Growth Charts, Sinus Infections, Game Night – PediaCast 288

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Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include growth charts, nitrates in baby food, sinus infections, leg bumps, family game night, and baby gate safety.

Topics

• Growth Charts

• Nitrates in Baby Food

• Methemoglobinemia

• Sinus Infections

• Leg Bumps

• Family Game Night

• Baby Gate Safety​

Links

• CONTACT DR MIKE – Ask Questions, Suggest Show Topics

• CONNECT NOW with a pediatric specialist from Nationwide Children’s – Referrals and Appointments

​

Transcription

Announcer 1: This is PediaCast.

[Music]

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

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast. It's 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 4, 2014, Episode 288. We're calling this one "Growth Charts," "Sinus Infections," and "Game Night." I want to welcome everyone to the program, we have a listener edition of the program lined up for you, so we we're going to be answering questions from our listeners so that's coming your way.

0:01:02.2

First up though I want to say thank you to the entire city of Louisville, Kentucky. Our family spent Memorial Day weekend there and we had a fantastic time. We went zip lining underground at the Mega Cavern. So this is really cool, it's like the only place in the world that I know of. We can actually zip line underground. So they basically have caverns with zip lines through them and there's nothing quite like zip lining over something you can't really see the bottom of. It's a little frightening but we had a great time, it was a fun time spent with family.

0:02:00.2enile 

We stayed at the historic bed and breakfast and I won't say the name. The proprietors were hospitable, the food was delicious but it was a little like staying overnight in Disney's haunted mansion. It was a bit on the creepy side, but it was fun and we all agreed that we'd stay there again. The main attraction though, the reason we stop through Louisville is Abbey road on the river. My daughter who is home from college, she's a huge Beatle's fan and as it turns out it all stemmed from her getting Beatles rock bad for Christmas a few years back. Next thing you know she's reading books about the Beatles, collecting vinyl records, attending British invasion concerts. I guess you could call her a groupie, that's kind of sad when half the members are deceased of the group. But anyway this was the big daddy of Beatles and British invasion events. Zoey's in the Midwest and a good time was head by all so thank you again to the kind folks in Louisville, we really did have a marvelous time.

0:02:59.7

And got to listen to some good music, hook up the sun, good food and most importantly, time spent with family so it was really great. This week's lineup "Growth Charts," a listener wants to know why there are so many to choose from and she's concerned because her doctor is not using the World Health Organization growth chart which is recommended by the American Academy of Pediatrics and the Centers for Disease Control. So why would a doctor not use the recommended chart? Are there legitimate reasons and does it really matter? What information do doctors glean from a growth chart, and how does the growth chart fit into the big picture of managing a child's health? And when is a growth chart concerning? All that and more coming up as we talk about growth charts. And then "Nitrates in Baby Foods," certain vegetables are high in nitrates, we'll take a look at why that is. What can you do to limit the nitrates in your baby's food, and we'll also discuss the dangers of nitrates, what exactly do they do to the body? And what's the difference between commercial baby food and homemade baby food with regard to nitrates?

0:04:07.5

And in the course of this discussion, we'll talk about a condition known as methemoglobinemia, big word, sounds complicated but it's not really too hard to understand, and I'll break it down for you. And then "Sinus Infections," how are they diagnosed and treated? In particular a listener wants to know about CAT scans, CT scans, and sinus surgery, so we'll cover that as well. "Leg Bumps," let me get a little bit more specific. How about a small leg bump on a new born. Listener wants to know what that could be, so we'll cover the possibilities and the typical workup. And then "Family Game Night," just fresh often events spent with the family really sort of got me motivated to talk about this again. Those of you who have been around the PediaCast audience for a while know that game night is near and dear to our family. And apparently it's near and dear to some of my listeners as well.

0:05:00.7

We have a mom with a board game recommendation and she wants to know what games we've been playing at home. Did we get any new ones around Christmas time? The answer is yes we did and I'll cover the new ones we've been playing, give you some suggestions on a family game night so that's coming your way near the end of the program. And then stick around for my final word on baby gate safety. Don't forget, PediaCast is your show as evidenced by our answers to listener questions this week. If there's a question that you have, or you'd like to suggest a topic idea, or you want to point me in the direction of a new story or journal article. It's really easy to get in touch, just head over to pediacast.org and click on the contact link. Also I want to remind you, the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you do have a concern about your child's health, make sure you call your doctor and arrange a face to face interview and hands on physical examination.

0:06:00.2

Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org. Let's take a quick break and I will be back with your questions right after this. 

[Music]

Dr. Mike: Alright first up is a quick thank you from Amanda in Lansing, Michigan. Amanda says, "Dr. Mike I'm a mom and a pediatric nurse practitioner student from Lansing, Michigan and I love your show." 

