Listener Question Marathon – PediaCast 273
Join Dr Mike in the PediaCast Studio for our final installment of listener questions for 2013. Topics include antidepressants & pregnancy, newborn oral hygiene, circumcision, family doctors, international food safety, tuberculosis, potty training, mystery rash, speech problems, choking phobia, vitamins, and medical marijuana.
Antidepressants & Pregnancy
Newborn Oral Hygiene
International Food Safety
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Announce 1: This is PediaCast.
Announce 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. We're in Columbus, Ohio it is episode 273 for November 20th, 2013 and I'm calling this one Listener Question Marathon. I want to welcome everyone to the show, I do have a super duper big one lined up for you today.
It is our last Answers to Listener Questions episode of the year and as the name implies I have a marathon of questions lined up for you, why? Well it's really simple, I care about my listeners, I ask for questions this year, you responded and I don't want any disappointed listeners out there. As it turns out I tallied them up and I previously answered 59 of your questions this year. I'm going to add 11 to that total today, that's going to bring the 2013 total to 70 questions answered, plus our News Parents Can Use editions, and our research round up's, and all of our interviews with pediatric experts. So we're going out with a bang, it's not the last show of the year but it is our last listener show. I do want to make a quick point here, answering 11 questions, this is not going to be a three hour episode, I save some questions that have quicker answers and we're going to run through those today.
Next year, let's see 70 questions answered in 2013, maybe I'll try to break that in to 2014 but of course I'll need your help to do that, start thinking about your pediatric or parenting related questions and we'll try to get yours answered next year. I want to mention this is our last show leading up to a two week break, next week is Thanks Giving and then I'm going to take a vacation week in early December. I'll be back in December for two shows, one on celiac disease and gluten sensitivity, and then a final News Parents Can Use edition before we take a two week Christmas and New Year break. That's the plan taking us to the end of this year and up to 2014, and then in 2014 we'll see if we can break that 70 questions answered number. Definitely get your questions, start thinking about them and get them in.
What are we talking about today? Anti-depressants and pregnancy, should you take anti-depressants while you're pregnant? Are they safe? Will they harm the baby? What's the harm of not taking them? It's a question on many a mothers mind and we'll tackle it. New born oral hygiene, one last listener circumcision question, it's a quickie and then we're going to put them out to the rest for a good long while, I promise. We've talked circumcisions plenty in 2013, might have to take a break form it in 2014. Family doctors, what's the difference between a family doctor and a pediatrician, and which one should you pick? My answer might surprise you. International food safety, if you're an American mother living in a foreign country and you have concerns about the local food, what should you do? And the same mom has a question about tuberculosis as well, we'll cover that too. Potty training, here's a crazy number, this is going to make the tenth episode of PediaCast in which I've addressed potty training in one way or another.
Pee and Poo and where it is deposited? Is obviously important to my listeners. I'll not only ask the question but I'll also provide the episode numbers for the other nine instances of PediaCast toilet talk so you can listen to your heart's content if your child happens to be in that stage of life. Mystery rash, I'm just going to leave it at that, you just have to stay tuned to find out what's up with the mystery rash. Speech therapy, we talked about this extensively in the previous episodes and I'll answer quick question on speech problems today and then point to the direction of a much longer answer from this past summer. Chocking phobia, a school age child suddenly develops an eversion to swallowing and prefers a mostly liquid diet, what could cause such a thing and is it serous?
And then vitamins, what's my opinion on daily vitamin supplements? And then finally, medical marijuana, and again that's pretty self-explanatory, stay tuned for some comments on medical marijuana. Nothing like making the final two questions of the year the most difficult and controversial of the bunch, vitamins and marijuana, so lots coming your way. Couple quick reminders, it is November the holiday is just around the corner and as you know every gift matters during the holidays. Here at Nationwide Children's Hospital we rely on your gifts and our effort to advance ground breaking pediatric research and to provide the best pediatric care on the face of the planet, please consider helping us as we help kids from across the United States and around the world. Many of you gave to Nationwide Children's last year, thanks again for that we really do appreciate your trust and your support.
This year as the gift giving season approaches I would simply ask that you consider including Nationwide Children's in your tax deductible, charitable giving, it's an easy thing to do, just head over to the show notes for this episode 273 and pediacast.org and click on the Every Gift Matters link, you can also call us toll free at 1855-885-5437 and I'll include that phone number in the show notes as well. Also PediaCast is on iHeart Radio Talk. Look, I can't make it any easier for you to listen, simply go to iheart.com or download the iHeart Radio app for mobile devices, search for PediaCast for our full length programs, and PediaBytes for our single topic short format programs, that's it then listen. When you tell your friends and neighbors about the show also tell them about how easy it is to connect, just go to iHeart Radio and search for PediaCast and PediaBytes. Finally a reminder, PediaCast is your show and I'm going to need lots of questions for 2014 so we can try to answer more than 70 of them, just head over to pediacast.org and click on the contact link and ask away.
Dr. Mike Patrick: We are back and first up is Shirley in Israel, Shirley says, "Hi Dr. Mike I took the anti-depressant Prozac during my pregnancy, my understanding from Israeli health officials was that doing so is pretty safe. I continued Prozac while breast feeding my baby although this lasted less than two weeks. My daughter is now 31 months old and is fine she speaks well and is smart and friendly. She's not potty trained yet but we have not pushed it because she doesn't seem ready. My concern began after I found an article on Pub Med called fetal exposure to anti-depressants and normal milestone development at six and 19 months of age." For those of you who are interested in seeing this article I will put a link to it in the show notes for this episode 273 over at pediacast.org. Shirley goes on to say, "just as the article reports my daughter was initially delayed in sitting and walking but now she's fine running and jumping the same as other kids her age."
