Looking Out For Number Two – PediaCast 378

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  • Dr Bryan Vartabedian (Texas Children’s Hospital) joins us to talk about his new book, Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas and Other Things That Come Out of Your Baby. The title speaks for itself, so please join us this week and learn all about baby poo!

Topics

  • Infant Feeding
  • Baby Poop
  • Baby Gas
  • Colic
  • Constipation
  • Diarrhea
  • Food Allergies
  • Probiotics

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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. We're in Columbus, Ohio.  

It is Episode 378 for June 7th, 2017. We're calling this one "Looking Out for Number Two".  I want to welcome everyone to the program.  

So, what are we talking about this week? I know the title is a little bit cryptic, Looking Out For Number Two. But remember, this is pediatric podcast, when you think about kids and the phrase 'number two', you got it, we're talking about poo. And not the lovable bear who goes by the name of Winnie but actual poo, in this case baby poo, as we consider the recently released book, Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas, and Other Things That Come Out of Your Baby. 

Gotta love my job, and the title of the book and the topic. Because as any pediatrician will tell you, poo questions come up often, not only for babies but kids of all ages. And to help me explore this topic…

[Laughter]

Dr. Mike Patrick: Okay, explore might not be the right word there. To help talk about baby poo, the book's author, Bryan Vartabedian, he'll be joining us from Texas Children's Hospital. 

And I have to tell you, I'm really excited to have Dr. V on the program today. We're fairly like-minded in using digital technology, social media, the internet, mobile apps to connect with colleagues, patients, and families. 

0:02:14

Dr. Vartabedian has a huge Twitter presence, over 30,000 followers which is a pretty big number for pediatrician. He also has an extremely popular blog called 33 Charts followed by many medical professionals, not only pediatricians but providers of all sorts as they consider the practice of medicine and technology in the digital age. And like we've done here at Ohio State, Dr. V developed a digital communications curriculum for medical students at Baylor. 

So, we have a lot in common and our professional paths do cross from time to time. So, it's a real pleasure having and join us today regarding a very useful topic for parents, baby poo.

We won't start or end with poo. We'll actually start with what goes in before we consider what comes out. So, we're going to talk about infant feeding, breast milk, formula, solids. When do you start? Which ones do you use? Then we'll take a look at what comes out, including spitups and burps, and stinkers, and of course, poo.

We'll also discuss how often babies should go, what should their poo look like, when is constipation a problem, when is the stools or too often, when should parents worry, and what can you do if there is a problem?

So, lots to consider as we journey through the wonderful world of  baby digestion here on PediaCast.

Before we get to Dr. Vartabedian, I do want to remind you PediaCast is your show. So, if there's a topic that you would like us to talk about, if you have a question for me or you want to point us in the direction of a news article or journal article, we always appreciate the input of our audience. 

Really easy to get in touch, just head over to PediaCast.org. Look for the Contact link and ask away. I read each and every one of those that come through and we'll try to get your topic or your suggestion or your comments on the program.

0:04:06

Also I want to remind you, the information presented in every episode of our program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you do have a concern about your child's health, be sure 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. We'll get Dr. V patched into the studio and then we'll be back to talk about baby poo, got to love it.  It's coming up right after this. 

[Music]

Dr. Mike Patrick: Dr. Bryan Vartabedian is a pediatric gastroenterologist  at Texas Children's Hospital, which means he takes care of kids with problems of the digestive tract. And he's an assistant professor of Pediatrics at the Baylor College of Medicine. Dr. V is also a talented writer and founder of a popular blog called 33 Charts where a community of healthcare providers is exploring the edges of medicine and technology in the 21st Century.

He recently return to his writing roots with the third book, the old-fashioned kind made of paper and pages, called Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas, and Other Things That Come Out of Your Baby. Of course, and this is no surprise, he made sure the book is also available in digital format for those who prefer e-reader over books.

That's what he's here to talk about today, not e-readers, but looking out for number two and all things digestive and babies. So let's give a warm PediaCast welcome to Dr. Bryan Vartabedian. Thanks so much for being here today.

0:06:08

Dr. Bryan Vartabedian: It's great to be here, Mike. Thank you for having me.

Dr. Mike Patrick: Yeah, absolutely. So, I mentioned you were returning to your writing roots. This is not your first book, right? You've had a couple before this?