0:07:04.3

"I listen to each new episode while I am travelling to and from clinical sites. I also have recommended your show to many patients that I see in the clinical setting and fellow pediatric nurse practitioner students. I just wanted to let you know that your hard work and information is appreciated by these students, keep them coming I'll be graduating in December and will continue to promote your show. Sincerely, Amanda." Thank you for your kind words, I really do appreciate your support and also appreciate you helping spread news about the show with patients and fellow students. Others of you out there, those who share the show with moms and dads, medical students, residents, nurses, nurse practitioners, pediatricians, family practice doctors, teachers, coaches, baby sitters, daycare providers, grandmas, grandpas, anyone else who has kids, teaches kids, takes care of kids, you get the picture. 

0:07:58.7

Please know that I really do appreciate all of your efforts and thank you for helping spread the word about PediaCast. First up in terms of listener questions, we have Lorie in Elmira, New York. Lorie says, "Hi Dr. Mike, although the CDC and the AAP both recommend that we use a growth chart provided by the World Health Organization for children under the age of two, my pediatrician is using a growth chart that comes from a different source. In looking online I have found several different kinds of growth charts. Can you advice why they are so many different growth charts in use and what the benefits and draw backs to each are. The chart my pediatrician uses has my child in a different percentile than the World Health Organization chart and that concerns me. How can parents pick the best growth chart to use for our children?" Well thank you for the question Lorie. So let's talk a bit about growth charts, first exactly what is a growth chart and then we'll talk about the usefulness of a growth chart, and then a comment on which particular chart you and your doctor should use. 

0:09:03.9

So how do we get a growth chart? Well first we survey a particular population. So we're going to identify the members of the population, all of these are going to be children of course. We're going to record each child's age and then we're going to record each child's growth parameters typically height, weight, and Body Mass Index for toddlers, school age kids, and teenagers and then we're going to swap out BMI for head circumference in babies. Also in babies instead of calling it height we're going to call it length. Then we're going to do some fancy statistical analysis with all of these numbers and come up with percentiles for each growth parameter at specific ages. So think for a minute about a bell shaped curve, if you remember back to your middle school years. To get a bell shaped curve and most of the values will lie between the 25th and the 75th percentiles with a smaller number of outliers below the 25th percentile and above the 75th percentile.

0:10:10.4

So often when we take a number that involves a population, you're going to get a spread of results and they're going to form this bell shaped curve with the middle numbers there being more of them, so hoping that make sense. And then we plot all these information on a graph with the age of the child or of all these children. The ages recorded along the horizontal axis or the bottom of the chart and then the growth parameter in question, the measurement that we get along the vertical axis or up and down on the growth chart. And then our percentile lines are going to travel from the south-west corner to the north-east corner across the graph. That's the growth chart sort of in its native form. We're just looking at percentiles when you take a population for each of these parameters and then there's going to be a different chart that measures each parameter. 

0:11:01.5

So you're going to put length on one chart, weight on the different chart, BMI on the third chart, head circumference on the forth chart, that sort of thing. So we take these growth charts and then for an individual child that we're seeing as a patient or you as a parent, we're going to use your child's age and growth measurements to plot points on the chart. So how is this useful? Well first it allows us to compare your child's growth to the population of kids that we've used to make the chart. And really more importantly, it allows us to look at an individual child's growth over time. Now what are we really trying to do here? So what's our goal? Well we want to know if a child's growth is normal, or is there a concern, right? I mean that's the bottom line, we want to know if there's a problem or not. And if there is a concern, what could be causing the growth problem?

0:11:58.2

So in order to tell if there's a concern, we have to make sure that we are comparing an individual child to the correct population of kids. So if we were going to compare Japanese child to a Scandinavian population we might find a kid who's very small on the chart. There might appear to be a problem but it's not really a problem of growth, it's a problem of comparing the child to the wrong population. Also the wrong population might not be an ethnic issue. It might be due to an already known medical condition. What if we're comparing a premature new born with a population of term infants especially during the first few months of life? Or a child with Down syndrome with a population of kids who don't have Down syndrome? Again there might appear to be a problem which isn't really a growth problem at all. So this is the reason for so many growth charts out there, folks are just trying to find the right population of kids to compare individual children to. Since we have a lot of different populations of children out there, we want to make sure we're comparing your child to the correct one.

0:13:06.4

Now what's the deal with the World health Organization's growth chart? Well they're basically trying to make a one size fits all growth chart for all kids. Why does the American Academy of Pediatrics recommend using it, as well as the CDC? And what if your doctor's using a different one? The reason that this is kind of a one size fits all growth chart is the World Health Organization growth chart use relatively new data. So it takes into account current lifestyles and current diets. I think it was actually made around 2006 or so, and they're using ethnically diverse population. So it's not really biased toward a particular size of child. So should doctors be using these one size fits all growth charts for run of the mill kids? 