"Here are my questions, is there similar research about this that you are aware of? Two, should I be looking for other delays, and is there anything I can do about it now? Thank you very much for providing such a valuable resource to the public, Shirley in Israel." Well thank you for the question Shirley. Prozac is an anti-depressant it's a selective serotonin re-uptake inhibitor or SSRI, that's the class of drug that Prozac belongs to. In addition to depression it's also used to treat anxiety and panic disorders, obsessive compulsive disorders, and eating disorders. This is a commonly used class of medications so I'm sure there's a lots of other parents out there or mothers to be wondering the same thing, is it safe to take during pregnancy? When we approach a drug and ask this question, is it safe during pregnancy or while breast feeding?
The first thing I do which is exactly what you did Shirley is to see what the folks who regulate medications have to say about it, and in your case you checked with Israeli health officials. In my part of the world I would check with the FDA which is the United States Food and Drug Administration. This agency is not going to look at just one study because one study, it's going to have a limited sample size. You're going to be talking about one region of the country, you can have issues when you're just looking at one study and then trying to apply that so we like to look at lots of different studies and that's what the FDA does over the year when they come out with their recommendations. They're going to look at the total amount of research on a particular drug, not just one or two studies and then based on that research or case reports they're going to assign a pregnancy category and then they're going to give some recommendations with breast feeding. And you can find out all this information on the FDA website at fda.gov.
When you do that, you look at Prozac, what is the FDA had to say? In terms of pregnancy they rate it a C, now what does that mean? Pregnancy category of C means that animal's studies have shown an adverse effect on the fetus so there is a concern, but there aren't enough adequate and well controlled studies in humans to say for certain if the drug is safe or not safe for the fetus. Therefore we have to take each situation on a case by case basis and ask if the potential benefit of using the drug in a specific pregnant woman is warranted in light of the potential risks, in other words we need to pull out our risk-benefit meter. What about breast feeding? Here the FDA does not recommend Prozac while breast feeding because a significant amount of the drug is known to be excreted in breast milk and the effect of this on the baby is unknown.
There aren't any studies out there where they intentionally gave a Prozac to a breast feeding mom and then look to see what effect it has on the baby. You know a lot of people aren't going to volunteer for that study so in this case the FDA uses case reports. They've only had two case reports of babies with high blood levels of Prozac because of exposure from breast milk. That doesn't mean that if moms take Prozac only two babies in the history of the world have high blood levels of Prozac, what this means is that they're aware of two cases where this was documented. In one of the case the baby had no symptoms at all, in the other case the baby had crying, sleep disturbances, vomiting, and watery stools, symptoms which may or may not have been related to the Prozac, we just don't know. That's where I would start, the FDA says, "Use Prozac cautiously during pregnancy and don't use it if you're breast feeding…, that's what my recommendations would be since these are experts who looked at multiple studies and are giving their recommendations.
Now what's up with this particular study that Shirley found on Pub Med? Does Prozac use result in developmental delay? Well this particular study did find an association but we don't know the character of that association. Did the Prozac cause developmental delay? Or did the mother pass a genetic problem to the baby, she's on Prozac for a reason, could the genetics of that underlying reason have been passed to the baby and show up as developmental delay? Maybe mom had developmental delay which is related neuro-developmentally to her current problem of depression and or anxiety and the baby is simply exhibiting the first stages of this genetic problem. Or perhaps mother's depression and or anxiety problem is not well controlled by her Prozac and she is providing a less than ideal developmental environment for the baby which results in developmental delay.
There're lots of possibilities here, the bottom line is each specific mother and her doctor need to talk through these issues and decide what the benefit versus risk looks like for any medication that's taken during pregnancy and while breast feeding. At the end of the day the answer that comes out of that discussion is likely going to be different from one family to another. One important thing after the fact is this, don't look back, in your case Shirley your child's doing fine, is developing normally, that's great. Should you watch for developmental delays and deal with them pro-actively if and when they arise? Yes absolutely but you should be doing that anyway, that's one of the reason all children have routine well child visits so we can catch these things and intervene early. Should you stay up all night worrying about the possibility of a developmental problem that hasn't happened yet? No, but if you are, maybe you can't help it which goes back to why you might have been taking Prozac in the first place.
I will offer this, let's hypothetical say the Prozac does cause a mild developmental delay you could then ask what would your child's development be like right now if you haven't been taking the Prozac? There's no way to know for sure but don't get yourself into thinking it would have been better, genetics would be the same, Prozac doesn't alter genes and the developmental environment both inside the womb and inside the home, those might have been worse if mom's underlying health condition had not been somewhat controlled with the medication. The grass may look better on the other side or with the other option but the green healthy grass you see in hind sight may very well be an optical illusion and that's why I say don't look back, just deal with what you have right now and do the best you can and always with the input of your physician during pregnancy and your child's physician after he or she is born.
I hope that helps Shirley and as always thank you for the question. Next up we have Joe in Great Falls, Montana, Joe says, "Hi Dr. Mike, I'm a father to a three month old baby and love your show. In the past episode you discussed parents cleaning pacifiers with their mouths while I'm not sold on adopting this practice. It does make me wonder about advice I received from my dentist, my dentist offered to prescribe a mouth wash for my wife and me to use before the baby was born to limit the bacteria the baby is exposed to. He also advised that grandparents and others not kiss our baby on the lips, this advice seems counter to some things you reported on exposing kid to healthy bacteria. I was wondering if you'll be able to clear up any of this information." Thanks for the question Joe. The episode Joe is referencing is PediaCast 255 which you can find at pediacast.org. Folks want to hear the pros and cons of parents licking their baby's pacifiers I encourage you to check that one out. I must admit in my 20 years of practicing pediatric medicine I have never heard the advice that parents should use a prescription mouth wash to protect their baby.
