authors points out the importance of this control group.

He says, "Group differences and post concussive symptoms are most pronounce shortly after injury comparing group averages' informative, but does not indicate whether individual children show significant increases in post concussive symptoms following mild head injury more commonly than after other injuries. Health providers need to be able to identify children with mild head injury who are at risk for persistent post concussive symptoms so they can target such children for appropriate management."

In other words, is it really the head injury causing the neurological problems we see following mild head injury or could this neurological issue be something that a company any traumatic injury whether that injury involves the head or not. So, what kind of neurological symptoms are we talking about?

Well, we can divide those into two categories, somatic symptoms which are things like headache, dizziness, and nausea. And cognitive symptoms which initially include amnesia and confusion, and persist as difficult concentration and impaired thinking skills which can lead to poor academic performance.

25:02

And cognitive symptoms which initially include amnesia and confusion, and persist as difficult concentration and impaired thinking skills which can lead to poor academic performance.

All right. So, what are the investigators find, well, first these neurological symptoms both semantic and cognitive reliably develop in kids following head injury. So, symptoms that were not present prior to the head injury do develop after the head injury. And the kids with broken bones did not see reliable increase in the somatic and cognitive problems.

So, it appears the head injury really is the cause of the symptoms and not just traumatic injuries in general. And then how long did the symptoms last, well at the three month follow up, somatic symptoms -so these are the headache, dizziness, nausea kind of stuff, and cognitive impairment, so thinking skill problems were reliably present at three months.

And at the 12th month follow up, many children still show signs of cognitive impairment including difficulty with attention and concentration, problems with critical thinking skills, and poor academic performance.

26:05

Dr. Yeates warns these findings don't encompass the entire population presenting to the emergency department for minor head injury. Many kids hit their heads and do not suffer any sign of concussion at all. But when post-concussive symptoms do appear, this study suggests they may last much longer than previously thought.

The authors sum up by saying, "Researchers needed to clarify which injury and non injury related factors increase the likelihood of reliable increases in post concussive symptoms." The current research suggest the injury severity is one key factor and advanced neuro imaging techniques may more clearly differentiate injury severity and its relationship to outcomes.

And finally in this week's News Parents Can Use, hospitalization for underage drinking is common in the United States and it comes with a price tag. The estimated total cost of this hospitalization is about $755 Million per year, that's according to a male clinic study in which researchers also found geographic and demographic differences in the incidence of alcohol related hospital admissions

27:06

The findings were recently published in the online version of the journal of adolescent health. On the roughly 40,000 youth aged 15 to 20 hospitalized in 2008, the year with the most data available, 79% were drunk when they arrived at the hospital.

abuse and addiction, and drinking are related emotional problems were among the diagnosed disease. When teenagers drink they tend to drink excessively leading to many destructive consequences including motor vehicle accidents, injuries, homicides, and suicides.

Says researcher Dr. Terry Schneekloth a male clinic addiction expert in psychiatrist."Underage drinking is common in the United States, 36% of the high school students reported having consumed alcohol at least once although the prevalence of heavy drinking which is more than five drinks in a row during any previous two week period is lower at 7%.

Alcohol use resulting in acute care hospitalization represents one of the most serious consequences of underage drinking," Dr.Schneekloth says.

28:05

Harmful alcohol use in adolescence is a harbinger of alcohol abuse in adulthood. The average age of those admitted to the hospital for alcohol related problems was 18 and 61% were male. Nearly a quarter of the hospitalizations included an injury, traffic accident, assault, or altercation.

For adolescent males and females hospitalization incident was highest in the Northeast and Midwest, lowest in the South, and intermediate in the West of the United States. Black Americans had lower hospitalization rates than whites. And Hispanics and Asian Pacific Islanders have the lowest rates.

Researchers say these demographic findings may help target substance abuse prevention effort toward geographic and ethnic groups at greatest risk. Of the 40,000 teens hospitalized, 107 of them died. The average age at death was 18, and 82% were males, 73% percent of alcohol related deaths involved in injury.

29:00

So, we know underage drinking can lead to substance abuse problems, injuries, hospitalizations, and even death. But how can you the parent -encourage your child not to drink when they're offered the choice.

The new study to be publish in the May 2012 issue of alcoholism clinical and experimental research suggest, teen impulses to drink can be curved by strict parental rules about drinking. The study comes from Rad Bow of the University in the Netherlands.

Researcher Sarah Peter says, "With the repeated alcohol consumption, cues they are previously associated with alcohol use such as the side of the beer bottle become increasingly important. This might be due to alcohol induced changes and the brain's reward system and the formation of memory associations."

The term approached tendencies, Peters added, "can be understood by asking if a person is inclined to approach or to avoid a stimulus. And most people tendencies to avoid are automatically triggered by threatening stimuli such as a snake, and approach tendencies can be triggered by appealing stimuli such as water when you're thirsty.

30:02

And heavy drinkers stimuli that have been associated with alcohol use automatically trigger a tendency to approach. So, if you see a beer bottle, you grab it. Studies have shown the adolescence is marked by a temporal lag in the maturation of two brain systems.

One related to emotional and motivational processes and one to control behavior and thoughts. Motion and motivation develop relatively faster in puberty, but control takes longer and is not fully develop until adulthood at around 25 years of age.

