Listener Question Marathon part 1 – PediaCast 334

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Description

  • PediaCast ends the year with a bang with questions from listeners throughout the United States and around the world! Join us for part 1 of our end-of-the-year Listener Question Marathon. Topics include pregnancy spacing, baby sleep, sleeping on tummy, toddler biting, peanut allergies, toddler talking, potty training, toddler anesthesia, and tonsils & snoring. It’s the first chapter of the BIG show that YOU made… Be sure to tune-in!

Topics

  • Pregnancy Spacing
  • Baby Sleep
  • Sleeping on Tummy
  • Toddler Biting
  • Peanut Allergies
  • Toddler Talking
  • Potty Training
  • Toddler Anesthesia
  • Tonsils & Snoring

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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, on Columbus, Ohio.

It is Episode 334 for December 11th, 2015. We’re calling this one, “Listener Question Marathon Part 1”. I want to welcome everyone to the program.

So it was supposed to be our last show of 2015, and I’ll explain why it was supposed to be in just a couple of minutes. But never fear, we will be back after the holidays and the New Year with lots more shows in 2016. In fact, we’ll be back to a fairly weekly schedule again at that point.

We have 13 planned CME shows. Those are our Continuing Medical Education shows over at PediaCastCME.org. Those are podcasts for pediatric providers and worth a listen to them because we provide free Category 1 Continuing Medical Education Credit. I mentioned it in this program because I know we have a lot of pediatric providers in this audience as well. So I just want to let you know, we’re going to continue the CME program in 2016 with 13 planned shows.

So we’re excited to continue and expand upon that project, but we also have about 30 plain, and yes, you did hear me right, 30 plain PediaCast episodes — that’s this program — planned for 2016. So we’ll have lots more news parents can use, answers to listener questions and interviews with pediatric and parenting experts. So it’s going to be a great time. We have a lots of content planned for you.

But we have a fabulous show or shows — I’ll get to it in a minute — to wrap up 2015. It’s Listener Question show, and in fact, it’s a Listener Question marathon. I did this a couple of years ago, and it was quite popular. We had tons of downloads for it.

0:02:29

Basically, I collected a bunch of the questions that I didn’t get to that year because you guys always do such a great job sending me so many questions we just can’t get to all of them. I picked a bunch of them that we didn’t get to and packaged them into one big end-of-the-year episode. My plan this time when I went through them, there were so many good ones. I had a hard time saying no.

And so, when I picked which ones we were going to answer, the final number ended up being 14. And I knew, yes, that’s right 14 questions. But I have to answer your questions. That’s why I’m here. And the ones I didn’t get to but they are important questions, they’re good questions. So I had a hard time in choosing, and I didn’t want to wait until 2016. I just wanted to start fresh with a new question bank in January.

So, my plan was to do all 14 questions in one episode. I actually recorded it. I recorded the whole show, all the segments, and it ended up being an hour and a half. I could have redone things and shortened them. I could have taken some questions out, and I thought, “You know what, let ‘s not do that.” Let’s just make this into two different episodes instead.

So we’re releasing one today on Friday, December 11th, which we usually don’t put out a show on Fridays. Usually, it’s Wednesdays is when our new shows come out. And so, the plan was not to have a show at all this week and have this big long end of the year show next week. I didn’t want to push them to Christmas or New Year, so as it turns out, you’re going to get Part 1 today, and then next Wednesday, we’ll release Part 2.

0:04:09

So with the 14 questions, as you can imagine, it took me a lot of time to prepare these two shows with so many questions and just to research the answers. Even if they’re answers I think that I know off the top of my head, I still like to look things up, make sure it’s still the latest evidence-based information that I’m giving you, so that you can trust it. So it took a lot of time, and that’s one of the reasons. I also took a vacation week the first week of December, but that’s one of the reasons that we’ve been gone a couple of weeks.

But you guys are worth it. I really appreciate your support throughout the year. In 2015, we had a record in terms of the number of downloads in a 12-month period with listeners throughout the United States and around the world. In fact, our questions between these two episodes come from California, Colorado, Texas, Missouri, Rhode Island, New York, Minnesota, Indiana, Arizona, Saskatchewan, Canada, Israel, France and, of course, Ohio. So we really do have a global community here at PediaCast. When you strip away the borders, we all have the same goal in mind. We love our kids and we want them to grow up as healthy as possible.

So yeah, it’s a lot of work answering so many questions but I love doing it because they are questions that are important to you. And you can always be sure that if you have a specific question in mind, there’s lots more parents who have the same questions. And so, if we can get those answers out in the context of a podcast, we can reach lots of people and hopefully answer questions for everyone.

Because it took so much work, I consider it my end-of-the-year holiday gift for you, between Part 1 and Part 2. Regardless of what you’re celebrating, it’s a great time of the year for families. In our home, we celebrate Christmas. We have our tree up. Most of our baking is done, presents bought and wrapped — well, placed in gift bags for the most part — but that’s a story for another day.

In fact, I think I probably shared this during past holiday seasons. We started giving our Christmas presents to one another in gift bags rather than wrapping them up a few years ago. The reason why in a recent blogpost, at 700Childrens.org, and I’ll tell you about that in a minute. But anyway, we’re getting most of our Christmas stuff done, excitement is in the air, as we love each other as family and give with our hearts. Terrific family time.