0:13:58.1

Now obviously there's going to be circumstances when another growth chart is clearly better, like a growth charts specifically for premature babies, or those for kids with Down syndrome. But in the absence of underlying circumstances, should doctors for the run of the mill kid follow the AAP and CDC's recommendation and use the most recent growth charts from the World Health Organization which have recent data and a diverse background population. The short answer is yes, we should however it's entertain some reasons why an individual doctor might be using an older chart. Number one would be electronic medical record. How easy is it to change out the growth chart depending on the software that you're using, so that could end up being an issue. Then you got to make decisions, do you make the switch for all patients and re-plot each child's pass growth? Maybe if you have computer software it'll do that for you which would be very nice but if you're still on paper charts, making a new growth chart with the new one and re-plotting everyone's growth is very staff intensive and may not be a practical thing.

0:15:08.6

Do you make the switch only with new born and then use two different charts until all the older patients using the older charts graduate from your office which may be a decade or two. So then you got to remember which of those growth charts that you're using. Do you make the switch only with kids at the extremes to see if there might still be a concern based on the newer data, what do you do? The right answer may differ from practice to practice and I think an individual doctor could well support whatever decision that they make. The final question and the most important one is, does this really matter? My personal opinion is probably not. For me, and I'm only speaking for myself. The most important part of the growth chart is a child's tend. Are they growing along a particular percentile? 

0:16:00.4

Whatever percentile that may be, I think really the shape of the growth chart is what's really more important because we will notice these growth charts have a certain shape to that curve. So kids, regardless of your ethnicity, regardless of your underlying medical conditions there is a form to a child's normal growth. And so, is the child's growth trend, does that look like it should look? Are they growing along a particular percentile, or they moving exponentially up or down. That is more important to me. What is the family pattern look like? What did moms growth was she really small and the sprout out up as a teenager or the other way around? Did she sprout fast, and then were they slow down and stop growing early? What's kind of the family pattern that's going to make a big difference on how you view this? And you're going to take into account their ethnicity and underlying medical conditions when you're looking at those percentiles.

0:17:02.6

So even though you may not be using a chart that's specifically looks at Down syndrome kids you know that this particular child has Down syndrome and they're going to look a little bit different percentile wise, but is there growth trend what you would expect it to be? See doctors aren't machines, our brain isn't like a computer where we just looking at one thing. A percentile on a growth chart is not viewed in isolation, we look at the whole picture. And we don't really need a state of the art fancy-dancy growth chart to do that. Your doctor may feel just fine with the growth chart he's using. So what's a parent to do? Well that's up to you and your comfort level. If this is a doctor you like, it's one you trust, it's one you feel makes sound decisions, then maybe you should trust these feelings regarding his growth chart of choice. On the other hand, if you don't really like your doctor, maybe your personalities don't quite mash, maybe you don't like his or her thoughts on a particular issue, then fine. Let the growth chart be the straw that broke the camel's back and find the doctor who uses the latest AAP and CDC approve growth chart.

0:18:04.4

So that's where I stand, yes in general pediatricians should follow the recommendations of the AAP. But there are times when that might not be practical. The question is, with regard to interpreting a growth chart, does your doctor reassure when reassurance is the right thing to do, and does he or she go looking for problems when there's a good chance a growth problem actually exist. That's what you want in a good doctor and I'm not sure the growth chart he or she uses is the right barometer to test that. So hope that helps Lorrie, thank you for the question, it really was a good one. The next question as it turns out also comes from Lorie. You know I usually limit questions to one per listener per episode, but this is another good one and I thought everyone could benefit from hearing the answer and hearing it as soon as I could get it out there immediately rather than waiting for the next listener show because i think this is an important one. 

0:19:00.1

So again Lorie in Elmira, New York says, "Hi Dr. Mike, I really appreciate the information you share on PediaCast. I was particularly interested in the information that you shared previously about botulism and homemade baby food because I would like to make food for my baby. In investigating how to do this i recently came across an article at the MAYO clinic website that indicated that one should not try to make baby food from vegetables like carrots, beets, squash, and spinach because they may be extremely high in nitrates and cause health problems for the child. I look for other articles about this and became quite confused, some claim that nitrates are easily process by children over the age of six months which is the recommended age to start solid foods. Others however said that nitrates in homemade baby food are a problem because you can't screen for them. Commercial baby food is screened therefore jarred food from the store probably has a lot less nitrates in it. I would be interested in hearing your take on this, thank you again for all the good work you do with PediaCast." 
0:20:00.5

Thank you for another good question Lorie. Let's talk nitrates in baby food. First off, what's the problem? Why are nitrates potentially harmful, and at what age do they stop being harmful? Well the presence of nitrates causes hemoglobin by way of the chemical reaction, and hemoglobin as you may recall from high school biology is a component of red blood cells and the job of hemoglobin is to carry oxygen to cells and the release the oxygen so that the tissues of the body can use it. It basically takes oxygen from the lungs and delivers it to the tissues. So the presence of the nitrates by way of chemical reaction causes hemoglobin to turn into a compound called methemoglobin. So again hemoglobin carries oxygen from the lungs and delivers it to tissues. Methemoglobin also carries oxygen, but the oxygen bonds very tightly to methemoglobin. 