The oral cavity is full of bacteria, in every adult, in every child and fairly soon after birth in every baby and that's OK, the oral cavity is supposed to be full of bacteria. When it's not full of bacteria yeast and fungus has a tendency to grow because it's a warm, moist environment and fungus is all over the place and in babies we see this in the form of thrush, they got thrush easily because they don't yet have a ton of bacteria inside the oral cavity. We all share our mouth microbes, whether we like it or not and whether we use mouthwash or not. Mouthwash is not going to kill everything and that's why we see patterns of bacterial resistance in families and communities because we're all sharing this stuff. With regard to kissing a baby on the lips, your dentist may have something there, you can certainly pass viruses that way plus other than mom and dad who kisses a baby on the lips?
Maybe that's a cultural norm for your dentist or maybe in Montana but in my neck in the woods, here in Ohio we don't typically kiss babies on the lips. For heads and cheeks yes but lip kissing, that's a bit more intimate. I don't know there's probably a bunch of people out there like, "oh we kiss or baby on the lips." Stephanie in Indiana says, "Dr. Mike I feel like new born circumcision is really a hot topic today, I know that the AAP states that the benefits of circumcision outweigh the risk but there is still so much controversy about performing a none essential procedure on a child too young to consent. What are your thoughts if it's supposed to be up to parents to decide, how do we know we are making the best decision for our little boys, thank you."
Stephanie I'm going to make this quick, our communications must have cross paths because I have covered circumcisions pretty extensively in the recent past. Check out PediaCast 265 from this past September and for some thoughtful comments by a British mum tune in to PediaCast 269, that was from October 2013, and you can find both of those shows at pediacast.org and iTunes and on iHeart Radio Talk. I also wrote a fairly recent blog post on the topic To Serc Or Not To Serc? That is the question, and you can look for the link to that in the show notes for this episode 273 at pediacast.org. Next up Tiffany in Grants Pass, Oregon, "Hello Dr. Mike, a friend of mine is having a baby and she is choosing a family practice doctor instead of a pediatrician, I'm not quite sure what the difference is, Is there a reason you should pick a pediatrician for your new born as suppose to a family doctor or does it really matter? It got me thinking and I thought of you, looking forward to hearing your response."
Thank you for the question Tiffany, with any decision there are pros and cons to choosing a pediatrician versus a family doctor. With regard to training, pediatricians come out on top because we do a complete three year residency after four years of medical school during which time we spent a 100% of our time learning to take care of children and if pediatrician is a board certified they must pass difficult examination testing their knowledge. On the other hand family practice doctors after four years of medical school, they also complete a three year residency but they don't spend as much to that time learning about pediatric medicine because they also learn adult medicine, gynecology, geriatrics a little obstetrics, a little surgery to round things out so their pediatrics training is watered down compared to a pediatric residency an the exam that board certified family medicine doctors take, the pediatric portion is easier.
For many kids that amount of training that a family practice doctor has is absolutely adequate especially if your child is relatively healthy. On the other hand if your child has asthma, or allergies, or ADHD, or any other number of chronic illnesses, then a pediatrician is more likely to be able to handle those problems without getting a specialist involved. It may be whether you see a family practice doctor or a pediatrician that the symptoms are going to be severe or complex enough that you still need to see a specialist but a pediatrician is going to be able to handle some more complicated things on their own compared to the family practice doctor and they also have more experience in kids. When you're coming up with the differential diagnosis they may be able to have a more complete list and be able to narrow it down a little bit better because they've seen these things more in the past because they see more kids. On the third hand some family practice doctors have an interest in seeing kids and they may have sought out more pediatric opportunities in residency, attended more pediatric conferences and kept up with pediatric literature and they may do a fine job taking care of some kids with chronic problems.
On the forth hand, many pediatricians are hiring nurse practitioners to help staff their offices so if you choose a pediatrician over family practice doctor you have to ask who's going to see your child? Is it going to be the pediatrician or is it going to be a nurse practitioner? And here again experiences differ, some nurse practitioners have lots of experience but others don't, and you may have choice of a nurse practitioner who's a new grad versus a family practice doctor who sees lots of kids and so the family practice doctor's going to be more experienced than the nurse practitioner at pediatricians office. That's not necessarily true of all nurse practitioners but some of them it is going to be the case especially if they're new graduates. On the fifth and sixth hands of our monster we have to consider availability and convenience.
Small towns tend to have few if any pediatricians but many family doctors and it may be difficult to get an appointment with the lone pediatrician in town and the doctor who can't fit you into their schedule he or she isn't going to be much help to your family. With regard to convenience there is something to say about having one doctor for the entire family taking care of everyone from the crib to the grave. Family doctors become friends and more likely to be seen as a member of your family so that's to consider. As a pediatrician I should say hands down go with the pediatrician over the family practice doctor, they have more training, they see more kids, that's true. But in the real world, in your world when you consider all the factors important to your family you may end up with a different opinion and there's not a thing wrong with that. Let's move on to Ericka in Bangladesh, Ericka says, "Dear Dr. Mike I love the show and listen regularly."
As an American mother, as well as a public health professional, parenting two young children in Bangladesh, I really appreciate this resource. I wanted to follow up about the recent question regarding botulism and homemade baby food as I am just starting to explore new foods for my six month old. I was planning to make a variety of foods for him including carrots and potatoes as I did for my daughter who is now four. I normally appreciate your cautious approach but his time I'm wondering how real a concern is botulism when making homemade baby food? Are there reported cases of the illness from this source? I could find little online but did run across an FDA report from the Bad Bug Book stating "Honey is the one dietary reservoir of botulism spores definitively linked to infant botulism by both laboratory and epidemiological studies…. If you want to see the Bad Bug book from the FDA I will put a link to it in the show notes for episode 273 at pediacast.org.