Dr. Bryan Vartabedian: No, I've started my writing, I guess, as a resident doing freelance writing for parenting magazines and wrote a book called FirstFoods and then another book called Colic Solved, which is about reflux and allergy. And so, I thought the time was right to write about poo.

Dr. Mike Patrick: Yes. So, how do that come up? Why write a book now about gas and poo?

Dr. Bryan Vartabedian: Well, you know, as a gastroenterologist at a pretty large children's hospital, I spend my days talking to parents about poo and all things about poo and gas, things that come out of babies. And I thought it make sense to kind of write down a lot of stuff that I picked up through the years and all the wisdom that I've learned. 

We're also learning a lot more about the bowel and the role of early feeding and microbiome in infant health. And so, I thought it might make sense to offer something that was kind of entertaining and kind of practical and up to date on a really important physiologic process and digestion, right?  

Dr. Mike Patrick: Yeah, absolutely. And we'll put a link to that in the Show Notes for this Episode 378 over at PediaCast.org. So, why don't we start with just sort of a walkthrough the various parts of the digestive system? Because as we talk about these things, I think it will be good for folks to have an image in their mind of what the different parts are as the food travels through?

Dr. Bryan Vartabedian: Yeah, that's a great question, Mike, because there's a lot more going on. I think when you talk to young parents, they tend to think that it's kind of like a laundry chute, milk goes in and poop comes out. But it's really a lot going on in between and really starts right at the mouth with a some of the enzymes that are so critical to early digestion right in the baby's saliva. 

0:08:01

The process of swallowing is very, very involved, as I discussed in my book. There are almost as many nerves in the all in the swallowing tube as there in the entire spinal cord . So, there's a lot of motility involved with swallowing. Milk, of course, hit the stomach and begin this most intense breakdown with some of the acids that will find there. And it's only into the small intestine where fats  are absorbed and a protein is broken down further and brought into the body where it can be used for growth.

And so, the remainder makes it to the colon, water's absorbed and poop comes out. 

Dr. Mike Patrick: You'd mentioned that the microbiome. What exactly is that and why is it important?

Dr. Bryan Vartabedian: So, when we refer to microbiome, we're talking about all the bacteria that live in the intestinal tract. We actually have, or a baby has bacteria that all throughout their body, from their skin to sinuses and in lungs. But I like to refer to it the baby biome — at least in my book, I refer to it as baby biome — is all those bacteria that live in the intestinal tract.

For all intents and purposes, a baby is born with effectively a sterile gut. There are some evidence that refutes that. But all intents and purposes, it's sterile. And babies pick up their bacteria from their environment, from the way they're delivered, and a lot by the way they're fed and the way they're handled, and by who handles them. 

So, we oftentimes pass along the bacteria to our kids and with that pass along potentially a risk of certain disease stage from things. And so, it's becoming very, very important and very, very interesting.

Dr. Mike Patrick: And folks who are interested in hearing more about the gut microbiome, PediaCast Episode 243, we devoted an entire episode. And I'll put a link to that in the Show Notes for folks who are interested, so you can find it easily. 

Now, always hear in terms of infant feeding that breast milk is best. Why is that? Why is breast milk best for babies? 

0:10:05

Dr. Bryan Vartabedian: Well, like it depends how much time we have, right? There's a lot to talk about which regards to breastfeeding but it's a living bioactive substrate. And so, babies are getting a whole variety of infection-fighting cells, antibodies, and even bacteria to seed that microbiome. And so, the fact that this is a living breathing substrate has real impact on the types of bacteria that babies get colonized with when they're breastfed or bottle-fed. If we look at the microbiome or the baby biome of both formula-fed and breastfed babies, they're entirely different. 

And while there are a number of elements in breast milk to contribute to some of the health and wellness enjoyed by breastfed babies, it's quite possible that the different microbiome that is formed with breast milk may contribute to that as well.

Dr. Mike Patrick: What are some reasons that a parent would need to use infant formula?

Dr. Bryan Vartabedian: Well, obviously, breast milk, for some of the reasons that we discussed, is the original substrate for feeding babies. And it should be the preferred form of milk and the first go-to source of feeding for baby. 

Some parents, of course, can't breastfeed due to maternal issues, medications, and what have you. So in that case, there are alternatives available for parents to use, infant formulas that do a great job of helping babies grow.