0:21:01.4

So methemoglobin does not give up the oxygen to the tissues, they just hangs on to it and the tissues need the oxygen to work properly. Now if we only have a small amount of conversion from hemoglobin to methemoglobin. So let's say less than one percent, the tissues are still getting enough oxygen. But once we hit levels higher than one percent we begin to have a condition called methemoglobinemia. So methemoglobin, anemia means it's in the blood so we have more methemoglobin in the blood inside red blood cells, more and more of that rather than hemoglobin. Now the symptoms of methemoglobinemia depend on how many nitrates are around, and how much hemoglobin is converted. So as an increasing amount of tissues are starved of oxygen we first see slight discoloration of the skin pale, to gray, to blue a condition known as cyanosis then we start to see trouble breathing as the body tries to take in more oxygen.

0:22:04.7

And then as we starve tissues of oxygen we're going to see heart problems, seizures, coma, and eventually death. So this is a pretty serious condition, I mean your body needs oxygen to function and to live. Now if it's caught early we can intervene. There is medication available that converts methemoglobin back to hemoglobin and we have other strategies for increasing oxygen delivery to the tissues. So why is this a particular problem for babies? As it turns out enzymes exist inside red blood cells that convert methemoglobin back to hemoglobin. So there's a protective mechanism in place, however infants especially those younger than six months of age have fewer of these enzymes available so it's easy for the protective mechanism to be over run if too many nitrates are ingested. 

0:23:00.6

I also want to point out there's some disease processes that result in a diminished amount of these protective enzymes during a child's entire lifetime, not just during the first six months of life but they have a decreased capacity to fix the problem internally their whole life. So nitrate exposure even after the age of six months can still be an issue, example of this is a disease called G6PD deficiency. And in addition to this, too many nitrates in the diet can even over run if you have too many of them. Even if you have a normal protective mechanism in place, too many nitrates in anybody can still be an issue. It's just babies are going to be more sensitive to that, and people with diseases that affect this auto correcting are also going to be more sensitive. It's going to take less nitrates to create a problem for them. In addition to the diet there are other possible causes of methemoglobinemia including certain antibiotics can do it.

0:24:04.5

Certain local anesthetics including by the way the anesthetic in gum soothing products like Orajel and Anbesol so you have to be careful with those with infants. They can overdose on those and it can lead to methemoglobinemia. Let's focus on a baby food. Where do nitrates in baby food come from? Well primarily from fertilizer run off which means vegetables that are in, or in close contact with the ground are the primary concern. Things like carrots, beets, squash, spinach, and I'll add green beans to the list since the American Academy of Pediatrics warns about them as well. So the AAP, their official recommendation as of right now, today which were in June 2014, the AAP recommends not feeding homemade baby food which contains these high risk ingredients. Again carrots, beets, squash, spinach, green beans.

0:25:02.7

So you should not use homemade baby food with those ingredients in young infants. What do they mean by young infants? They use to say three months or younger but since the age of solid food introduction increase to six months they change the wording from infants younger than three months to young infants. Because they didn't want to give the impression that it's OK to feed solid foods to babies' younger than six months of age. And you know I think too, they want to be somewhat none specific in case of particular child has a problem and then you can come back and say, "Well the AAP said it was fine, OK now we've got to argue over what is the definition of a young infant." So in general babies over the age of six months, I wouldn't call them young infants anymore and knowing that the American Academy of Pediatrics used to say three months or younger, I think that for me if I'm looking at risk versus benefit that sort of thing.

0:26:04.1

For me in choosing for my child, I would say homemade baby food, even made of these high risk items should be OK after six months of age. As long as you wash the food well, you feed the food fresh, and you don't can the food because botulism is still a concern up until about 12 months of age. And actually in can food it can be a problem if it's longer than that if it's not done properly. Now does that mean there is no longer a risk of methemoglobinemia after six months of age? No, the risk is still there, but it's a low risk and our risk-benefit meter slides from risk outweighing benefit to benefit outweighing risk at about six months of age. But there is still a small risk, for instance what if your child has undiagnosed G6PD deficiency? It's unlikely because the condition is rare but it is possible. What if the food you are giving is extraordinarily high in nitrates? 

0:27:01.9

Again not likely but possible. By the way as it turns out the biggest risk of too much nitrate ingestion actually comes from infant formula made with well water. This is a risk even after the age of six months because babies can consume so many nitrates that they over run that protective mechanism that they have. Fertilizer run off can easily sip into ground water and contaminate wells, so if you have a well be sure to have a check for bacteria of course but have a check for nitrates as well. Safer to use bottled water or processed city water to wash vegetables and make formula. So thank you again for another excellent question Lorie, I hope that helps and please write back in any time. Next up we have Cynia in Portland, Oregon. Cynia says, "What is the effectiveness of surgery to relieve chronic sinus infections? My daughter suffers from repeated infections which trigger her asthma."