Ericka goes on to say, "Normally I would air on the side of caution and purchase commercial baby food however American and British made baby food available for purchase in Bangladesh is shipped and stored at a very high temperature potentially impacting the safety and nutritional content. There are other concerns I have about my baby's diet, fresh fruits and vegetables available for purchase in Bangladesh have high levels of pesticides and preservative, you may have heard about the terrible case of insecticide poisoning among Indian school children. Well that is a different example, high amounts of chemicals in fresh produce is a problem here as well. On the plus side I am able to purchase some but not all types of frozen fruits and vegetables imported from the United States under relatively good conditions from the US commissary. Taking all these factors into account what would you recommend in terms of maximizing the safety and nutrition of my baby's diet, should I purchase the commercial baby foods for high risk items like potatoes and carrots even though I'm worried they were not shipped and stored under ideal conditions?"
"Will there be any difference between the baby food sold in glass jars versus the newer plastic containers? My baby loves apples, would it be better to make apple sauce from local apples with some risk of pesticides and other chemicals or purchase commercially available US made apple sauce which is not really formulated for babies? Any advice you have is much appreciated including general tips for handling baby food and feeding and if you have time to address the second issue I would appreciate some insight into the BCG vaccine for infants, tuberculosis is a reality in Bangladesh although not something my baby would necessarily be exposed to. The most common source of exposure is domestic help such as child minders so there's always that risk. I have received conflicting advice about this including the recommendation that we avoid the vaccine as the baby would then always have positive skin test which will be a problem when we live in the US later on. Thank you for your help, Ericka." Well thank you for writing in Ericka, let's tackle the botulism issue first and to honest you've already done all the work yourself on this one.
You've looked at the benefits and risks of several options and now you have some decisions to make and you should know by now that I'm all about helping you see the benefits and risks but you've got to make the decisions. I will provide a few additional comments for you but ultimately you got to look at the facts, make a decision and then don't look back unless of course new information presents itself. With regard to botulism and for those interested in hearing a complete discussion on homemade baby food and botulisms spores, check out PediaCast episode 258 at pediacast.org in iTunes and on iHeart Radio Talk. I do also provide some clarifications on botulism in a response to a listener question on PediaCast episode 263, 258 and 263 we cover infant botulism and homemade baby food. So why does honey often show up? Well it's because the jar of the material is still around the test when botulism symptoms start showing up.
Jars of other food are long gone by the time botulism is diagnosed, and since the source of botulism is not found in the majority of cases we have to assume the culprit was a food other than honey even though there's none left to test. The Bad Bug Book from the FDA which she reference, they understand this point, under the section associated foods the FDA says, "The types of foods involved in botulism vary according to food preservation and eating habits in different regions. Any food that is conducive to growth and toxin production and when process allows spore survival and is not subsequently inadequately heated before consumption can be associated with botulism. Almost any type of food that is not very acidic PH above 4.6 can support growth in toxin production by clostridium botulinum. Botulism toxin has been demonstrated in a considerable variety of foods such as canned corn, peppers, green beans, soups, beats, asparagus, mushrooms, ripe olives, spinach, tuna fish, chicken, chicken livers, liver pate, lunchmeats, ham, sausage, stuffed eggplant, lobster, and smoked and salted fish."
So again I will be very cautious about canning your own food, fresh seems best to me. With regard to insecticides and chemicals you definitely want to wash produce well before serving. Are there any organic options available in your area? Do you know anyone who grows their own produce locally? I'll make mention of the apple sauce as well, there's no significant difference between commercially available, processed, US made apple sauce marketed to adults versus that marketed to infants, the biggest difference is going to be the label graphics and the container size. Adult apple sauce is fine for babies as long as it is appropriately processed, I also say this, what solutions have other Americans or other foreigners, British citizens for example in your social circle used, and how has the health of their children faired?
It's not scientific but it sure helps to know what others in your situation are doing and how that's worked out for them, and you also have your four year old, you know what you did for her, she's doing great doing the same thing now is probably going to be good. There's some risk, there's always risks but if fared well for you before and it likely will again. With regard to the BCG vaccine, a little background on that. The BCG vaccine is a vaccine for tuberculosis, it fakes the body into thinking you've been exposed to the full blown organism, the full strength organism that causes TB, so you make anti-bodies and then if the real deal tuberculosis causing organism comes your way the anti-bodies attack it and hopefully prevent you from getting tuberculosis. This is a good thing right? I mean shouldn't everybody get this? Well if you live some place where tuberculosis is rampant, then yes it's a great thing, but if you live some place where tuberculosis is relatively rare, some place where you rely on the PPD's skin test as a screening tool for tuberculosis, then it's not so great, why?
Because once you've had the BCG vaccine and you make anti-bodies against tuberculosis then your PPD will always be positive not because you have the disease necessarily but because you have anti bodies against tuberculosis floating around in your blood which is the PPD is testing for. Once you've had the BCG vaccine, the only real screening tool for tuberculosis when you don't have symptoms present is a yearly chest x-ray which is a lot of radiation exposure over the course of a lifetime or you get by without screening and you wait until symptoms develop by which time you spread tuberculosis to your friends, love ones and co-workers. If you work in a job that's low risk for tuberculosis or live the rest of your life without significant exposure you may not need yearly TB screenings.