0:06:32

Over the years, I really come to consider you, the PediaCast audience, really part of my family as well. I appreciate your support throughout the year, your words of encouragement, your sharing the show with others and with your own pediatric providers, and your participation in the form of questions.

So that’s what we’re going to do here at the end of the year, answer your questions and in a very big way on a huge wide ranging variety of topics including, and here’s the rundown — I’m not going to do too much explaining at this point because we have so much to cover — but the topics that you wanted me to talk about in this episode include pregnancy spacing, infant sleep, tummy time, toddler biting, peanut allergies, toddler speech, potty training, toddlers and anesthesia, and tonsils and snoring.

Then, when we come back next Wednesday, we’re going to talk about rubber field turf and cancer. The sports fields, they have the little rubber bits in them. Could exposure to the rubber be a concern for cancer ? We’re going to talk about that. The answer may surprise you. There’s still kind of a question mark on it. So we’re going to go through and explore and talk about risks and benefits, that sort of thing.

And then, we’re going to talk about vegan diets, homeschooling, constipation and stuttering, egg allergy and vaccines. That’s all coming up next week.

So you guys asked a lot of good questions and when you think about that whole list, it’s a lot of what I would call bread-and-butter pediatric topics, just topics that really do come up a lot in the primary care office. We’ll spend some time talking through those things. Really excited about it.

0:08:14

So lots of questions coming today, more coming next week. Now, I do want to point out as we got through all of these questions, it may spark another question in your mind. As I’m answering something, you may think of a piece of the puzzle that I didn’t address. It might spark in your mind a different question or you may have a question in mind right now.

My point is that even we’re answering — well, maybe I should say, especially — since we are answering 14 questions during these episode, that it’s going to be important to refill the question bank. So if you do have a question or one of our answers sparks another question in your mind, let me know. It’s easy to get in touch. Just head over to PediaCast.org and click on the Contact link. You can also call the voiceline at 347-404-KIDS. That’s 347-404-K-I-D-S, which is 5437 if you end up needing the digits.

Before I forget, and I mentioned this earlier, and here I was going to forget. Someone would probably say, “Wait, you told us you’re going to let us know about the blogpost you wrote.” Yeah, it’s over at 700 Childrens.org. It’s on family traditions during the holidays, regardless of what it is that you celebrate. As I said, in our house, we celebrate Christmas. You may be celebrating something different, but it’s just a good time of the year for family traditions regardless of what it is that you’re celebrating in your home.

So we talked a little bit in the blogpost about how to cultivate traditions within your family. Really, it makes great memories. And then, those traditions can carry on as you do what your parents and your grandparents before you did, and your kids to some degree will also probably continue those traditions on with their kids. So, it’s really a way that we connect the past with the future. If you want to hear more of my thoughts on that. We’re kind of a goofy family as it is, so some of our traditions may be a little bit atypical and non-traditional. That’s OK. They’re our traditions. They’re great for us.

And so, I talked about those in the blog post. You can find that in 700Childrens.org. An easy way to find it too is just to go to PediaCast.org and click on the Show Notes page for this episode, 334. I’ll have a link to it there, so you can find it pretty easily.

0:10:31

All right, before we get going, I do 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 have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at PediaCast.org.

All right, let’s take a quick break and I will be back. We’ll get started with those 14 questions that you guys asked, right after this.

[Music]

Dr. Mike Patrick: All right, we are back. Paul in Lafayette, California, says, “Hi, Dr. Mike. Love your podcast. I’d been telling my friends to tune in. I listened to your podcast about pregnancy spacing, Episode 293, I believe, and I have a follow-up question to that.

“My son will be one year old in March, and my wife and I plan to get pregnant again in a few months. That means our kids will be spaced about 22 to 24 months apart. Unfortunately, we don’t have the luxury of waiting until our son is 18 months old before we get pregnant again. Since we can’t wait, do you have any suggestions for anything we can do to ensure a healthy pregnancy in baby? Are there any precautions we should take?

“My wife lost a lot of blood when giving birth to our first child. Does that mean we need to even more conscious about iron levels? Also, no matter how many iron rich foods she eats, it sure seems hard to meet the daily requirement for iron. Should she take an iron supplement in addition to her prenatal supplements which contain no iron?

“I realize these questions might be more suited for an OB-Gyn but I respect your input and just wanted to ensure the health of our future family member. Regards from a concerned husband and daddy — Paul.”

0:12:43

Well, thanks for the follow-up question, Paul. So we did talk about ideal pregnancy spacing back in Episode 293, and I’ll put a link to that episode in the Show Notes for this episode, 334, so you can find it easily. Based on evidence, researchers recommend waiting at least 18 months following delivery before you get pregnant again, although 24 months is actually your best bet. And if you like more details on the evidence such as why and what are the risks, be sure to check out Episode 293.

Now, Paul’s question is, what if we can’t wait that long? For others, it may be we tried to wait that long but it didn’t work. Another pregnancy occurred, and it’s not been the full 18 to 24 months between delivery and conception. So what now?

Well, keep in mind that an increased risk of problems with the pregnancy or problems with the baby does not mean that it’s absolutely going to happen. So there’ll be many, many, many pregnancies and babies who end just fine even if spacing is less than ideal. Likewise, there will be many many pregnancies and babies who run into problems even when ideal spacing is observed and followed, right? I mean, best laid plans and all.