0:28:02.4

"We are now into the recommended time for a CT scan. Her dad is a doctor and concerned about surgery. He isn't sure what the literature has to say about the effectiveness of a surgical fix for whatever problem may present from the CT scan. We don't want to put a six year old under sedation for a scan if surgery doesn't have a reasonable chance of making her healthy. Thank you." Well thank you for the question Cynia. Let's talk about sinus infections. First off, they're difficult to diagnose, you can look inside the ears, you can listen to lungs but the sinuses are a bit trickier. We use to say, and this is actually before my time so I never said this. But like in the 60's and 70's people would say, "I still hear this myth today so we're not doing a very good job of busting this myth." But we use to say green drainage from the nose was a sign of a sinus infection. Once the drainage turns green, now it's a sinus infection instead of a viral upper respiratory infection. 

0:29:03.4

We now know that this is not a reliable sign and in fact even I was training 20 plus years ago we knew it because even then we were saying that this is not right. But like I say we still need to bust this myth. Viral upper respiratory infections can also cause copious green drainage. OK so then we said, well if symptoms are lasting longer, then let's say 10 days or so then the viral upper respiratory tract infection has turned into a bacterial sinus infection. The problem with that is some viruses can last longer than 7 to 10 days. You can have overlapping infections with different viruses that easily last two weeks or more, and allergic rhinitis can last months and it can also cause similar symptoms including some green drainage.

0:29:58.1

Now usually it's not going to be as thick a purulent, really green like there's puss in it kind of drainage, it's going to be more clear but what one person's definition of its green to another person may be a little bit different. So allergic rhinitis can also still be contributing in here. The other thing that we have sort of making the problem of diagnosing sinus infection difficult to do. As parents you say, "Well the last time that my child had these symptoms, my doctor prescribed an antibiotic and my child got better." So it must mean it was a bacterial sinus infection or else they wouldn't have improved after we started the antibiotic, that's when we hear a lot. But did your child really get better because the antibiotic did something, or by the time you finally went in to see the doctor and was prescribe the antibiotic and took it for two or three days, did the immune system finally win the battle and kill the virus? In other words if you hadn't started the antibiotic would your child have improved around that time anyway.

0:31:00.4

These are age old questions asked by pediatricians and parents everywhere. Now just as much as we don't want to over diagnose sinus infections and over prescribe antibiotics at the same time we also don't want to under diagnose sinus infections for kids who really have them. So sometimes it does become necessary to rely on imaging to tell us if one is really present. Now that doesn't mean that every kid who we think might have a sinus infection needs a CAT scan to figure out if there really is one there or not. I'm just saying sometimes we do need to rely on that especially if an individual kid we keep calling it a sinus infection but we're not sure if that's what it really is, do we want to keep giving antibiotics. So at some point it does become necessary to rely on imaging to see if this is really what's going on. So what are our options? Well plain x-rays aren't that great at diagnosing sinus infections in kids. You need really need something that allows you to look inside the sinus cavity.

0:31:58.9

CAT scan as it turns out do a great job but they do result in radiation exposure and in some cases sedation is needed for younger patients. Although if you use a pediatric facility, you're likely to have a limited CT scan, so not one that does the entire brain. With less radiation exposure and CT scans done in pediatric facilities are less likely to require sedation even for the youngest of children. So if have a six year old who needs sedation for a CT scan, that kind of comes into question are you sure they really need sedation for that? Can you find some way to keep a six year old still while you're doing the scan? I guess if they're really highly anxious kid, maybe they have autism and they have really bad stranger phobia. There may be certain circumstance where a six year old might have to be sedated for CT scan but that's the exemption not the rule. 

0:32:58.8

Now with MRI you get a nice picture of the inside of the sinuses and there's no radiation exposure but the cost is higher, the wait time might be longer and young kids will likely require sedation even in pediatric facilities because you're inside along tunnel with clanging noises and it's a little scarier than a CT scan is. Ultrasound sure would be nice, no radiation, unlikely to need sedation but we aren't there yet. Ultrasound is not an established method of visualizing the sinuses on a routine basis yet. But there are some studies looking into it but again it's not really available for routine use at this time. So there's our dilemma and Cynia your family are caught between a shell in a hard place, what should they do? 

0:34:05.5

What most of you know I can't answer that because we don't practice medicine here on PediaCast, we don't tell individual families what to do. But i can say this, If I trust my child's doctor I would keep trusting my child's doctor, and if my doctor says it's time for a CT scan of the sinuses, that the benefit of the scan outweighs the risk that's what I would do for my child. I'd make sure it's done in the pediatric facility, one that's going to limit the CT radiation to the sinuses and one that's going to do the exam in a way that's going to make a six year old comfortable and hopefully not need sedation. And if my doctor said I should see an ENT specialist because of the results of the scan or because of her current clinical diagnosis of sinus infection, I would make sure my child saw a pediatric ear, nose and throat specialist and i want my child to see a pediatric allergist as well. And if my child had frequent occurrences of other bacterial infections, things like pneumonia, urinary tract infections, ear infections, skin infections, meningitis and or blood infections.