This means adolescence have less control than mature adults and are more likely to engage in reckless behavior. In addition alcohol affects the emotion and motivation system by making them hypersensitive to cues associated with alcohol use while it affects the control system by decreasing the ability to control behavior.

This means that adolescence are the higher risk for an imbalance between impulsive behavior and reflection. So, this really kind of describing something that we as parents of teenagers and as adults in the society.

31:03

Fellow teenagers we kind of understand that teenagers are impulsive and sometimes reckless. And this just kind of explains it from a neuro developmental point of view. So, a total of 238 adolescence aged 12 to 16 years participated in the study with equal number of boys and girls included.

Peter says, The team's results indicate that approach tendencies are related alcohol, however the team also found that if parents set strict rules regarding their offsprings alcohol use, adolescence could inhibit this approach tendencies particularly males.

On the other hand permissive parenting seems to exacerbate the link between approached tendencies and alcohol use. So, if a kid who has drink before and the bottle is kind of their approach thing.

They see the bottle, they want to reach for it, impulsively and grab it, and start drinking. That process can be inhibited by strict parental rules about drinking and permissive parents then does not inhibit that behavior.

32:06

Previous research has shown that stricter parental rules tend to be associated with less alcohol use among children, however this is the first study that specifically investigated the role of parents in relation to teenage impulsivity.

Peter speculates that young adolescence likely internalize parental rules in such a way that approach tendencies can be more successfully inhibited. In summer the research team says, 'The link between parental rule setting and adolescent alcohol use is well established with more rules being associated with less alcohol use.'

This study extends previous research on this topic by showing parental rules might also be related to the degree to which approached tendencies are linked to changes and alcohol use with approach tendencies predicting an increase in alcohol use for teenagers who have permissive parents.

The study suggest that parental rule setting is particularly relevant to adolescents who are already in an increased risk to develop alcohol related problems for reasons such as genetic factors.

33:04

So, the take home for parents, if you don't want your children to battle alcohol problems, set rules now. And I'll add this, be sure to model acceptable adult drinking behavior.

All right. That concludes our News Parents Can Use, and we're going to come back and answer your questions right after this.

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All right. first stop in our listener's segment is Crystal from Utah. And Crystal says, " Dr. Mike, I begin listening to your podcast in 2007, and I'm so grateful for this invaluable resource that you provide.
34:05

We just found out that we may be relocating to Denver sometime during the summer, and is neither my children or I have ever moved from our home state before. I am nervous about how my children are going to handle this.

I have two sons ages eight and five. And two daughters ages six and 18 months. Do you have any suggestions of how to help my children prepare for and handle such a drastic change? Thanks, Crystal.

Well, Crystal thanks for your question. And I love these questions where there is no definite science behind it. We've talked about one research study of that moving causes stress a couple of weeks ago. But that didn't really offer any suggestions on how to help your children adapt.

And so, this is really just coming from mine, and this is certainly not something that you learn in medical training. But just from my own experience as a parent of kids who have done this. I can talk to you about it from that perspective.

And first I would say for your six month old, it's not going to be a big deal at all. Your six month old, as long as they see your face and you change their diaper, and you put food in their belly, they're going to be happy.

35:09

Your 18 month old, yeah they'll probably do fine, you know the people in their life are traveling with them, their toys travel with them, that's really -they're going to feed more off if your older kids are having issues that anything else.

But just in a perfect stay, again as long as their little bubble were all be 18 month old still surrounding them, which it will be, I mean, you still have your things and you still have the people in their life. Then they're going to be less affected by this. It take some to getting used to a new house, a new room, but your 18 month should do pretty well with that.

Now we come to your five year old and your eight year old. And it's going to be more difficult for them, I mean they have a history with your home, with the community. And the first thing to realize is that there are going to be fears and tears.

And each kid is different, you know, it's going to affect some more than others. But you'll realize that that could be there. That your kids -your older kids really may have difficulty with this, and no matter what you do.

36:09

And so, you do have to support a healthy morning, be there, hug them, and encourage them. My daughter Katie, I think when we looked back at every move, she would say that overall she love being where we were. I mean, when we moved to Florida, she loved being in Florida.

When we move back to Ohio, she loves being in Ohio now. But at the same time she cried with each of those moves. And as much as she was looking forward to going to the new place, there is still a part of you that's left behind and mourns that.

And so, I think there's a normal mourning process when kids are upset, and there's a new magic way to get around that, it's just part of the grief stages that you go through, and you just have to love them and support them, and let them know you're there.

And the degree of control has been taken away from them because they don't really have a choice in this. You know, you didn't sit down as a family and vote on it.

37:04

And so, I mean, you have to be sensitive to that and just give them encouragement and support and love, and that's going to be really important. Now, there are some things though that you can do to make this an exciting process at the same time.

And one of those is to sort of guide and engage discovery that is customized to your child's currency. What do I mean by that? Well, it's just -what do your kids love? And what can you explore in the new place based on what they love. I mean, if they love playgrounds and parks, you know, what facilities are available close to where you're moving.

If they love to ride their bike, well bike trails are available. What kind of entertainment do they like? Theater, theme parks, you know. What kind of restaurants, what sports team are there? So, if you are getting ready to move to Denver, it might be a good time and say, "Hey, let's look into the Denver broncos", especially if when your kids loves football.