But this does become an issue if you want to work in health care, educations, social services, prisons, other high risk occupations, or in areas where there is some sporadic tuberculosis occurrence. What's a mom to do when living in a foreign land? Get your child the BCG vaccine or not, here's why I really would rely on the advice of the scientist and epidemiologist who track this sort of things and the buzz place for that is the Centers for Disease Control and Prevention at cdc.gov. They have a very nice tuberculosis fact sheet and it includes a very well worthy description of the BCG vaccine and it spells out guidelines for its use in children, and I'll put a link to this in the show notes for episode 273 over at pediacast.org and I would encourage you check that resource out as you make your decision. It's pretty easy, if someone is giving you advice that's counter to what the CDC is saying that's not advice I would listen to, if someone else is giving you advice that matches up with what's on the CDC fact sheet on BCG vaccine I would go with that.
I'm not going to spell out what those recommendations are because PediaCast live for quite a while on the internet and the recommendations might change and so your best bet is really going to cdc.gov and look in for the tuberculosis fact sheet and it'll give you a nice spell out guideline for BCG vaccine used in kids living in foreign lands. Let's move on to Yale in Israel, "Dear Dr. Mike I love your show, I recently listen to episode 238 from last January during which you said two year olds are on the young side for controlling number two", just so everyone is clear we're talking about moving bowels when I say number two. "In the day-care my two years old attends, they have started potty training all the children together. They're without diapers all day except for naps and they get stickers for peeing and pooping in the toilet. My daughter is one of the older ones in the group so we went along with it.
We were on day three and it does seem to me that she is not ready yet, she has frequent accidents for pee and poo and sometime seems unaware of it. My questions, one, once a child is ready how long the process should take? When do you know it's time to quit trying? Number two do you think she will feel bad if we stop the process considering most of the children in her group are potty training well? Three, I heard that back in the days when children were in cloth diapers, potty training happened earlier, is this true? Thank you, Yale." Well thank you for the questions Yale, you know there's a wide range of studies to there on potty training with an equally wide range of results. There's even a study showing that infants as young as nine months old can be potty trained and we talked about that particular study in episode 244 if you want to look that up. You mentioned episode 238 has information on potty training as does episode 262, potty training is a popular topic on PediaCast, why?
Well it's because for a time a parent's world seems to revolve around potty training, I'm going to answer Yale's questions but there's lots more to consider about potty training, so those of you out there who would like to hear more, be sure to check out and here's the full list of episodes relating to potty training in one way or another, PediaCast episodes 4, 27, 35, 117, 176, 196, 238, 244, and 262. Let's get to Yale's specific questions here, number one, once a child is ready how long should the process take? When do we know it's time to quit trying? In my experience and this is going to be anecdotal, most of the time we rely on research here on PediaCast but after 20 years of practicing pediatrics I can look back and say, "Hey, here's some observations that I've made."
In my experience it usually takes a few weeks between truly ready and consistently doing it. Does that mean you should wait a few weeks before giving up? Not necessarily, I would say pause the program when frustration sets in, frustration on your part or your child's part and that might be a few days or it might be a few weeks, it really varies from family to family. There's very little right or wrong about potty training other than letting frustration turn to anger and punishment, you definitely do not want to go there. Number two, do you think she will feel bad if we stop the process considering most of the children in her group are potty training well? It's only been three days you may want to go a little bit longer than that unless you've reached serious frustration although I don't really get that from you based on the description that you've given.
I think it's unlikely that she'll feel bad, in my experience most two year olds really don't care which to some degree's beautiful, I mean they don't care what people think, they don't care what other two year olds think, they are their own world, they're doing their own thing and when you get a bunch of two year olds together, there's not a ton of cooperative play. I don't think she's really going to feel bad unless the teacher or other children are giving her a hard time or making fun of her. You do want to make sure the teacher and other kids are sensitive to your child's failure especially if you aim to back off on trying. If your child is upset about it which means comments are probably being made and that situation is not corrected. She comes home crying because kids are making fun of her, again unlikely to see that at age two, at age for yeah, but age two? Less likely but if that is happening and it's not being corrected, you may need to find another day-care option.
Number three, I heard that back in the days when children wearing cloth diapers, potty training happened earlier is this true? I don't have any research data on this but it sure makes sense. Cloth diapers back in the day worn as absorbable as cloth and disposable diapers are today and less absorption means less comfort and discomfort is a motivating factor. Not that we want to intentionally use discomfort to motivate potty training but if it's there naturally because the pee and poop set on a non-absorbent diaper, it certainly will likely help move things along. At the end of the day Yale, my feeling is if you give it some time even though your daughter is on the young side, if she's around kids her age who are successfully potty training and she's in a supportive environment a better showing up doing pretty well with it and certainly sooner than if she were in a different environment but again if frustration sets in don't let it turn to anger or guilt, stop trying and pick up where you left off at some point down the road.
How long do you give it? How long before you try again? There's no right or wrong answer there, it's a matter of what works best for your family. I hope that helps and for more concrete information on potty training check out PediaCast episodes 4, 27, 35, 117, 176, 196, 238, 244, and 262 and now you can add 273 to the list as well. Those of you who have been waiting to hear about the mystery rash, wait no longer Heather in Peoria Illinois says, "My now four year old daughter has been getting this horribly raised red and painful rash that appears on the back of her thighs. We have tried several rounds of steroid creams and anti-fungal to no avail."
"We think it's a gluten allergy, if she eats gluten for two days in a row it seems like the rash will appear so we try and keep her gluten free but we figure somewhere along the way she will find a cheerio under a desk at pre-school and eat it. Here's my question, shall we take her in for the horrible allergy testing or just let her learn the consequences of sneaking forbidden foods? Are there any cases of anaphylactic shock to the gluten like there are for say, peanut allergies? Sincerely, Heather." Well thank you for the question Heather, first of all I will say that when we talk about food allergies we don't talk about a particular one ingredient in the food, we talk about the food that you're allergic to the food. For Instance when you say you're allergic to peanuts, we don't pick out one protein in the peanut, we'd say you're allergic to peanuts and no one eats gluten, if you can't buy gluten at the store. Gluten is a component of wheat and other grains. We really don't treat gluten as an allergy in the traditional sense.