Now, one of the reasons for waiting does concern replenishing nutrients because pregnancy is tough on a mom. Lots of nutrients get used up and they have to be replaced which is best on slowly over time. Now, you can speed things up to a degree but you can also overdo it and get in to toxic ranges of nutrients that build up too fast in the blood, which can bring about trouble of its own.

0:14:28

So your best bet as you mentioned, Paul, is to talk to your OB-Gyn. Start taking those prenatal vitamins as soon as possible. They do contain iron by the way, along with other important nutrients for pregnant moms and developing babies, such as folic acid, riboflavin, iodine, zinc, calcium, vitamin D, lots of others. Your doctor may add an additional iron supplement on top of the prenatal vitamin if there’s evidence of anemia or low numbers of red blood cells, which it sounds like could be an issue for your wife, Paul. But, if she’s not anemic then, it may not be necessary. So again, check with your doctor.

It’s also important to eat well all the food groups. Drink plenty of water. Get enough sleep. Do a little exercise. Don’t drink alcohol or use recreational drugs. Don’t smoke. You get the picture. In other words, take care of yourself.

Now, there are other risks other than the nutritional issue, such as placental abruption and placenta previa. These are things that are also more likely with less spacing between pregnancies. You have less control over these things. They either are or they are not going to happen, but good and frequent prenatal care from your OB-Gyn should catch problems early rather than late. So the complications can be identified and dealt with in a timely manner.

Folks out there scratching their heads, placental abruption, that doesn’t sound good. Or placenta previa, what in the world is that? If you really want to know or you want to hear more regarding evidence recommendations and risks as they relate to pregnancy spacing, be sure to check out PediaCast 293. Again, I’ll put a link in the Show Notes for this episode, 334, over at PediaCast.org.

0:16:14

All right, next up is Michelle, very close to home. Hilliard, Ohio. She says, “I was referred to PediaCast by your wife in Hilliard Moms in the Know, and I love browsing through your show.” Yes, Michelle, my wife is a terrific advocate of the program, both online and offline. As it turns out, she’s a nurse in our urgent care system here at Nationwide Children’s. So if you have a nurse dispensing discharge directions in the Urgent Care, and she mentions, “Hey, you can learn more about this or that on PediaCast,” it’s probably my wife.

[Laughter]

Dr. Mike Patrick: Michelle goes on. She says, “I’m a first time mom of a 12-day-old baby girl. My question is about her sleep patterns and when to start a going-to-bed routine. My husband and I have been taking turns, staying up with her during feedings and trying to get her to sleep so the other could rest a few hours and do the next shift. I don’t want to fall into a habit of staying up late holding her or letting her sleep in a bouncer.

“Tonight, we put her in a crib with the baby monitor and had been checking on her and soothing her back to sleep as she wakes. We also have a Pack ‘n Play with the section that rises that she could sleep on. We just want to do what’s right and healthy. I’d be so grateful for any advice.”

Thanks for the questions, Michelle. First, you want to make sure that you listen to our episode on safe sleep that was not done too long ago. It’s Episode 302, 302. You’ll also find Episode 241 helpful. That’s our Parenting 101: Baby Basics episode.

Another good one that covers baby sleep issues is PediaCast 284. And another, which includes an interview with the sleep expert is back at PediaCast 270. I’ll put links of all of these episodes in the Show Notes for this one, 334, over at PediaCast.org so you can find them easily.

0:18:08

So here’s the bottom line — during the first month or two, you don’t really want to worry about sleep patterns or habits. Just let your baby sleeps when she wants to sleep. Let her be awake when she wants to be awake. Let her eat when she wants to eat. There’ll be a time for establishing patterns and dealing with problems later on after the first couple of months.

What do you do at that point? Check out the shows I mentioned because they are chockfull of helpful hints. In the meantime, make sure your baby is sleeping in a safe environment — on her back, on a firm surface with nothing in the crib with her. No pillows, no blankets, no teddy bears, nothing.

Don’t let her sleep in a bouncer or car seat unless she’s travelling in the car. Otherwise, car seats and always bouncy seats are never safe places for babies to sleep. More on that in PediaCast 320.

You know, while I’m going through this, we do have lots of great resources on baby sleep — Episodes 241, 270, 284, 302, 320. Again, I’ll put links to all of those episodes in the Show Notes, Michelle.

They’ll give you something to listen to during those middle of the night feedings. Hopefully, they won’t put you to sleep, and maybe just maybe, my voice will sooth your baby back to dreamtime after the meal. You’ll never know. I’ve had people write in regarding that very thing.

Thanks for listening, Michelle. Thanks for writing in and welcome to our PediaCast community.

Jim in Boulder, Colorado says, “Hi, Dr. Mike. My almost six-month-old son can roll from his back to his stomach but not the other way around. With my first son, I was told to always put him on his back, but if he rolled over in the middle of the night, it was OK to leave him on the stomach. However, my first son could roll to his back before he could roll to his stomach.

“Does the same rule allow the infant to stay on the stomach if they roll over apply if the infant can’t roll to their back? Up till this point, it hasn’t been a problem for me because… screamed the minute he roll over. However, he’s getting more comfortable on his stomach and I just found him sleeping on his stomach.