What's interesting is that some of the probiotics that we find in breast milk or some of the living organisms that we find in breast milk such as lactobacillus reuteri are now being added in infant formula. And so more and more, a lot of the formulas in milks that were giving babies who can't breastfeed are doing a better job of coming closer to breast milk. Not matching up but becoming closer.

0:12:15

Dr. Mike Patrick: Yeah, absolutely. What formulas do you think parents should use if they can't breastfeed?

Dr. Bryan Vartabedian: Well, it's interesting because if you look at what I call the Great Wall of Formula at some of the baby superstores, it really can be mind-blowing for young parents. 

Dr. Mike Patrick: Absolutely.

Dr. Bryan Vartabedian: And so, I try to simplify them in my book, Looking Out For Number Two, but your trusted provider or pediatrician will hopefully help give you some guidance. But for most babies who can't breastfeed, they're going to go on what I refer to as a standard infant formula. And it's going to be cow's milk-based formula that's with the proteins and processed to be appropriate for babies. And so, we might refer to that as a standard infant formula. That's going to be fine for most babies. 

Dr. Mike Patrick: And if they need something different, then their provider will be helping them along and figuring out exactly which one they need to choose from there.

Dr. Bryan Vartabedian: Absolutely. I will add, increasingly, parents are making informed decisions about certain kinds of formulas. And it's interesting, when I was writing this book, Looking Out for Number Two, I wrote it from the mindset that parents are far more empowered than they were even 10 or 20 years ago. 

And so, being educated about the different kinds of formulas is important. Parents can make formula changes on their own, but I strongly encourage them to get the input of a trusted pediatrician or healthcare provider.

Dr. Mike Patrick: Another thing they can be confusing for new parents is when to start solid foods. Because recommendations have changed over the years and they probably hear one thing from their provider — maybe grandma and grandpa, aunts and uncles — telling them something different. When does evidence suggest now would be the ideal time to start solid foods? And does the order in which they're introduced matter?

0:14:08

Dr. Bryan Vartabedian: It's a great question because there's a real sense of urgency among young parents to get started on solids. And I have to admit that sometimes grandparents push this. I don't know what it is about grandmothers but they really want to push solid foods on their babies. 

Four to six months, closer to their six month on solid food is a great place to start. In terms of order of operations, we used to have very very strict orders of operations in terms of introducing solid foods. There is once that concern that starting fruits, for examples, before vegetables would lead kids to prefer sweets over vegetables and that simply isn't the case. 

Probably the most pressing issue for babies is iron during the middle of that first year. Believe it or not, meat is beginning to take a larger role in some of the first foods that we offer. Cereal is a great source of iron, and that's why it stands as one of the best first foods to start with.

Dr. Mike Patrick: And then what about transitioning to whole cow's milk? When should that take place? 

Dr. Bryan Vartabedian:  Yes. The transition to milk out of the carton or whole cow's milk simply typically occurs around a year of age. Some parents will probably cheat a little bit, but the reason we don't like to give milk out of a carton to babies under a year is that it can be very irritating to the lining of intestinal tract and lead to problems like iron deficiency and anemia.

Dr. Mike Patrick: So that's going to be about 12 months of age. But each kid maybe a little different in terms of could be a little later and  you want to talk to your doctor about that.

Dr. Bryan Vartabedian: Yeah, absolutely. 
         
Dr. Mike Patrick: Now, let's start with actually instead of poo, let's start with gas. So, burps and stinkers, a lot of times parents will think well, this is uncomfortable. Is passing gas uncomfortable and what should parents do about it, if anything?

0:16:02

Dr. Bryan Vartabedian: You mean, gas from below or gas from burping? 

Dr. Mike Patrick: Well, either place. 

[Laughter]

Dr. Mike Patrick: Because it comes out of both ends, right?

Dr. Bryan Vartabedian: Yeah, burping is kind of an amazing phenomenon because it's a natural consequence of the disorganization the babies naturally have during the first few months of life. They naturally swallow air due to some discoordination. And so, burping is nature's way of releasing some of the gas from above. 

Not all the gas can be burped up and some of it goes downstream, of course. It can be painful for babies because if you think that gas is being sort of the stuff that takes up space, they can distend the colon. And it can reach into certain pockets of the colon and cause distension of pain. So a lot of gas going downstream can be very painful for babies. 