By the way stay tuned because episode 274 it's going to come out December 11, is all about celiac disease and gluten sensitivities, more to come on that. Bottom line, if your child has an allergic reaction to a gluten containing grain we would call that a wheat allergy, or a barley allergy, or whatever the grain maybe the problem. There're components other than gluten in these grains and any of those maybe the actual problem. Doesn't gluten cause celiac disease? Isn't that an allergy? Well not really, not in the traditional sense that we talk about allergies and hyper sensitivity reactions in anaphylaxis and again if I'm being a bit mysterious about this, we're going to talk more on December 11 about how gluten damages the intestine and causes celiac disease.
There is a rash that can go along with celiac disease called dermatitis herpetiformis, this is not a true allergy but it is associated with gluten intake and it is treated by eliminating gluten from the diet. If your child has that it's likely they are having intestinal damage as well even though you may not see symptoms, if that's truly what this rash is it may not be that. But like most things we talked about on PediaCast none of this is something that you diagnose at home, you need to see your pediatrician to look at this rash and they will likely connect to you with a pediatric allergist if this rash keeps coming back and nothing seems to be working other than eliminating gluten from the diet. You really do need to see an allergist or if you think that gluten maybe the culprit, instead of an allergist your doctor may refer you to a Gastroenterology specialist especially if you have one in your area who is also a celiac disease specialist, a visit to them may be helpful in figuring out if gluten is the problem and if intestinal dam's silent, intestinal damage is occurring along with this rash.
This is all something that you do want to know because if gluten isn't the issue why go to the trouble of eliminating it? The gluten free diet is not an easy diet so if your child's rash is not from gluten save yourself the trouble. The testing is not horrible, horrible allergy testing, I don't think that really exist, gluten problems aren't diagnosed with the skin test, it's a blood test that looks for anti-gluten anti-bodies so we're talking about a quick needle poke and some blood collection, really that's not horrible and honestly even if your child did need a skin test to look for a variety of possible other allergens I wouldn't classify today's skin testing as horrible. The information you get is well worth any mild discomfort.
One word of caution, whoever is testing a child for gluten sensitivity, they will likely not want you giving your child a gluten free diet before they conduct this test and the reason for that is a gluten free diet can result a falsely negative test, so be sure to clarify that with your doctor before you do any testing. So yes Heather, have that rash checked out, do it now, you do want to find out what's causing it, it might be gluten then again it might not. Let's move on to Caroline in Severna Park, Maryland, Caroline says, "Hi Dr. Mike, I became a regular listener after discovering your show in 2008 and I found it enormously helpful and informative. I know you took a break for a while so I was very happy to find you had returned to podcasting, thank you for all the great information you provide. I was hoping you could answer a question for me about speech development….
"My older daughter is six year's old and in first grade, she's always spoken with a slight lisp but we assumed it would eventually go away as she got older. However it does not seem to be going away or even getting less noticeable, I've emailed her teacher and requested a speech evaluation through her elementary school but I'm not sure this is the best place to start. Do your patients ever ask about speech issues and if so what is the normal progression for something like this? We were wondering if we have to have her evaluated by an independent speech pathologist but I'm not sure how to go about finding one, could you take a little bit of time to talk about speech development, what's considered normal for this age and what might need more attention? Thank you so much in advance all the best, Caroline from Maryland." Well thank you for writing in Caroline. Speech development does vary widely from child to child and one of the biggest factors is the answer to this question, does the speech problem cause communication difficulties in everyday life in school, social or family relationships? Our relationships and development's struggling because of the speech problem, if so help is needed more urgently, if not your child could still uses speech evaluation but it's not quite as urgent.
You really got to look and see what is the degree of the speech problem, how is it compared to other kids that age and how is communication going and development going in all of that? If you have any concerns whatsoever having a speech evaluation is never going to be a problem, there's not much risk involved with that other than cost and time but how urgently that needs to be done really depends on what's happening from a developmental and communication stand point. And the school can often help with that because they're observing your kid in a classroom setting with other kids their age over many hours and plus they see so many kids that teachers have a good notion of when it's a problem and when it's not a problem and getting plugged into the school speech therapy program sounds like a good thing. Many schools have excellent speech resources but others don't.
If you have concerns that the school speech resource is either not going to do a good job for you because maybe they have reputation for that, or maybe it takes a long time to get in and so you're not real happy with the direction that the school's going with regard to speech, then I would talk to your child's doctor and I would talk to your child's doctor anyway. It might be, "Hey I'm concern, the school is looking into this but if things aren't going well we may need you to help us find another path," or your doctor may say, "Oh you go to that school, yeah we need to find you a different path." Talk to your child's doctor about it, they see kids with speech problems every day and can do a good job of pointing you in the right direction. Now here's where things get a little dicey, speech services aren't always covered by insurance they may get expensive, does your child really needs speech therapy or will the speech problem work themselves out? Well I answered this question in considerable detail back in episode 257 I would encourage you to check that one out PediaCast episode 257 at pediacast.org.
By the way our speech pathology department here at Nationwide Children's took a listen to that episode and to be honest I was little nervous because I did say what I thought might be some controversial things in the speech pathology world but as it turns out they gave my comments their official stamp of approval so take that for what's it's worth and tune in to episode 257 if you want to hear more on that. Next up we have Christine in Key West, Florida, she says, "Hi Dr. Mike, my five year old granddaughter has developed a choking phobia during the last two weeks, we aren't really sure what triggered it, she hasn't choked on anything we know of all she'll say when attempting to eat is that she's afraid she would choke and turn blue. I just wondered if you have any advice or if you have covered this in a podcast previously. Both my daughter and I have turned into her food slaves and have become obsessed with getting her to eat. She would drink yoghurt and she will eat bread with Nutella then we give her Pediasure she doesn't have problem drinking, we're becoming frustrated as you can imagine….