Let's get to know the team players, the season before let's start to follow them a little bit, I know it's a little bit late now for – and you have been disappointed when you followed them.

38:07

You know what I'm saying. You really just take whatever it is that your kid's currency is. What do they really like? And try to explore what's at this new location that they can really kind of dig into. And start that now, you know just some pre-moving exploration to get a taste of that.

So, you know, just an example from our own move and sometimes it's process backfires a little bit. My son loves a particular pizza based in Ohio called Donato's. I mean, it's like his all time favorite food. In fact when he was younger, when you ask him what he wanted to do when he grew up, he wanted to volunteer at a Donato's Pizza place because he loved their pizza so much.

Like -you don't have to pay me, I'll just show up and make these things as long as they'll let me eat a little bit of when I'm at work. So, he loves Donato's Pizza.

39:00

And when we moved to Florida, it was like -that was his big thing -do they have Donato's? I mean, if they have Donato's I'm fine move me anywhere, it's the Donato's that I want.

And so we looked it up online and as it turns out, Donato's is pretty much grew in Central Ohio, it's kind of a Mom & Pop Pizza Place. And then it became more of a bigger company -I think McDonald's bottom for a little while than it was sold back to the original owners. And they did expand the market out of the Ohio, and Kentucky, Indiana kind of region into two markets, one was Charlotte, and one was Orlando.

So, there were Donato's in Orlando where we were moving. So, we're really excited, we Google mapped it, we found out hey, one of them would deliver to our new house, this is cool. All right. We are really excited about this.

So, we moved and comes time to get our first Donato's, and we call, and I tried to call the number and when they said that it has been disconnected, that was our first sign that 'uh oh, there's going to be a problem'.

40:02

And so, we couldn't get a hold of them and little Google search later and we find out that the week before we moved, all of the Donato's in the Orlando area closed down. They pulled out of the Orlando market, I kid you not. And so, we had a pretty disappointed guy on our hands.

Now, fast forward almost three years later, we're back in Ohio and -actually four years later, we're back in Ohio and he is reunited with Donato's Pizza. Of course whenever we came to visit family, we had to make sure Donato's trip was in line.

So, anyway getting back to Crystal's question. This is just one example, it did backfire on us. But he was still looking forward to the move because Donato's was there. So, what in Denver can your kids get really excited about? And really try to push that on.

There may be some tears, but this is also a time for you to venture and a time for your family to sort of come together as a team. So, hope that helps Crystal, and as always thanks for the question.

41:07

All right. Next stop we have Tara in Irvington, New York. And Tara says, "I recently knocked over a lamp in my bedroom, and the compact fluorescent bulb shattered next to my seven month old son's crib. He was setting in his crib at that time.

I didn't preceded to do everything wrong, I cleaned it up as I would any light bulb. I began by taking my son to the living room and placing him in his pack n' play, I didn't seal the room or open a window.

I cleaned the hardwood floor with the broom and vacuum the entire carpet and threw it all in the kitchen trash. I didn't brought my baby back into the room. It was then, that I remembered there were some precautions I should take, so I Googled it. I was shocked at the complicated procedure I should have followed.

And I'm most alarmed about my son's possible exposure to Mercury vapors. I called poison control and they told me to throw out my vacuum and don't let the baby sleep in the bedroom for 24 hours. The next day, my pediatrician said to wait 48 hours. The doctor told me she was more worried about mercury's effect over time and that it wouldn't make any sense to test him now.

42:05

She suggested I clean again and wait for symptoms of mercury poisoning. Also, my son's nebulizer fell right next to the light bulb so it's covered in mercury too. I threw that away. So, my question is, could my son really suffer permanent damage due to one light bulb?

Should I tear up the carpet in the rooms, since he will soon be crawling on it. My pediatrician seemed alarmed and she said, she would freak out too which wasn't really what I was looking for. Your opinion. Thanks, Tara.

Well, thanks for the question Tara, we really appreciate you writing in. And just in the nick of time, Dr. Marcel Casavant has popped into the PediaCast studio to help me answer this one. Dr. Casavant is the Medical Director of the Central Ohio Poison Center. He's also chief of pharmacology and toxicology here at Nationwide Children's Hospital.

And a professor of Pediatrics and Emergency Medicine at the Ohio State University College of Medicine. So, Dr. Casavant, thanks for stopping by and helping us out.

43:02

Marcel Casavant: You're welcome. Good afternoon.

Mike Patrick: Great to have you here. So, what's the deal with compact fluorescent bulbs? I thought they were supposed to be better for the environment, but apparently they have mercury inside of them. So, what's up with that?

Marcel Casavant: Well, it's a very complicated story. Yes, they are supposed to be better for the environment and they clearly are in that they use a lot less energy to produce the light for our homes and so where you burning less fossil fuels and that's great for the environment.

However in the process they are using mercury and that as long as mercury stays in the light bulb we can all be comfortable with that. But when the mercury comes out of the light bulb there are some issues. The good news is the amount of mercury in one of those complex fluorescent bulbs is very small.

And there's no real acute danger from mercury poisoning. The bad news is, if that mercury stays in a carpet or in some other areas where a child may have long term exposure, many hours per day, for weeks, months, or years, it's possible that there could be some accumulation of mercury in that child.

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Mike Patrick: Sure. Now, mercury sounds dangerous. What exactly does it do inside the body? Why is that a problem?