0:35:06.2

If I also dealt with any of these things especially on a recurrent basis, then I might also want someone to look into my child's immune system to make sure it's working properly. An allergist who's also an immunologist could do that as could a pediatric infectious disease specialist. So at the end of the day there're really are lots of options and directions you could go and that's why the best advice I can give is to follow the advice of the doctor you trust, the one who is partnering with you in real time, not in a podcast to look out for your child's best medical interest. What about sinus surgery, well that depends on the CT scan results, it also depends on your child's past medical history, the presence or absence and treatment outcomes or environmental allergies, the results of a possible immune system workup, the advice of a pediatric ear, nose, and throat doctor. So again lots to consider sinus surgery may play a role but only if the root cause can be solved by surgery and you've looked at other options and rule them out. 

0:36:05.4

In determining those things may take a bigger workup and looking at the big picture to make a decision and my best advice again is to partner with the real time pediatric doctor, one you trust and make sure any specialist you see are pediatrics specialist. They're the ones who'll be in the best position to help you decide what to do for your particular child. So hope that helps Cynia and as always thank you for the question. Alright let's move on to Jane in Guelph, Ontario. Jane says, "Hi Dr. Mike I have a 10 day old new born who's born with one centimeter diameter round lump on the outside right upper calf. It doesn't seem too mobile but there is no discoloration, pain or movement restriction." 

0:37:02.7

My pediatrician ordered an ultrasound and an x-ray just wondering if I should limit diagnostics to an ultrasound first and then if no information proceed with an x-ray. I am concerned with the side effects of x-ray particularly if it's something malignant. Could an x-ray denature cells further to cause a real problem? Thank you, sincerely a concerned mother." Well thank you for the question Jane, I always appreciate it. So what about a one centimeter diameter round lump on a newborn's lower leg overlying the calf? Lots of possibilities, the most common of which would likely be diagnosed by ultrasound. Things that come to mind and this is not meant to be an exhaustive list, hemangioma which is comprised of a collection of blood vessels under the skin. Usually these go away on their own over a long period of time but they still need to be watched. A skin cyst is possible. Ski infection is less likely since your child was born with the lump but an ultrasound would pick up a cellulitis, or an abscess. 

0:38:04.2

Malignant tumor in a new born on a leg would be less likely but certainly you want to know if that's going on or not. And is the bump something connected to the bone especially if it's a hard bump, you'd want to know that. I agree with you, the ultrasound is a good first step, the x-ray is less likely to be helpful in this situation just given the likelihood of our different possibilities. But if the ultrasound doesn't produce a diagnosis then I think x-ray, a plain film would be reasonable next step and then if that doesn't tell you what it is then a CAT scan or MRI may also be a helpful in the evaluation of this leg bump in a new born. I'm really not too worried about radiation exposure of a plain film, just a regular x-ray on the leg. Abdominal CT scans and head CT scans are the biggest concern as far as large amounts of radiation exposure is concerned. 

0:39:05.3

If the bump is a bone tumor which is highly unlikely given your description but not impossible, then an x-ray would provide more information than the ultrasound. And you could make the case that leading a bone tumor grow unchecked is much more risky than radiation exposure from a plain film of the leg. So again we're talking about benefit versus risk as always ask your regular doctor, it's a pediatrician in this case to explain his reasoning behind each test and to go through the risk versus benefit of each one. For me there's really no risk in the ultrasound, there's a very small risk in a plain film and probably the benefit is going to outweigh any risk. And really for a leg one time CT scan is probably not going to be an issue either. It's more important that you figure out what this is and so you know what to do for it.

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so for me if I'm presented with a leg bump in a new born, I do think it's perfectly reasonable to evaluate it with the ultrasound first, then an x-ray second as you propose but I certainly would not fault a doctor for ordering both of them at the same time. On the other hand a good clinician maybe able to make a diagnosis without getting an ultrasound or an x-ray at all just given clinical exam. I'm not saying these tests are even required. But they do sound reasonable with little risk involved in my opinion. But as always say you need a doctor who can do a hands on physical examination, you can't make a diagnosis or decide which test to get or in what order by means of a podcast. I can say the workup sounds reasonable which it does but the opinion of the doctor seeing your child, that opinion will always tramp mine. So I hope that helps Jane, and as always thank you for the question. Next up we have Ashley in West Virginia. Ashley says, "Hi Dr. Mike I love your show. We are a big fans of board games and we have a game night every week.