"I would also like to know how long you think we should let this continue before taking her to her pediatrician, any advice at all would be great, thank you." Thank you for the question Christine. This is the kind of thing I would have someone take a look at her immediately whether it's your pediatrician or even take her to an emergency department is probably a good idea. I just want to clarify, when folks write in with something that I am concerned about like in this case and I say you need to see someone immediately, I don't wait for few weeks before if this makes on the show, I shot an email back and said, "Hey you got to get this checked out." Don't rely on that because I don't get email reliably, if you're concerned, call your doctor. We say that in our disclaimer and I mean it, you don't want to wait on my opinion if something could be potentially serious. Why is this potentially serious? Well it's possible that your child has a foreign body in her esophagus.
This is a common story, sudden onset of difficulty swallowing or fear of swallowing. Symptoms continue for a few days, they drink enough fluids to prevent dehydration but their eating pattern is definitely changed. They don't admit to swallowing anything they shouldn't have but you take an extra and low and behold there's a quarter sitting in the esophagus or something else. So this is one of those cases when you do want to see your doctor much sooner rather than later because if there is a coin or some other foreign body causing this symptoms it will need to be removed and a complications can set in if the foreign body starts to cause erosion, or an ulcer, or it comes back up and then aspirated down on the lung, these are things you really do have to pay attention to. If there's not a foreign body then you're dealing with a new feeding aversion, there's not something stuck there but she still doesn't like eat certain things. You still have to look for potential medical reasons for this. And keep in mind kids at this age describe things in terms that they understand but terms that don't always make sense with the final diagnosis.
I feel like I'm going to choke, could that describe acid reflex for example? Maybe, maybe not. You definitely want a good history in physical completed by your child's doctor and I'd get that done gain as soon as possible. Let's say there's no foreign body and we can't find a medical reason for the symptoms, that leaves a behavioral issue not to say your child is making these symptoms up but saying that she does have an unreasonable fear and this can stem from a near choking episode that she might have had herself but doesn't remember the specifics well enough to tell you about it, or a choking episode that she witnessed or the one that she heard about, whatever the reason she's afraid to swallow now. If this persists she's probably going to need some help. Some kids develop eversions to certain textures, certain consistencies of foods, certain food items or they just become very picky and because of the way they're acting you keep giving them what they want. This can all become a very frustrating problem and it can affect your child's health and family life.
Again your pediatrician is a good place to start as he or she likely has dealt with this in the past and who have some resources to tap into. Like here in the Columbus area with Nationwide Children's Hospital we have a full blown feeding clinic so kids who have this kind of aversions that don't have a medical issue, and don't have a foreign body, or an atomic problem, we have a clinic they can go to that deals with these kind of feeding problems but not all communities have that. Occupational therapist especially pediatric occupational therapist they deal with swallowing, ear, nose and throat physicians, gastroenterologist or GI doctors are all ones who also deals with swallowing and feeding problems. Don't assume that it's a behavioral issue right out of the gay, it is important to make sure as soon as possible that you're not dealing with the foreign body or an underlying medical issue.
Next up Elizabeth in Texas, "What do you think about daily vitamins for children? My kids are good eaters, selective but healthy, one doesn't like milk so we give her a calcium supplement sometimes, another eats less meat and I feel better if he gets a vitamin with a bit of iron, the third is picky about veggies, super skinny and goes for carbs first. I tend to press a multivitamin if I think she's missed something that day. Hubby and I take fish oil for cholesterol management, well fish oil help the little brains develop as I hear…. Thank you for the question Elizabeth. Here's my feeling on supplemental vitamins, if a child is healthy and growing well, and eating a well-balanced diet with daily intake of fruits and vegetables, and breads, and meats, and dairy and because this child eats so well here she is consuming the recommended daily dietary allowance of vitamins and minerals including 400 international units for vitamin D each day, if that describes your child then supplements are not necessary and getting vitamins in the manner of their food that's the preferred way. Now on the other side if your child is not healthy, if they aren't growing well, if they show signs of a nutritional deficiency then you'd definitely need to talk to your child's doctor regarding the need for supplementation of specific nutrients.
Let's face it, the vast majority of kids do not fit into either of this categories that I've just described, here's the description of the typical kid, they're healthy, they're growing well or at least well enough but they aren't eating like mom or dad wants them to eat. They're picky, they don't like fruits and vegetables, they're on the go, meal time is frustrating and mom or dad is worried they aren't getting the nutrients they need. The question becomes then should you supplement these kids with the daily vitamin? And that's a good question and to be honest I could provide you with research that supports two different answers, the first answer is yes, you should give your child an age appropriate daily multi-vitamin, the second answer is no, you shouldn't and it's fairly good research out there to back up both claims. Now I will say this most of the research that backs up supplementing looks at biological markers, the research will say if you give them the supplement and their blood levels go up, or their cholesterol goes down with this biological markers but very few of these studies tie in daily supplements to a health outcome.
You can find some that show that and other say, don't make any difference at all. The bottom line is here, I think we really don't know the right answer to this question. Here's another question many parents ask, will daily multi-vitamin help my child? And my question response to your question would be what help are you looking for in a daily multi-vitamin? If your child is healthy and growing well enough that's the category of kid that we're talking about here right? I mean they're healthy and they're growing well enough just kind of a picky eater. What are you trying to help? Whatever it is, whatever problem you perceived that's there that you're trying to help you should probably talk to your doctor about it.