Marcel Casavant: You know, it's funny that you say mercury sounds dangerous, to me mercury sounds dangerous, and to you it sounds dangerous. It's remarkable how many people in the community remember playing with quicksilver as kids, and it doesn't occur to a lot of people that mercury can be dangerous.

Mike Patrick: Yeah.

Marcel Casavant: Yes, mercury really is dangerous. The good news with quicksilver is there's minimal absorption through the skin. The bad news.

Mike Patrick: Now, when you say that you're talking about like you'd have the ball that you could kind of roll around and you would split into little -yeah.

Marcel Casavant: Yeah. Do you remember we did that when we're kids on the counter, on the doors, and that sort of stuff. The trouble is if a little bit if that spills, and then over weeks or months they vaporized and we are breathing those vapors over long period of time, that can cause some problems.

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Mike Patrick: And what exactly in the body does the mercury do?

Marcel Casavant: Well, the mercury finds lots of enzymes in the body that are used to using what we call divalent cations, so things like calcium and magnesium, and iron that have 2+, and the mercury can have 2+ and so, all of these enzymes will try using mercury the way they use the other metals in the body and don't stop working correctly.

What we mostly worry about is how the brain develops in the presence of mercury. So, kids in particular exposed to mercury vapors over long period of time, we worry about how their brain develops.

Mike Patrick: So the symptoms of mercury poisoning then would be cognitive kind of issues if you were exposed over a long period of time?

Marcel Casavant: For the issue of today's discussion, yes that's exactly what we're worried about is brain development, it's IQ points, it's how am I able to learn in school and master sensory input and control of language, and all of those kinds of things as we grow up.

46:05

Mike Patrick: Sure.

Marcel Casavant: Other kinds of mercury can cause other problems. Mercury salts can cause gastroenteritis, vomiting, and diarrhea, and kidney trouble. Mercury fumes and vapors in high concentrations can cause some lung injury.

Mike Patrick: Sure.

Marcel Casavant: But what we're mostly worried about when we talk about the broken light bulb, the broken fever thermometer, other sources of mercury in a child's environment is the brain development.

Mike Patrick: Now, once you have an exposure to mercury, so let's say a bulb broke, or thermometer broke, and you're worried that you're baby did have breath in vapors of mercury. How is that treated?

Marcel Casavant: The treatment is to first to recognize that it's happened and then to stop the exposure. So, as your listener wrote, she did all the wrong thing. So, the room was not sealed off, the child was in the area, the child was brought back in very quickly, all of those are sources of further exposure. So, the real treatment for an acute vapor exposure is to stop the exposure.

47:05

Mike Patrick: And once you stop the exposure, you know, as long as it hasn't been continued exposure over many weeks, the body will make more of those enzymes that then aren't bound to mercury and that should kind of correct itself.

Marcel Casavant: Correct. Over a few hours of exposure there's minimal uptake from most of the situations. And certainly from a compact fluorescent light bulb that broke, there's minimal exposure in the first few hours.

Mike Patrick: Sure.

Marcel Casavant: And the mercury that has been taken up by the child will be eliminated. And safely so, and without causing any problems.

Mike Patrick: Yeah. Now, I'm sure that with as many compact fluorescent bulbs as there out there right now, there are a lot more listeners than just Tara who have probably had this happened where a CFL bulb is broken, or they have them in the house and so they're wondering, OK, if an accident happens and one falls and breaks, what should they do?

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Marcel Casavant: Great. So, the first thing is to be aware of the fact that they can fall and break. And if you're smart you'll put out a tarp or a drop cloth first before you're even adjusting any of those light bulbs. I remember the first one I put in had no problems at all.

But the next time I wanted to replace the light bulb I pulled the package off the shelf, package of six, and all five of the remaining ones dropped.

Mike Patrick: Oh no. The medical director of the Central Ohio Poison Center.

Marcel Casavant: Absolutely. Very susceptible to the same kinds of problems with these products as everyone else's. So, now there's some advice that when you're working with these you put down a drop cloth first, and the if it falls and breaks, it's easily contained.

Mike Patrick: Oh, great idea.

Marcel Casavant: So, the next thing is if it falls and breaks you do want to take children, pets out of the area quickly. You don't want them breathing the vapors, but you also don't want them walking through the broken parts and then tracking the fragments throughout the rest of the house.

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Marcel Casavant: If you have an air conditioner turn that off, or your heating system HPA doesn't turn that off, so if there are vapors being generated you don't spread those throughout the house. And it's great to close off the doors to the rest of the house and open up the windows to fresh air to increase the ventilation. And in case there is any vapor building up, to get that ventilated outdoors as quickly as possible.

Mike Patrick: Sure.

Marcel Casavant: After that what we do is try to find all the pieces and put them all together in a plastic bag. Many of these CFL bulbs contain their mercury in the form of a small pellet, and if you can find that pellet and just pick it up and put it in a plastic bag, there's no further worry of vapor for days, weeks, or months down the road.

Mike Patrick: Sure.

Marcel Casavant: Pick up all the glass pieces, any dust that's with it, any fragments. You can use things like duct tape to pick really small pieces that you might be able to see, but are hard to pick up.