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"We learned about some of our favorite games from your show namely Ticket to Ride and Settlers of Catan. I'm wondering if you and your family received any new games for Christmas, or if you have any newer recommendations for board games that you love. We recently bought and really enjoy Forbidden Island. Family members work together as a team to try and save ourselves from drowning when our island is gradually sinking. It's very fun, I would love to hear some of your favorites. Thank you so much for all you do, Ashley." Well thank you for writing in Ashley. So Forbidden Island, that sounds intriguing. I definitely need to look it up. I haven't talked about games, our family games, our game night on the show here for quite some time. For my newer listeners, our family is absolutely a fan of the old fashion game night. My wife and my son, and myself play games frequently and my daughter joins us when she's home from college. She and her college friends play board games often when she's off at school. 

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At our house we host the occasional big party style game night every now and then where we invite loads of family and friends and we have table set up all over the house. And we really find playing games more enjoyable than gathering around the television every evening although we sometimes do that too. Games are great because you can still talk to one another, you can use your brain, you can compete, we just find it time well spent as a family. This is something that's really near and dear to my heart and if it's not something that's really been on your family's radar, think about giving it a try. Ours started with Hi Ho Cherry-o when my kids were little and they have a great story about my daughter being a sore loser and basically throwing her little bucket of cherries all over and stopping off to her room because she lost. You do have to be a little careful with Hi Ho Cherry-o because the pieces can be chokeable size so you have to definitely be playing that with your kids and monitoring.

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My son loved Mouse Trap and we graduated up to Monopoly and all its various forms, life, clue, all the standards. And we've tried and loved many of the newer titles, things like Killer Bunnies, which is pretty interesting game. Settlers of Catan, Ticket to Ride as Ashley mentioned. Back in 2011 and 2012 I used to routinely ask guests o this program about their favorite games at the end of each interview, and truth be told we added a number of games to our family's collection through those recommendations. I really ought to start doing that again, not sure why I stopped really. I think it was because I was starting to get repeats o games but i really ought to start asking that again because we did get some great recommendations that way. So Forbidden Island, definitely I need to check that one out, thank you for the tip on that Ashley. So new games in our house, we did get several for Christmas and the newer ones have actually been card games rather than board games. 

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So it seems like we're kind of in a rot with cards rather than board games at present but it always circles back around. Deer in the Headlights has become a new family favorite. Pretty easy rules, not a ton of strategy which is good sometimes. Fairly fast phase game play and you can easily talk, and joke, and laugh, and tell stories, or talk about your day as you play. Squarrels is another one, kind of a cross between squirrel and quarrel and that adequately describes the game, it's a fun one. Basically you collect nuts and it is a card game but you have to pay close attention to this game. There's a bit more strategy, it's really fast phased ad it can get a little physical because you got to reach in and like slap the deck kind of thing. It doesn't really promote a ton of conversation because you really have to be paying attention, but definitely fun and worth a try.

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Five crowns is not a new game for us but it is a fun card game with a twist. My wife and I love playing that one together. We'll take a deck to Panera or Starbucks and play away. Of course that always brings people over to the table, what are you playing, so sometimes you can get game ideas by eating out. My son played Five Crowns at a summer camp and actually got it from me for Christmas a couple of years ago. It's had a lot of game play, in fact we actually need to get a new deck soon. So Five Crowns is another good one. And then Farkle is a great dice game that we break out from time to time. So those have been the hottest ones in our house most recently. Deer in the Headlights, Squarrels, Five Crowns, ad Farkle, we still love Settlers of Catan, my son's not so much of a fan but we get them to play, and Ticket to Ride think we all love, and the Killer Bunnies and all the add-ons that go along with that is a hoot although it can get a little confusing pretty fast.

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Not a great one for little kids, and now Forbidden Island, you have to check that one out. And I need to start asking my guest about games again that's always good for a new recommendations. So there you go Ashley, thank you for reminding all of us about family game night. Definitely a great alternative to setting in a same room and staring at a screen all evening. Start them young, lots of great games out there for little kids and you build a tradition and memories that last a lifetime. Alright that wraps up our round of listener questions for this week. Don't forget, if you have a question for me, if you have topic idea, or want to direct me toward a journal article, or new stories please do so. It's easy to get in touch, just head over to pediacast.org and click on the contact link and ask away.

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Alright we're going to take a quick break and I will be back with a final word on baby gate safety, that's coming your way right after this.

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Dr. Mike: Alright we are back with a final word o baby gate safety. If you're a parent, chances are you have used or will use a baby gate at some point. Baby gates are designed to help protect young kids from stairs and other dangers around the home. If you use these in your home, take note. A new study from researchers in the Center for Injury Research and Policy at Nationwide Children's Hospital has found gates can lead to injury if used incorrectly. 

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The study, published in the May-June print issue of Academic Pediatrics, is the first nationally representative study to examine injuries associated with these gates. From 1990 through 2010, emergency departments in the United States treated more than 37,000 children younger than 7 years of age for baby gate-related injuries. That is an average of 1,794 per year, or about five injured children per day. More than 60 percent of the children injured were younger than 2, and they were most often injured by falls down stairs after a gate collapsed or when it was left open, leading to soft tissue injuries like sprains and strains and traumatic brain injuries. Children aged 2-6-years-old were most often injured by contact with the gate itself after climbing on it, which can lead to cuts. Dr. Lara McKenzie co-author of the study and a principal investigator in the Center for Injury Research and Policy at Nationwide Children's Hospital says, "Baby gates are essential safety devices for parents and caregivers, and they should continue to be used….