0:20:09

“For current standards, we don’t have anything in his crib other than the firm mattress with the sheet on it. As an aside, he’s getting at least half an hour of tummy time when he first wakes up and again in the afternoon. All his other movements seem normal. He has even started scooting backwards. I have seen him roll from his stomach to his back a couple of times. Actually, four times, but it’s very, very rare.

“As always, thanks for your wonderful podcast – Jim.”

Well, thanks for the question, Jim. It’s a good one. And I’m sure many out there are wondering the same thing. If I put my baby to bed on his back and he rolls over on to his stomach, do I have to flip him back over? Well, it depends, the answer for most will be no. You don’t have to flip them back over. But you do still need to place them to bed on their back, and you still need to follow all of the safe sleep rules which Jim was kind enough to mention.

Now, as a reminder, we also have a show on safe baby sleep, Episode 302, which you should check out if you aren’t sure about all of the rules.

The fact here is that if your baby has enough strength and coordination to flip from back to front, then they’re likely to have the strength and coordination necessary to correct their positioning if they ran into a breathing problem. It’s not a guarantee but it’s likely.

It sounds to me, Jim, it’s not issue of your baby being able to roll from front to back. He can do it. You’ve seen him do it four times, so he can do it. The question is, does he want to do it? It sounds like he prefers being on his belly, and every time you put him on his back, he’s just going to roll over to his belly again over and over because that’s where he wants to be, and you’re going to have some very long nights with neither of you getting any sleep.

I would still initially place him to bed on his back on a firm surface, with nothing else on the bed — no pillows, no blankets or stuff animals, nothing. But if he flips on his own at six months, it is OK to leave him. Is it absolutely 100% positively safe? No, but is anything?

0:22:09

In your particular situation, Jim, paying attention to all the other safety factors, sounds like you’re doing the right thing. Now, at the beginning of the discussion, I said, the answer for most will be no. You don’t have to flip them back over. If it’s the first time or two that your baby has flipped, and your baby is less than six months of age, then it’s not a bad idea to put him or her back on their back after you noticed the flip from back to front, just in case it was a fluke.

You know, yes, it happened but they’re less than six months of age and it’s probably not going to happen again. In this case, I probably would flip them back over on to their back. But if they keep doing it over and over, then it’s not a fluke. The strength and coordination is there on a regular basis and that’s when it’s time to leave well enough alone.

Still, you want to put them on their back in appropriate clothing on a firm surface, no pillow, no blankets, no teddy bears, nothing, and let them flip to their little heart’s content because once they get going, you’re unlikely to really stop them anyway.

Hope all that makes sense and is helpful. As always, thanks for listening Jim. Really appreciate the question.

Next up, we have Amanda in Texas. “Hi, Dr. Mike. Could you please do a podcast on toddler biting? My son is one year old. He attends daycare and has been bitten. All of a sudden, he has started getting really frustrated and biting his own arm when I try to change his diaper. I quickly diverted his attention and gave him a book, and he calms down. He’s hitting all of his milestones correctly. Should I be concerned? Should I call my pediatrician? I’ve looked online and it seems other parents have concern in this area as well. Also, how do I deal with this? Thank you.”

Well, thanks for the questions, Amanda. You guys are full of good ones today.

You really have two issues here — your child biting himself and the daycare where he was bitten. Now, with regard to your son biting himself, it does sound to me like you’re already doing the right thing. If diverting his attention seems to work, keep doing it. That’s easy enough.

0:24:11

Now, unless your child starts biting himself to get more of a reward, then you’re doing the right thing. But if he’s biting himself and you’re rewarding him, and the biting has become a tool to get you to do something in particular, at that point, the biting becomes a problem. And the best way to deal with that — which I realize is not your particular problem, Amanda, but there are those out there who know exactly what I’m talking about, so I just want to expand our conversation a bit for them — if your child’s biting himself as a manipulation tool, I would ignore it. You know, don’t pay attention to it at all. Don’t give him what he wants. Just flat out ignore it. It’s the rare child who actually hurt themselves more than once on purpose. So they quickly learn that it hurts and “I didn’t get my way” and they move on to other strategies.

On the other hand, if your child does repeatedly hurt him or herself to get their way — and these are most likely going to be older children that we’re talking about — then you do want your family know because you and your family may need more sophisticated help in solving that problem.

Again, in your case Amanda, diversion is great as long as it’s working and I think the behavior will extinguish itself in time, especially if you don’t focus on it too much.

Now, your other issue, Amanda, is the daycare center. I can see your child getting bitten by another child once. It’s going to happen from time to time, but if it happens recurrently, I would want to know more about why this is happening. Is there adequate supervision? Is there enough staff? Is there a root problem in the center that needs to be addressed?

By the way, another resource that folks may find useful related to all of this, I wrote a blogpost at 700Childrens.org around this time last year called “Why Your Toddler Is Biting and Hitting?” Some of you might find that helpful and I’ll put a link to it in the Show Notes for this episode, 334, over at PediaCast.org.

0:26:08

Again, thanks for the question, Amanda. Always appreciate it.

We have Alexandra in St. Louis, Missouri. She says, “Hi, Dr. Mike. I have a question about food allergies. My daughter is eight months old and has been thoroughly enjoying the addition of real food now instead of her strict diet of breast milk.