50:04

Marcel Casavant: You definitely don't want to use a vacuum cleaner because that can contaminate the vacuum cleaner really permanently. When I learned how to do this, I was taught it's OK to use the vacuum cleaner just throughout the bag, but that was wrong advice.

So, anybody who's heard that from me or from other experts over the years, it's been shown that even the fanciest vacuum cleaners can be contaminated all the way through when you clean up mercury with them.

Mike Patrick: So, it's not a good idea?

Marcel Casavant: So, we want to get all these pieces together and put them in a plastic bag, and then we want to get that plastic bag safely disposed off. Now, all these works perfectly for non porous surfaces. If this falls on a wood floor, if it falls on a formica counter for instance, clean up is very easy.

It gets more complicated when the mercury is broken over a porous surfaces, and when it's broken over furniture or carpets, it can be very hard to find all those pieces and clean them up. You may think you've done a great job with it, but still left behind some beads of mercury.

51:08

And in those cases sometimes the best thing is just to get rid of that porous items, and sometimes that means cutting the hole in your wall to wall carpet, and sometimes it means just getting rid of the carpet.

Mike Patrick: If there's a question of whether there's mercury vapors present or not. So, let's say that happened and you cleaned it up, so you're really kind of worried about it, and you want to rest at night. Is there someone you can call to come out and test for mercury vapors?

Marcel Casavant: Yes. You know, the mercury vapors are invisible to ordinary humans like you and I. But health department folks have meters that they can use. The Environmental Protection Agency has meters they can use to come out and check you home.

Not might be one piece of advice, not for the ordinary spill, but the entire situation where a lot of bad things have happened all in a row, and the mercury contamination has been spread from room to room, a vacuum was used.

52:01

It's on a porous surface -that carpet, I suspect to call to their local health department would be very helpful. To have somebody come out, and measure, and say, 'there is no mercury vapor here. You and your child are safe. Or there is mercury vapor here, and here's where it is, and here's what we need to do to get rid of that ongoing exposure.'

Mike Patrick: Sure. Now, knowing that there's mercury and these bulbs when one of them has reached the end of its life, and isn't working anymore, so it hasn't broken. It doesn't sound like a good idea to just throw in the trash can and it ends up in the landfill. What should folks do with CFL bulbs that don't work anymore?

Marcel Casavant: In many places you're not allowed to throw those in the trash. I just checked with our local regulations and here in Central Ohio we are allowed to throw them in the trash, but I agree with you, that's not a very good idea. Many communities have solid waste recycling place, and hazardous waste recycling places.

53:00

And in Central Ohio the solid waste authority of Central Ohio will accept those bulbs back, and they will recycle not only the mercury, but the other components of the bulb as well.

Increasingly around the country more and more retailers are saying when you're ready to buy new bulbs, take the old ones back to us and we'll get them recycled safely.

And then there are number of places you can find on the Internet that are willing to for a price take your recyclable bulbs back -mercury containing bulbs back for recycling.

Mike Patrick: Now, what about other kinds of bulbs? So, we see the traditional incandescent bulbs that are out there, and there's halogen bulbs, and LED bulbs, are there any chemical or toxicologic hazards with those light bulbs?

Marcel Casavant: I'm not aware of any other particular concerns with those kinds of light bulbs that you mentioned. The older fluorescent light bulbs contain even more mercury than these compact fluorescent bulbs. So, those are real concerns as well. Those long 4 foot two, those contain mercury in significant quantities.

54:04

But as far as incandescent's and the LED's, and the halogen bulbs, I don't believe those are any particularly toxic.

Mike Patrick: Great. That's Dr. Marcel Casavant, ladies and gentlemen. And we appreciate you stopping by. Let's move on to our next question, and this one comes from the Skype line.

Marcy: Hi, Dr. Mike this is Marcy from Bellmore, New York. I had a question about my daughter who is four years old. She has had frequent ear infections, and has had fluid in her ear that has been very difficult to go away, hasn't gone away.

And her pediatrician has recommended that she might be a good candidate for ear tubes or tubes in her ear. I was wondering if you could talk a little bit about that on the podcast. Thanks very much. Bye.

Mike Patrick: All right. Well, thanks Marcy for using the Skype line we appreciate it. So, kind of to sum up, your four year old daughter and she has frequent ear infections, she has chronic fluid behind the eardrums, and your pediatrician recommended ear tubes, and you want us to talk about ear tubes a little bit.

55:09

So, what are ear tubes? Well, it's a little piece of plastic with a hole in the middle of it. so, kindly think of it as a small tunnel. So, a link of plastic and in terms of size, if you want to kind of picture in your mind.

If you think about an ink pen, so just kind of a standard cartridge ink cartridge that goes into an ink pen, that's about the diameter with a hole in the middle. And basically just fits right through the ear drum. And so, the idea here is that the space behind the ear drum will ventilate to the space in front of the eardrum at a kind of drain that area out to get the fluid out.

And we'll talk in a minute about other indications for putting ear tubes in. But in your case it sounds like there's fluid that's been there for a long time, and your doctors talking about getting that fluid out.

So, if you put a tube through the eardrum it will help facilitate the drainage of that fluid and possibly help prevent that fluid from re accumulating in that space in the future.

56:08

And then with the ear tube what it'll end up happening is over time the body kind of forces that out and then you get a little scar where the tube was, but it's very small, so we're just talking about very small scar and generally that doesn't cause much of a problem for most kids although we'll talk about complications in just a couple of minutes.