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"It is important, however, to make sure you are using a gate that meets the voluntary safety standards and is the right type of gate for where you are planning to use it…. Dr. McKenzie recommends parents think of pressure-mounted gates as products that should only be used as room dividers or at the bottom of stairs because those kinds of gates are not designed to withstand much force and will not prevent a fall down stairs. For the top of the stairs, only gates that have hardware, which needs to be screwed into the wall or railing, will be strong enough to prevent a child from falling down the stairs. The fact that the rate of injury associated with this safety product nearly quadrupled during the time period covered by the study, going from 3.9 per 100,000 children in 1990 to 12.5 per 100,000 children in 2010, shows more can be done to prevent these types of injuries. Study researchers recommended a combination of efforts to educate families on correct ways to use gates and changes in gate design to reduce these types of injuries.

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I got to pause here for a minute. When we talked about the numbers of injuries associated with baby gates quadrupling over the study period, you also have to ask, is the use of baby gates increasing over the study periods. So in other words if more parents are using baby gates which are a good thing then probably more kids are going to be getting hurt on or around the baby gates because more parents are using them. SO we want to make sure that we're using the gates correctly ad I imagine that if you looked at a falls in down stairs in houses where there was no bay gate, you'd find that there were more of those at the beginning of the study period. Again this is my own hypothesis, it's not based on tested material but it makes sense. Dr. McKenzie, who is also a faculty member at The Ohio State University College of Medicine, said that while voluntary standards issued by the American Society for Testing and Materials have helped decrease baby gate hazards, making the standards mandatory and expanding which aspects of the gates are covered by the standards would improve the safety of these types of products.

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She adds, "Current standards are voluntary and concentrate on things like the size of the openings, height, vertical strength, bottom spacing, configuration of the uppermost edge and label warnings. While these are important, making them mandatory and adding standards to address designs that limit children's ability to climb gates, prevent gates from collapsing, and provide better cushion to children if they fall on the gate would prevent many of the injuries we saw in our study…. Parents and caregivers can also follow these tips to help reduce injury. Use hardware-mounted baby gates at the top of stairways. Gates that only press against walls, called pressure-mounted gates, are not secure enough to prevent falls. Install gates in homes with children between 6 months and 2 years of age.

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If possible, remove the gates when the child turns 2, or when the child has learned to open the gate or climb over it. And finally if removing a gate is not possible because of other children in the home, use a gate without notches or gaps that could be used for climbing. So baby gates, use them but in the right circumstance, pay attention to which gate you chose ad how it's installed, and most importantly continue to supervise children when they're around or interacting with the gate. And that's my final word. I want to thank all of you for taking time out of your day to make PediaCast a part of it. I really do appreciate the loyalty of my listeners and as I mentioned earlier in the program, really appreciate those of you who share the program with your family, friends and co-workers, I really do appreciate that. That does wrap up our time together today. PediaCast is a production of Nationwide Children's Hospital. Don't forget PediaCast and our single topic, short format program PediaBytes are both available on iHeart Radio Talk which you'll find on the web at iheart.com and iHeart radio app for mobile devices.

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Our show archive which includes over 250 programs as well as our show notes, transcriptions, terms of use and contact page are available at our landing site which is pediacast.org. We're also on iTunes under the kids and family section of their podcast directory. You'll find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Podbay, and most other podcasting apps for iPhone and android. We're also on Facebook, twitter, Google Plus, ad Pinterest and we really appreciate you connecting with us there and sharing, re-tweeting, re-penning our posts so you can tell your own online audience about our little show. And more of you have been doing that or if really noticed quite an increase in the number of you who are sharing our post and favoriting our tweets, that sort of thing and that goes a long way to helping to spread the word about the show. We also appreciate you talking us up with your family, friends, neighbors, and co-workers.

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Anyone with kids, anyone who takes care of children and as always be sure to tell your child's doctor about the program. So the next time you're in for a sick office visit, or well child check, or ADHD re-check just say, "Hey Doc, we've come across this podcast, it's evidence based, comes from one of the largest children hospitals in the country. It's called PediaCast, check it out and share that with your other patients." And posters are available under the resources tab at pediacast.org. It's not about getting more listeners and getting more downloads, and the number's truly this is about getting good information that parents can trust into the hands of more parents so that we can make a difference in the quality of parenting and medical care that we give to our kids, that's what it's all about. Again thank you to all of you for listening and staying with me. Until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids. So long everybody.

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

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what it's all about.  Again thank you to all of you for listening and staying with me.  Until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids.  So long everybody.

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[Music]

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

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