“At the suggestion of our pediatrician, we skipped baby cereals and went straight to puree of fruits and vegetables. I’ve been sticking to foods that are on the least allergenic list and avoid the highly allergenic foods. As we approach her first birthday, I am getting very nervous about when and how to introduce nuts. As a teacher, I have seen a number of students with nut allergies dramatically increase over the last several years. Is there a suspected reason for this?

“I believe the AAP recommends waiting until babies have reached one year old to feed them nuts but I know some cultures give their very young babies nuts and have lower instances of nut allergies. I’ve also heard the longer you wait to introduce nuts, the higher the chance of allergies.

“What’s a parent to do? As the oldest of eight children and an early childhood teacher, I am super laid back about my first born, but this matter still worries me. Thanks so much – Alexandra.

“P.S. We are huge Ohio State fans here in Saint Louise. Go Buckeyes. Our daughter was even born a couple of years before the National Championship game, and we named her Elliot. Coincidentally, the Buckeye’s MVP’s last name.”

Thanks for the questions, Alexandra. It’s comforting to know there are Buckeye fans in Saint Louise. We’re everywhere. You can’t get away from Buckeye fans. Win or lose, even with the loss and not being in the National Championship picture this way, we are excited about playing Notre Dame in the Fiesta Ball coming up on New Year’s Day. We’re a loyal sort even when things don’t go our way because as the old song goes, “We’ll win the game or know the reason why.” That pretty much sums the Buckeyes up and Buckeye fans.

0:28:05

OK, back to the question. Peanut allergies — with regard to advice, there are two types of families out there that we have to think about. Those with a family history of peanut allergies and those without a family history of food allergies. If you have a family history and especially if there’s a family history of peanut allergies, you want to let your pediatrician know about this early and have your baby seen by a pediatric allergist and you can do this as early as four months of age. Your allergist can skin test your baby and come up with a plan based on the test.

Now, if there is no family history of peanut allergy… In other words, your infant is low risk. Although I would say that if you are in a family and there’s a lot of food allergies in the family, maybe not specific peanut allergies but there is a prevalence of food allergies in general, I still might get the advice of a pediatric allergies before you embark on anything. But if there’s no family history of peanut allergy, not much family history of food allergy — in other words, your infant is low risk and they’ve never had a rash associating with eating nut products or any other foods — then you can begin introducing peanut butter anytime between 6 and 12 months of age.

Now, if your child develops a rash after eating peanut products, you want to stop giving it and call your doctor right away. Also, babies and young children can choke on peanuts, so don’t give them whole nuts and don’t use chunky peanut butter. Just stick with the smooth stuff.

For more information on this, I do have a couple of nice resources for you. First, there’s a blogpost at 700 Children’s written by Dr. David Stukus. He’s an allergist here at Nationwide Children’s. It’s called “Prevention of Peanut Allergies: Are We Ready to Take the LEAP?” The other is an article from the American Academy of Pediatrics over at HealthyChildren.org. That one written by Dr. Claire McCarthy at Boston Children’s, and it’s called “Peanut Allergies: What You Should Know About the Latest Research”.

0:30:03

I’ll put links to both of those in the Show Notes for this episode, 334, over at PediaCast.org. And, as always, Alexandra, if you have additional questions or further concerns as it relates to peanuts and food allergies, be sure to talk to your child’s doctor. And, of course, thanks for the question. I really appreciate you writing in.

[Music]

Dr. Mike Patrick: We have a question from Andrea in Rhode Island, “Hi, Dr. Mike. You’ve been by my side for the past two and a half years. Through every cough, fever and screen time discussion, I had fallen back on your podcast and used them as my first line of information to talk to my doctor or my husband so I know what the right questions are and understand what’s happening.

“My question to you is this, how much verbal capacity should a two-year-old boy have. My son has had constant chronic ear infections since he was four months old. He had tubes in his ears at approximately 15 months old and he’s now 23 months old. He has about 10 to 15 words, but most of his communication is pointing and whining until we guess what he wants. His cognition is excellent. He understands everything from “Please sit down” to “Go give your cup to daddy” and “Put the car in your toy box.”

“At approximately 18 months, we went to audiologist and had him tested. His hearing was very close to 100% with no scarring from the ear infections. He has no hearing problems at all, miraculously. I know I can have early intervention evaluate him if I ask, but I’m wondering if that is jumping the gun.

“If 10 to 15words at two years old isn’t alarming, what is the best and fastest way to beef up your child’s ability to speak? I currently read at him five out of seven nights a week. I’m reading The Lion, the Witch and the Wardrobe out loud in the same room he’s occupying. I talk to him all the time, throughout potty changes, while he’s playing, while we’re in the car, et cetera. Now that I think of it, could I perhaps be talking too much and not giving him a chance to talk? I’ll stop here and let you have a chance to answer. Thanks for all your help and your constant companionship — Andrea.”

0:32:33

Thanks for the vote confidence, Andrea, and for listening all the time and contributing to the show with your questions. I really do appreciate it. You’re really making my job pretty easy here because you’ve done and are doing all the things I would do. Your son’s hearing is normal. That’s always an important thing to check when speeches are concerned. His receptive language is great. In other words, he understand what you are saying, even complex things. You’re interacting with him verbally in many ways and often through reading and talking and playing together. All good things and exactly what I would do.