And sometimes the tube doesn't come on its own like it's supposed to and so your child has to have another procedure to get the tube out at some point in the future. So, why would you do this? Why would you put a plastic tube to the ear drum that's got a little hole in it.

Well, in the case of recurrent bad ear infections, it's a pretty easy decision, you have this kid that's just miserable with fever and pain, and perhaps vomiting, and they get on antibiotic. And soon as their off of that antibiotic, it just comes back and you do the second antibiotic, and they'll give you a third antibiotic. And at some point you're just -is as craziness and you're just sick of it, and you want your child to be better.

57:06

And so, ear tubes can help break that process. And we're going to talk about exactly why they work to do that in just a minute. And in that case, it's kind of an easy decision to put the ear tube in.

The other situation where we talk about ear tubes are when you have chronic fluid behind the ear drum which in your case Marcy is what you're talking about. And this is actually more of a difficult decision because you have to consider many factors.

If it was a perfect world and there were no risks or complications associated with ear tubes, you could say, yeah fine drain the fluid off. It's not supposed to be there, let's put the ear tube in. But there are complications and problems that can arise, they're not common, but they can arise with this.

So, you have to look at a risk benefit kind of ratio, and when you're talking about a kid who has acute ear infection that are recurrent, and they're having fevers, and they're uncomfortable, and they're on multiple antibiotics, you know it's easier to say that the benefit outweighs any risk.

58:04

But if the kid is not having any issues associated with it, it's a little harder to try to figure out that risk benefit balance, and it's something that you and your doctor have to come to agree together.

Now, if that fluid is causing any kind of discomfort, if it's causing enough of a hearing loss, and it's affecting their quality of life, if it;'s causing enough of a hearing loss that it's causing speech problems. You know, these are the kind of situation where it maybe worthwhile to put the ear tubes in.

And I will point out with regard to speech, there have been some studies that looked at kids with chronic fluid -not infection, but just chronic fluid from a past infection that's just still there behind the ear drum. And it does show that they do have some hearing loss that's there when the tube is there.

They're not deaf, but it's a little bit of a hearing loss. And so, they looked at a group of kids with that kind of hearing loss and then kids who didn't have any chronic fluid behind the ear drum.

59:00

And then they followed them out prospectively in a longitudinal study to see what the rates of speech delay and speech problems were. And what they found was that there was really no difference between the two groups, so that yes chronic fluid there can cause speech or hearing problems, but it does not appear to cause speech problems that degree of hearing loss.

Now having said that, we're again looking at a group average of kids with chronic fluid versus kids without chronic fluid. And your individual child may not hold true to that observation. So, in other words, even though study show that having chronic fluid behind the ear drum, it can lead to hearing loss that's temporary, but it won't cause speech problems.

Well, maybe in your child it is causing speech problems because not all kids you know, follow -we're talking studies versus looking at the average. It is statistically significant that these things are correlated, but in any individual kid the opposite might be true.

60:02

And so, this is again something that you just have to kind of come to an agreement between you and your doctor of whether the benefit versus risk ratio is really there for you.

But if your kid has chronic fluid and their speech is fine, their hearing is not affected to any significant degree, they're comfortable. How long do you let that fluid set there? You know, talk to your doctor about it, they may want you to have an interview with the pediatric ENT doctor -ear, nose, and throat doctor kind of get their opinion.

But you have to run in and do surgery? Maybe not. That's something that you may be able to watch for quite a long time. So, let's go ahead and focus on why do ear tubes work in the case of recurrent ear infections.

And to do that we have to think about a structure in the body called Eustachian tube, and that's a tube that connects the back of the throat to the middle ear space. And the purpose of this tube is to equalize the pressure on both sides of the ear drum.

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So, you doesn't get a fluid build up, I mean in order for the ear drum to move when sound waves move it, you want equal air pressure on both sides. And so, you have air coming in to the ear canal on the outside, and air coming into the mouth and up to the Eustachian tube on the inside, and that equalizes the pressure so that the ear drum can move freely.

Now in order to keep stuff from the mouth out of that space, the Eustachian tube is lined with little hair cells that have cilia like hair like projections. And their job is just to anything that enters the Eustachian tube from the mouth, it's their job is to push it back down to the mouth, and say,'hey you're not supposed to be here'.

And so, that's kind of what happens with the Eustachian tube. Now, what occurs when you have a virus is a couple of things. So, you get a viral upper respiratory infection, and the virus can infect those cells, so the cilia doesn't work properly. So now, mouth bacteria is able to go up the Eustachian tube, and those hairlike projections don't work to push the bacteria back down to the mouth.

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Also, you get mucus that gets made when you have an upper respiratory infection. And that mucus can block the Eustachian tube, so now any bacteria that went up there not only does it not get pushed back down to the mouth, it can't even get back down to the mouth because now you get mucus kind of blocking that tube.

And so, the bacteria stay in that middle ear space and set up shop, they reproduce overwhelm the space. The body says, 'Hey, this bacteria is not supposed to be here sends in white blood cells to kind of mop them up and take care of the infection.' And next thing you know, you have puss and inflammation, and you have an acute air infection. So, it's kind of the process of why that happens.