And so, I always like to tell parents whenever they get a lot of gas from below in the baby, they first start by thinking of what's going into the baby because gas only comes from two places. Either it is swallowed by a child or it is created by the bacteria that are there. So you want to think about how good is the latch that the mother has. Is it an appropriate nipple system that they have, so is the baby screaming and yelling a lot? And that can lead to air swallowing as well. 

Dr. Mike Patrick: And gas drops, do they do much of anything to help with gas problems?

Dr. Bryan Vartabedian: Gas drops are pretty generic term, Mike. 

Dr. Mike Patrick: Yeah, the Simethicone is kind of what's coming to mind. 

Dr. Bryan Vartabedian: Yeah, yeah. Not proven to do a whole lot, but quite expensive. And I suggest, just a moment ago, we always have to think what the source of baby's gas may be. The reason I question the term gas drops is because we're starting to see the evolution of newer form of the gas drops with probiotics that adjust the baby biome and can impact that types of gas that's created. So there are some probiotics. So I guess being one that may play a role in helping irritability in babies. 

0:18:05

Dr. Mike Patrick: Yeah, I did see a study and had read a blog post by Dr. Chad Hayes called To Burp or Not to Burp, That Is The Question. And it just brought up this idea that maybe if babies aren't having any problems — so if they're not fussy, they don't seem to be in discomfort from gas, they're not spitting a lot — then maybe you don't have to burp them after every meal as sometimes it's taught to parents. 

Dr. Bryan Vartabedian: Yeah, that's a great point. And some babies certainly need to be burped more frequently than others. I think that sometimes parents get in their head that they have to take time between the right breast and the left breast to burp their baby. But as I always tell my parents, they have to really follow the temperaments of their baby. 

For some babies, they're aggressive feeders and don't want to take a break. And so all the screaming and crying and carrying on that comes from their not feeding is going to lead to more air swallowing and kind of defeats the whole purpose. So that's a great point. 

Dr. Mike Patrick: And then, babies who spit up. This is something that causes a lot of dismay for many parents when babies spit up . But really spitting up can be normal. When would spitting up be a problem and when can it just be sort of  be tolerated?  

Dr. Bryan Vartabedian: Yeah, so spitting up a normal physiologic process. It's a manifestation of what we call gastroesophageal reflux or physiologic reflux which everybody has, you and I an almost baby. So babies are going to do that. The spitting tends to slow down between 6 and 12 months of age, where 5% of all babies are spitting as much as they did early in life. So 95% of babies by their first birthday are going to be over most of it. 

The things we look for that would be concerning would be like a lung and choking problems, growth problems, or profound irritability or screaming. Those are circumstances where you talk to your provider about the possibility of using medications to control their reflux. Even though, even those circumstances sometimes, we just let them burn it out. 

Dr. Mike Patrick: And then what about colic? Where does this fit in with the gastrointestinal tract? 

0:20:06

Dr. Bryan Vartabedian: Well, if we look back to 1954 when colic was first described, we didn't know anything about what was going on inside of the baby's intestinal tract. And there is some data that support that 30% of babies with "colic" have conditions such as allergic enteropathy or milk protein allergy. So there's other evidence to support that there may be alterations in the microbiome that are impacting behaviors. So that time has passed, we learn more and more that some of these babies with unexplained irritability actually have explainable causes. 

So for parents who are listening, we really want to have a trusted provider who's going to exclude common conditions like allergy, even reflux, or considering the possibility of probiotics which may have a positive effect on colic, or a positive effect on irritability. So the term I tend not to use very much, because I tend to think about the causes behind this rather than just blanket terms. 

Dr. Mike Patrick: So if you find the cause, it's probably not colic because there's a cause for it and you can treat it. So colic still just becomes this unexplained fussiness in some babies. 

Dr. Bryan Vartabedian: Yeah, exactly. And I think that when we talk about the witching hour between four and seven at night, it's true if you look at any baby with an ear infection or even teething or anything like this. They tend to be crabbier late in the day because they're tired. They're fitting in with our schedule which is being awake during the daylight hours. And so, just like me at the end of a long clinic, I kind of get edgy and colicky myself. 