If you have early intervention services available, it certainly wouldn’t hurt to get their two cents. They may say, “Yeah, you’re doing everything you can. Keep at it. Sort of like I’m doing. But they might come up with some additional ideas. They probably will. Ideas that will make you say, “Hey, why didn’t I think of that?” But will they have the magic bullet? Will they really be able to help your child gain more language in a shorter period of time? Probably not, but you’ll never know. And if you get some new hints and some added reassurance from them that you’re doing everything you can, then it’s probably worth using that resource.

By the way, my son, he’s 18 years old now. He communicates just fine, with lots of words. Perfectly normal speech and cognition. He was in the same boat your son is in. He had tons of ear infections but normal hearing. His receptive language was excellent, but at two, he was still grunting and pointing at things more often than speaking. Now, he did have an older sister who started reciting nursery rhymes when she was 18 months old. She talked plenty for him on lots of occasions, and still does from time to time.

0:34:16

The bottom line, Andrea, what your experiencing is still within the range of normal., The important thing at this point is to check hearing, which you’ve done. Make sure receptive language is developing. Check with pediatrician that all other developmental indicators are on track and provide lots of verbal stimulation, which early intervention may be able to help with or at least reassure you that you’re doing all that you can. Then, you wait. That’s what’s left.

So thanks again, Andrea, for the question and for making my job easy by including all the pertinent details and what you’ve been doing up to this point. Really sounds like you’re doing the right thing. Really appreciate it.

We have a question from Lori in Elmira, New York, “Hi, Dr. Mike. I’ve listened with interest to your podcast about potty training. A friend of mine posted an article from a fellow physician about his concerns in regards to early potty training, which is potty training before the age of three. He believes that early potty training leads to problems with constipation and urinary issues. As I have a 22-month-old, and we’re currently working on potty training, I’d appreciate hearing your feedback on this article.”

Then, she provides a link, which I’ll provide in the Show Notes for this episode, 334, over at PediaCast.org. She also says, “Thanks for your amazing podcast – Lori.”

Well, thanks for sending the article my way, Lori. Again, I’ll include link to it, PediaCast.org Show Notes, Episode 334.

The article is called “The Dangers of Potty Training Too Early”. So what’s my take? Overall, it’s a good article from a reliable source. The author is an associate professor of pediatric urology at Wake Forest University, so he knows a thing or two about dysfunctional voiding.

His point is this, when young children to hold their pee and poop, they often hold it too long because they get busy playing and they don’t want to stop to go void. They don’t want to disappoint mom and dad by going in their pants so they hold it for long periods of time. This leads to constipation and urinary tract infections, and there are several mechanisms by which this happens, but it does happen and there’s plenty of evidence to support that.

0:36:25

But keep in mind, it’s not the early potty training itself that leads to these problems. It’s the child’s tendency to hold their pee and poop for hours when they should be going more frequently. I will add this too — specialist tend to have a bit of an anecdotal skew on their specialty. He sees children with urinary problems and constipation all day long to the tune of 100 kids a week. Those are his numbers. And most of them were potty trained early and chronically hold their bowels and bladders. That’s why they ended up seeing him.

But, that doesn’t mean this is the experience of every toddler potty trained before the age of three. For every 100 that he sees in his clinic, how many early potty trainers have no problem at all? Thousands, tens of thousands, hundreds of thousands, I don’t know, and he doesn’t know either because to find out, you’d have to follow large groups of kids prospectively. Have one group potty trained early and then another group potty trained late and then follow the kids forward to see what percent of each group had clinically significant problems.

That study, at least according to the article had not been done. It would be an interesting study but we don’t have that sort of data. On the other hand, he does make some valid points.

So what’s a parent to do? Well, your best bet really is to go with the flow literally in the case. Don’t push it. Sorry, I can’t help it, folks. Just let nature takes its course.

[Laughter]

Dr. Mike Patrick: If your situation allows, just let potty training happen naturally. It will happen. Don’t rush it along. Unless you have to.

0:38:03

The author decries that daycares require potty training without acknowledging why they require it. If you have to change diapers for three- or four-year-olds, how many more hands do you need on deck? What does that do to the cost of daycare, and what about the parents who must work? They need child care and the only thing available requires that your three year old be potty-trained. What then?

We have to help parents in the world in which they live, not an imaginary perfect world. So I think the take home here is this — if you can take it slow, take it slow. That’s the best practice. But if you can’t take it slow, if you must potty train early, then it’s equally important that you make your child take frequent breaks, like every couple of hours. Interrupt what they’re doing. They must go sit in the potty and try, period. They must interrupt what they’re doing.

And this has to be the rule not only at home but at daycare as well, and you may have to ask them to document how often your child tries. Maybe they’ll institute that rolling mandatory potty break for all the kids. That would be something.

Share the article with them, share this podcast, so they understand why holding pee and poop really does lead to constipation and urinary tract infection. But it really is the holding that’s the problem, not the early training in and out of itself.

So that’s my two cents, Lori. Overall, it’s a good article with a good caveat. Thanks for sending it my way, really do appreciate it.

All right, next up we have Kelly in Saint Paul, Minnesota, “Dear Dr. Mike, thank you for the PediaCast podcast. I appreciate that you combine scientific evidence with your own experiences to help inform parents’ risk-benefit calculations.