Now, why do some kids gets more than others, you know some kids get viral infections than others because they're in day care or around other kids, and more prone to getting infected. Some kids have a problem with their immune system, and so they get infections more often. And other kids have an anatomy problem where their Eustachian tube is wider and kind of floppy.

63:04

And so it's easier for bacteria to get up there and if they kind of flop closed and you got mucus sort of gum and everything up, that can also obstruct that Eustachian tube and make it not do its job properly.

Other kids may have thinner kind of skinnier, longer, more rigid Eustachian tubes that are going to work better. So, these are other factors that kind of go on to why some kids gets lots of ear infection and other kids don't.

So, that's kind how ear infections oftentimes happen. And so, what does the ear tube do? Well, if that whole process is happening and bacteria get up into the middle ear space behind the ear drum, and can't get back down to the mouth through the Eustachian tube, rather than being trapped in the middle ear space, they can actually go through that tube and becomes skin bacteria on the outside of the body.

So, in that way it kind of helps to ventilate that middle ear space and prevent ear infections from occurring, and then when they do occur, the fluid can drain out through that tube, and that's why they're helpful.

64:07

In terms of risks with putting ear tubes in again it involves general anesthesia which has it sown risk, it's a surgery, you can get recurrent infection associated with the tube itself sometimes and then especially fungal infections can happen.

And then we talk a little bit about scar tissues a possibility too in the ear tube fall off. So, each case is unique, it's definitely something you want to talk with your doctor about, but hopefully that discussion helps you out, Marcy. And again thanks for writing in.

And finally, we have Maria in Indianapolis. And Maria says, "Hi Dr. Mike. Love your podcast. You've really answered many of my questions through this wonderful source of information.

My question now is this, I have a 14 month old boy who's had a chronic cough since he was four months old. His symptoms are always the same runny nose followed by a very harsh, forceful, and wet sounding cough, no fever, and he sleeps well.

65:02

He sees the pulmonologist and is currently on Qvar also Albuterol as needed and Prevacid for possible silent reflux. They have not given me a diagnosis except that he has reactive airway disease, his chest and lung X-rays are all normal.

Can you elaborate on reactive airway disease. Every time this happens what seems to be two weeks out of every month, my pediatrician attributes it to viral infections and we just wait it out. I feel helpless seeing him cough and be sick so often. Thanks, Maria in Indi.

Thanks for the question Maria. So, let's talk about reactive airway disease. First we have to sort of define what it is. You know, it's really a nice way to say that a baby has asthma. It doesn't mean that they're going to have it their whole life, and it may only last one year kind of on and off.

It may last longer than that. But it's kind of instead of using the word asthma which has kind of a stigma chronic disease feel about it. What we call -what happens with asthma in younger babies we call it reactive airway disease. Kind of nice way to say asthma without saying asthma.

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And we do recognize that not all kids with a reactive airway disease will have asthma as they get older, and they try to weed out which ones will and which ones won't. Probably the most reliable way to do that is to look at your family history.

If there's a family of baby history of babies who wheeze when they're babies, who then don't wheeze as they get older, then that's more likely to be the case that you're child is going to follow. On the other hand if a lot of babies grow up to be kids with asthma, who grow up to be adults with asthma, then it's a little less likely that your child is going to outgrow it.

Now again it's not 100%, but is is helpful if you look at your family history to kind of determine where your child is going to go with their reactive airway disease/asthma kind of pathway. Now, so what exactly is happening here? Well, the bronchials which are the small airways down deep in the lungs, they're lying with smooth muscle.

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In response to certain things and it can be viruses, it can be cigarette smoke, it can be -you know, any kind of Anogen substances not suppose to be down there. The body can react by causing lots of inflammation, and in kids with reactive airway disease, their lungs react more to those foreign invaders than other kids do.

So, if you give a kid with reactive airway disease a virus, they are more likely to over react to that virus and cause inflammation down deep in their lungs. And that inflammation obstructs airflow and that causes wheezing.

And when it's significant it can cause you to have to work harder to breathe, to move air in and out, and kids can tire in. So, the danger is that if you don't treat it, of you're not up on it, that kids could get into problems breathing because of their reactive airway disease. Now, in contrast to that, there's another disease that we see in little babies called Bronchiolitis.

And in this situation rather than there being a lot of inflammation that's causing this wheezing, it's really more that the virus and the one in most particular that does this is called RSV or Respiratory syncytial virus.

68:11

And it causes a lot of mucus and cellular debris that causes the obstruction. And so, the types of things that we use to treat reactive airway disease which will get to in a minute, don't help as much with RSV Bronchiolitis because it's a different mechanism of what's happening to cause that air flow obstruction down deep in the lungs.

So, how do we treat reactive airway disease? Well, just as your doctor is having you do the type of things that we do. One is the Qvar that you're using. Qvar is an inhaled steroid medicine, and the idea here is that if you do an inhaled steroid, steroids reduce inflammation.

And so, if you kind of have a lower level of inflammatory ability down deep in the lungs when those irritants come whether their virus or something in the environment, you're going to have less of an immune response, and less inflammation because of this inhaled steroid that's there everyday.

69:07

So, that's what the Qvar. The Qvar is for prevention. To prevent bad inflammation from happening in the first place when you're expose to the things that normally would cause the inflammation.