If they don't really have any problems that you can put your finger on, if they're healthy and growing well but they're picky eater so what? I mean what do you expect the vitamin supplement to do exactly? Once you get above the daily recommended allowance which even picky eaters usually get that, your body is just going to get rid of the extra anyway and you can make some pretty expensive urine by giving your child daily supplements. Then there's the question of absorption, how well do pill based nutrients get into the blood stream? Again even if you do improve the blood concentration of vitamins and other supplements, or you improve these bio-chemical markers that we can measure with the blood test like cholesterols the question remains what's the real benefit to your health? I read one study from a particularly popular brand of daily supplement that said, "Study show that those who take our product have fewer sick days." So I thought, "I'm going to dig into this little bit deeper," well it turns out their idea of fewer sick days, they had two fewer days of stuffy nose each year or it wasn't two fewer days of calling in sick, it was two fewer days of stuffy nose each year compared to those who didn't take the product.
Two days, is that really worth hundreds of dollars that you spent on yourself or a thousand dollars you spent on your family for the product over the course of the year? Two days? Two less days of stuffy nose? mMy opinion, no, not worth it, you're entitled to your own opinion on that one. Bottom line Elizabeth, a good diet is better than a daily vitamin in age appropriate daily vitamin is probably not harmful but also unlikely to be significantly helpful. Is it worth the cost? You have to decide that and you do want to stay away from mega doses of supplements because this can have toxics effects. What is the American Academy of Pediatrics say about vitamin supplements? For those interested in their opinion head over to the show notes for this episode 273 at pediacast.org and I'll include link to an article at healthychildren.org called Where We Stand on Vitamins.
Hope that helps Elizabeth and again thank you for writing in. We have one final one, Tiffany in Concord, Massachusetts says, "Hi Dr. Mike, there was an article i the Boston Globe recently about the use of medical marijuana in children specifically to help alleviate the side effects of chemo drugs. Thankfully I don't have personal experience with this but I'm curious about your opinion and whether you know of any studies that have or will be done, thank you, Tiffany. P.S. Here's a link to the article." And if you're interested in seeing the Boston Globe article on medical marijuana see the show notes for this episode 273 at pediacast.org. Here're my personal feelings on marijuana. If you're using marijuana as a recreational drug even if you live in one of the states where it's legal, Colorado or Washington as of this recording. If you're using it as a recreational drug I would say stop, get a life, stop supporting the illicit drug culture in industry which leads to many ruined lives, broken families and debts.
Stop abusing your bodies, stop trying to escape, get some help, forge meaningful relationships with other human beings, yes it takes time, yes it takes energy, yes it takes selflessness, yes it's difficult but trust me you'll thank me down the road or keep going in the direction you're going with the hopes that someone, someday will pull you out of the ditch. What about medical marijuana? Well you know to relieve pain and suffering, this is something different. Using a substance to escape is different than when you have a serious illness and you're trying to relieve pain and suffering. And if you can't see difference between those two things then you're not going to understand why I have the opinion that I have.
If medical marijuana is legal in the jurisdiction that we're talking about and it's relatively safe depending on the circumstances then I'm all for knocking out pain and suffering, thank you for asking Tiffany. The Boston Globe article that you sent me, it was pretty moving and I'll provide a link to it in the show notes episode 273 at pediacast.org. That wraps up our Answers Listener Question Marathon, 11 of them, 70 in 2013 and we're going to break that mark in 2014. If you have a question for me, or a comment, or a topic idea, or you want to point me in the direction of a news article or journal article we had all of those things in this episode, then just head over to pediacast.org and click on the contact link. I do read each and every one of those that come through and we'll try to get your question or comment on the program in 2014.
Let's take a quick break and I will be back to wrap up the show right after this.
Dr. Mike Patrick: A big thanks to all of you out there who made 2013 a great year for listener questions, 70 answered questions, that's a big deal. Let's get a running start on 2014 I need new questions. If you have a question, comment, topic idea, news article, journal article, whatever head over to pediacast.org, click on the contact link and let me know. If you don't mind, this is our last show before Thanks Giving, I do want to wish all of you a very happy Thanks Giving, those of you in the United States who celebrate this holiday.
You're going to probably be getting with family and I would just ask you to please, any family members that you have with children including teenagers and college age students, or any who are expecting children, please tell them about PediaCast. You're word of mouth is the best source of referrals that we have and let them know. It's really easy to find us, we're at pediacast.org, we're in iTunes, and we're on iHeart Radio Talk which is in iHeart radio. If you go to iheart.com or download any of the mobile apps for iHeart, you are going to be able to search for PediaCast or PediaBytes and I can't make it any easier to find the net. Please talk PediaCast stop over the holidays and get your 2014 questions submitted and that's going to be my final word for this episode.
I do want to thank all of you for taking time out of your day to make PediaCast a part of it, don't forget PediaCast and our single topic short format programs PediaBytes are available on iHeart Radio Talk. Reviews and comments on iTunes and iHeart would be most helpful because parents really pay attention to what you have to say. We have lots of reviews on iTunes, if you haven't left a review on iHeart Radio please consider doing that, we don't have many reviews there and so reviews and comments would really be helpful as our links, mentions, shares, re-tweets, re-pens all those things on the social media sites. We are on Facebook, Twitter, Google Plus, and Pinterest, and also be sure to tell your child's doctor about PediaCast. Let them know it's an evidence Based program aimed at parents, we don't water things down but we also explain things so moms and dads can understand without things being dumb down.
The posters are available on the resources tab at pediacast.org. That's it, two weeks off for Thanks Giving, please everyone enjoy your families, I'll be back in December for December 11 for a show on celiac disease and gluten sensitivity and then we'll do one more News Parents Can Use episode to wrap up 2013 and then we'll look ahead to the New Year. Until next time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids, so long everybody.
Announce 2: This program is a production of Nationwide Children's, Thanks for listening. We'll see you next time on PediaCast.