“You discussed blocked tear ducts on PediaCast 75, and similar to the parent who asked a question on that show, I have a 18-month-old child with a blocked tear duct. I understand that it’s likely that our child will need surgery to remedy this. I’ve also read about potential long-term effects from general anesthesia in young children, for example, from the American Academy of Pediatrics and The New York Times.”

She includes a couple of links to articles. I’ll share those with all of you in the Show Notes for this episode, 334, over at PediaCast.org.

She goes on to say, “Can you describe the state of the debate about general anesthesia in pediatrics? Thanks again for making this podcast available and for the opportunity to ask questions. Sincerely, Kelly.”

0:40:22

Thanks for bringing these articles and the subject to our attention, Kelly. This controversy stems from a study that was done a few years ago that looked at just over 5,000 children, and 350 of them underwent procedures with general anesthesia before the age of two.

And here’s what they found, 36.6% of those having multiple procedures, so more than one with general anesthesia went on to develop learning disorders, and 23.6% of those having one procedure went on to develop a learning disorder. Now, compare that with 21.3% of those who had no exposure to general anesthesia going on to have a learning disorder.

So, if you had multiple surgeries before age two, you had a 37% chance of having a learning disorder later in life. If you had one surgery, you had a 24% chance, and if you had no surgeries, you had about a 21% chance of developing a learning disorder. In other words, the difference between no surgeries and one surgery was about a 3% increase in risk. But the difference between no surgeries and more than one surgery was about a 16% increase in risk.

And they did control for comorbidities, meaning the kids in the surgery group versus the non-surgery group had the same types of illnesses.

OK, so what do we make of this? Well, first, it’s a retrospective study. So the researchers looked at older kids, determined if they had a learning disorder or not, and then asked about history of exposure to general anesthesia. And this is a much quicker way of getting results compared to randomizing children at the beginning and then following them prospectively for several years. But it also inject some problems into the equation.

0:42:17

For example, expression of a given diseases isn’t always the same. Sometimes, it’s worst than others. Sometimes it requires surgery. Sometimes, it doesn’t. Ear infections, for example. Sometimes babies need air tubes and sometimes they don’t. So having a history of ear infections doesn’t look the same from one kid to another.

Now, if you’re at the front end with kids that have ear infection sitting in front of you, you can make some inclusion and exclusion criteria. In other words, you can say, OK, the kid with the history of 10 documented ear infections in the past 12 months who have exhausted all reasonable antibiotic approaches, who has dense pus behind the ear drums and can’t hear and has a fever again, maybe he’s not the best candidate to randomize to the no-surgery group. He needs tubes regardless of how you want to spend your risk-versus-benefit meter.

Now, retrospectively — so you’re at the other end looking backward, this kind of details get missed. So, you include this child in your study, and you compare him with the child who had one-year infection that got better with amoxicillin, who never had another ear infection and never needed surgery. Well, now, child number one on the other hand went on to need a second set of ear tubes before age two and a third set before kindergarten, and he does go on to develop a learning disorder while the child with one ear infection does not.

So are we really comparing apples with apples here? Or is one of these kids really an orange? Did exposure to three episodes of general anesthesia really caused the learning disorder? Or, was it that an unrecognized and poorly intervened hearing problem that stemmed from chronic ear fluid and ear drum scarring? Or, was that same child around cigarette smoke which contributed to the chronic ear infections? Maybe that smoking mom was a teenager and there was no early intervention involved. Maybe the frequent antibiotics played a role. That’s as much of a possibility as the anesthesia at this point.

0:44:25

So, these studies aren’t the greatest and definitely not the sort of study to bet the bank on. On the other hand, maybe general anesthesia really does contribute to learning disorders. It’s possible. We just don’t know at this point.

But here’s the thing. There are plenty of other reasons to avoid unnecessary general anesthesia in surgery. Things like bleeding, infection, sepsis, aspiration pneumonia, pneumothorax, allergic reactions, malignant hypothermia, cardiac arrest and death. We shouldn’t take surgery and general anesthesia lightly in any medical specialty including pediatrics. But if the benefits of the surgery already outweigh the known risks which happen infrequently, but do happen, then is adding the risk of a possible learning disorder way down the road based on a study that has lot of room for air, is that going to saw your risk-benefit meter in the other direction? That depends.
It depends on the reason for the surgery. It depends on your own risk-benefit tolerance for your family’s risk-benefit tolerance. Which is why we have to make each decision on its own, thinking about your family’s specific and unique set of circumstances. And, the best person to help you do that is your child’s regular doctor.

Hope that helps, Kelly. Bottom line, you have a kid with a blocked tear duct. If it’s really causing an issue and by 18 months, the ophthalmologist feels that it’s unlikely that it’s going to resolve on its own and your child has lots of drainage and they’re getting infections a lot, you have to weigh that with the risk which are minimal. Certainly, we don’t have a study out there that absolutely shows that general anesthesia causes learning disorders.
So you have to take all that into account. If it were my child in the situation that I just described, who has recurrent eye infections, lots of drainage, 18 months old, the ophthalmologist is telling me this probably not going to get better on its own, for me and my family, I think that my risk-benefit meter would swing in the direction of “It’s a benefit. Do the surgery. Get this thing fixed.” Knowing that there some risks, but they’re low.

0:46:32

That’s my opinion, if it were my kid in the situation I just described. Your milage may differ and by all means, Kelly, be sure to talk to your pediatrician about it.