But not only helps to prevent, once you actually have lots of inflammation and health steroid isn't going to help you out too much. Then what we do is the first thing we use is what's called a rescue medicine. And this is what the Albuterol does. And the idea here is that remember these small bronchials are lined with smooth muscle, and Albuterol relaxes the smooth muscle.

And so, if you can relax that muscle, you increase the diameter of the airway and then that is going to allow more airflow despite the inflammation that's there.

Now, if you have a kid with RSV or Bronchiolitis, and the airflow obstruction is not from inflammation, it's more from mucus and cellular debris, then dilating that smooth muscles is not really going to help you out too much because you just have a lot of gunk inside the actual bronchial itself.

70:11

And so, you still have airflow obstruction even though you're relaxing the muscle. And so, that's why kids who have RSV typically wheeze regardless of what you do, and it's just a matter of getting the mucus sucked out and supporting them.

And by kids with reactive airway disease the rescue medicine like Albuterol does help. And then the other thing that we do with those kids is start them on an oral steroid so it's a much more potent steroid experience than their inhaled steroid is.

These are medicines like prednisolone or Orapred, and so they decrease the inflammation inside the lungs in a bigger way, and help them get through that episode. I do want to point out that the rescue inhaler is you have to know which one your rescue inhaler is.

So, if you have a kid with reactive airway disease and they start wheezing, they start having trouble breathing -Albuterol you have to know your rescue medicine is the Albuterol or the the Zopanax is the other one.

71:05

And so, that's the first one that you have to use, you don't monkey around with the steroid medicine, you get the bronchodilator in to relax those smooth muscles and open up the airways a little bit bigger. And that's the first thing that you have to do.

Now, so how do you prevent reactive airway disease. Well, you have to avoid whatever it is that's irritating you. So, for some kids if they're young and they're in day care, and they're getting virus after virus after virus, so they're exposed in some other fashion.

They go on to a church nursery, or you're involved in a social organization and your kids are out and about, and they're around other kids. Whatever it is, if they're prone to getting their reactive airways disease acting up when they get a virus, then you have to kind of avoid them getting viruses.

And sometimes that means taking them out of certain situations. Or if it's cigarette smoke that initiates it, or if it's cat dander that causes it to occur, you just kind have to look at their life and figure out what their initiating factors are and try to remove that as much as you can.

72:06

And then of course the inhaled steroid medicine we've talked about. There's also some non-steroid agents that decrease the immune system from overreacting and those are medicines like Singulair is one example that many of you that probably heard of.

In terms of prognosis or expectation with reactive airway disease, again a lot of kids outgrow it. The reactive process kind of burns out, and their immune system kind of simmers down, and doesn't have these overreactions anymore. Also as you get older the diameter of the airways increase so there's less obstruction.

And for a lot of kids, it's sort of a combination of those two things as they get bigger, they kind of outgrow their reactive airway disease because their bronchials are getting bigger, and because their immune system kind of slows down and doesn't have this crazy reactions to whatever it is that Anogen is for them.

So, then other kids their reaction stays the same even though they get bigger and it turns into what we then called childhood asthma. And again, you got to look at your family history to try and figure out which of those things is going to happen in your particular case.

73:09

So, I hope that helps Maria, just a little discussion over reactive airway disease. If you like to hear lots more about asthma, check out PediaCast episode number 186 where we have Dr. Karen McCoy join us.

She's a pulmonologist here at Nationwide Children's Hospital and we'll put a link to that episode in the show notes for you. All right. We're going to take a quick break because we're running way over. And we'll get back to some final thoughts right after this.

[Music]

74:05

All right. I want to remind you that if there's a topic you like us to talk about or you have a question for us, it's easy to get a hold of me, just go to pediacast.org and click on the 'Contact' link. You can also email pediacast@gmail.com or, call the voice line, at 347-404-KIDS. That's 347, 404, K-I-D-S.

Also, if you're a runner, think about joining the Nationwide Children's Hospital Columbus Marathon, and we'll put links in the show notes for you. We're looking for a patient champions and we're looking for children's champion to help us raise money, and it's a great way for you to qualify for the Boston Marathon if you're looking forward to that.

Again, the links are all in the show notes for you. And if you are planning on traveling to Columbus for the marathon, make sure you let us know because we make it a little get together for those coming in to Columbus. We can meet in person, have dinner together, I think that will be a lot of fun. So, let us know if you're planning on.

75:01

In terms of do I run, so I know that's part of the next question on your mind. And as my daughter likes to say, "I only run if there's a pack of wolves chasing me." But hey, we can eat dinner together.

All right. I have someone to thank. Dr. Marcel Casavant for stopping by the studio and talking to us about mercury. And of course thanks to all of you for making PediaCast a part of your day. Don't forget to let your friends and family know about PediaCast through your blogs, on Facebook, in your tweets. And remember that we're available with social media as well.

We're on Facebook, Twitter, and Google+ now, and we have to look into having a hang out at some point here in the future. Again we also, and I think this is important, we'd like for you the next time you're at your pediatrician's office, just to mention us.

So, when you go in for your next well check up, or your having a sick office visit, just tell your doctors say, "Hey, there's this great evidence based pediatric podcast. out of Nationwide Children's Hospital. that I would encourage you to let all of your patients know about. So, that's a great way that you can spread the word about the show

76:03

All right. and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody!

[Music]

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

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