All right, next up we have Nicole in Prince Albert, Saskatchewan in Canada. She says, “Hi, Dr. Mike, I have a question regarding children and snoring. My son and daughter both have had adenoids removed. One at age one, and the other at age five, due to snoring and sleep apnea. They’re both on Singulair for allergies and Prevacid for reflex. Both have started snoring again.

“Question number one, can adenoid re-swell or grow back? I was told by the pulmonologist that children should never snore, so I took them to the ENT. Both of their tonsils are very enlarged. Both unlike the pulmonologist, he said snoring is normal. He left the decision of surgery to remove tonsils in mine and my husband’s hands. After going through the possible risks, I was left questioning what to do.

“So my second question — is snoring normal in children? I know you base your answers on research. Thank you for that, and keep up the great podcast. I listen to every show — Nicole in Prince Albert, Saskatchewan, Canada.”

I hope I’m saying that right. I think that’s probably the American way of saying Saskatchewan. So, Nicole, basically, you want me to be the tie-breaker here. You want a third opinion. Thanks for the question and for the vote of confidence. I really do appreciate that.

So is snoring normal? What is the tie-breaker response? I would say let your pediatrician be the real tie-breaker. But I will tell you what I think. Snoring is a noise. Now, here’s the question — is the underlying thing that’s causing the noise, whether that be in large tonsils or adenoids that weren’t completely removed and have become large again, or a flappy airway due to some genetic issue or some other problem, the thing that’s causing the noise, is that thing causing any other problem or is it just causing a noise?

0:48:35

If it’s just causing a noise and you’re doing surgery, and the only reason for doing it is to get rid of the noise and something goes wrong during and after the surgery, then the first thing you’re going to ask yourself is why in the world did we take that risk just to get rid of the noise?

Now, on the other hand, if the underlying thing is causing sleep apnea — so obstruction leads to brief oxygen desaturation because your child momentarily stops breathing, which causes your child to stir and reposition to make their airway open again, and that’s happening many times per night and then your child is sleepy during the day and may be having difficulty concentrating, or they’re doing poorly in school — well, now, we have more than a noise problem. We have a life problem.

Then, if something goes wrong which is very, very unlikely, but it’s possible, at least then we can say, well, we had a legitimate reason to take those tonsils out because quality of life was truly suffering because of them. It wasn’t just a noise.

That’s why I think doing a sleep study is helpful. Is snoring normal? No, it’s not exactly normal but the real question is this, is the snoring associated with another problem? Or, is it just noise and big tonsils and nothing else? That’s the question your family is dealing with. So you have the pulmonologist saying it’s not normal and the ENT is saying it is normal. Honestly, I might have thought those opinions would have been reversed but that’s the problem with my own bias.

Bottom line, let your pediatrician be your tie-breaker. See what he or she has to say about the situation. I will add this, another sleep study may well help you decide what to do. My two cents, anyway.

0:50:20

Thanks for the question, Nicole and for listening all the way from Prince Albert, Saskatchewan, Canada. I really do appreciate it and I appreciate that you listen to every episode. Nicole, when we switch over past the New Year and we go to our new format with the three segments per episode, since you’ve been a long time listener, shoot me an email after a couple of episodes and just let me know what you think about that new format. Really appreciate that.

[Music]

Dr. Mike Patrick: All right, we are back with just enough time to say goodbye and thank all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.

Well, it’s not goodbye yet for the holidays. We are going to take a break during the last couple of weeks of December, but we will be back next week on Wednesday. I believe that’s December 16th, 2015 with Part 2 of our Listener Question marathon. So stay tuned for that. It won’t be too much longer, just a few days.

That is all the time we have today though. PediaCast is a production of Nationwide Children’s Hospital.

Don’t forget, you can find PediaCast in all sorts of places. We’re in iTunes and most podcasting apps for iPhone and Android, including the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher and TuneIn.

0:52:00

We’re also on iHeart Radio, where we not only have this program, but also PediaBytes, B-Y-T-E-S. You’re going to search for all one word, PediaBytes. Those are shorter clips from this show, and you can weave them together with other content providers to make your own custom talk radio station.

And then, there’s the landing site, PediaCast.org, where you’ll find an archive featuring hundreds of past episodes, transcripts of each program, in case reading suits your taste, and a handy contact page to ask questions and suggest show topics.

We also have a voice line if you’d rather phone in your question or comment. Our number there is 347-404-KIDS. That’s 347-404-K-I-D-S or 5437, if you need the digits.

We’re also on Facebook, Twitter, Google+ and Pinterest with lots of great content you can share with your own online audience.

And, of course, we always appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids or those who take care of children, including your child’s healthcare provider. Next time you’re in for a sick office visit or a well-check up, a sports physical, a medicine re-check, whatever the occasion, just let them know you found an evidence-based pediatric podcast for moms and dads. We’ve been around for nearly a decade, lots of great content deep enough to be helpful, but in language parents can still understand.

And, while you have your providers’ ear, let them know we have a podcast for them as well, PediaCast CME, similar to this program. We do turn he science up a couple notches and offer free Category 1 CME Credit for listening. Shows and details are available at PediaCastCME.org.

Thanks again for stopping by, and until next time, this is Dr. Mike, saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[Music]

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

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