Dr. Mike Patrick: Yeah, absolutely. So let's turn our attention to baby poo then. What is poo and what's normal? How should it look — consistency, color, how often should babies goes? What is a normal scenario look like as we think about baby poop? 

0:22:00

Dr. Bryan Vartabedian: Well, it's really an evolutionary process, right? Because during this fourth trimester of development, the whole gut is evolving and changing. And so, right from day one of life, babies are certainly breastfeeding. They're getting different substrates in the milk during the first couple of weeks of life. And as the bacteria take over and as motility improves, the frequency of pooping, the appearance of poop, all changes. 

And so, to say that there's one kind of poop or one expected thing is kind of not the right way to look at it because it's really changing over time. And what babies produce is most often a product of what we put in. And so, the way a baby's poop will appear is probably most connected with what we're getting. 

So for example, breastfed baby, we're going to see that yellow, mustardy seedy poo. Whereas, the baby who's fed standard cow's milk-based formula is going to have a brown or a stickier, mushier kind of poo. So all of that, of course, are going to change as solids are introduced and the microbiomes changes. 

Dr. Mike Patrick: So really wide variation of what's normal. What would be considered warning signs that, okay, so there's a lot of variety in terms of what it can look like. But what are the things that are definitely not normal that should raise concern if parents are seeing this in their babies?

Dr. Bryan Vartabedian: Yeah, so in terms of color, we would think about white poo. Poo that's white lacks the normal pigment that gives its brown or green appearance. And that can indicate a problem with the liver so that is something you want to have to checked out immediately. Of course, a red poop can indicate blood. Certainly, there are types of antibiotics that can do this, so you want to be checking with your provider on this. 

And then black poo. Black poo can indicate all blood or blood from the upper intestinal tract. Those are colors we want to look at. 

0:24:00

Beyond that, we'd want to look at the efforts that a baby puts into the bowel movement. So rather than looking at or counting bowel movements, or having a bowel movement every single day, which isn't necessarily something the baby has to have, the efforts that they're putting into that elimination was probably the most important thing in defining constipation or problem with elimination.

Dr. Mike Patrick: And for folks who were interested in some pictures, we do have an infographic called The Poop Palette: What Do All of Those Colors Mean? And it just has a rundown of those warning signs and different consistencies of poop. And I'll put a link to that in the Show Notes for this episode, 378, over at PediaCast.org. 

In terms of constipation, when would you call a baby stool pattern an issue in terms of it possibly being constipation? How often should 
babies be going and how many days need to go by before you would think about calling it constipation? 

Dr. Bryan Vartabedian: So it really depends on what the baby's being fed and, again, the effort that they're putting in. So for  breastfed baby, waiting for moms milk to come in. Things are going to be slow the first few days but a good rule is after four days of life, four poops a day should be expected at least for the first four weeks of life. 

What happens after that, after a month or two of age is kind of interesting as babies hit what I call the Big Slowdown. So babies who are pooping perhaps after every feed or two to three times a day will start to slow down. And they may poop even once a day, once every two to three days. I'll occasionally see breastfed babies that poop once every two or three weeks, believe it or not. 

While it's unusual it happens, again, what we look at in those babies after doing a thorough physical exam, of course, and its oral history, again, it's the effort that that baby is putting in and how hard a time they are getting that poop to come out. 

Dr. Mike Patrick: So this is the sort of thing where if you're concerned, talk to your doctor. It may be normal, but if you're concerned, let them know, so that they can kind of walk that journey with you in figuring out what's going. 

0:26:09

Dr. Bryan Vartabedian: Yeah, the poo journey. 

Dr. Mike Patrick: yes, yes, absolutely.  What are some things if you and your physician do think that the baby's constipated. They're having some difficulty getting it out, but there's no other sign of any medical reason for it. What are some things that parents can do about constipation to help loosen the stool up? 

Dr. Bryan Vartabedian: Well, I would start by saying the first thing we probably don't want to do, except on rare occasions, is to stimulate the bottom. Because if you stimulate the baby's bottom with a thermometer or Q-tip, that bottom's going to relax and it's going to make it easier for that baby to poop. The problem is, the baby is going to get quite accustomed to that and they kind of have to learn to do that on their own without that kind of rectal stimulation. 

Besides that, if the baby is passing really hard turds, we want to think about first what that baby is getting. If we're putting rice cereals for example into the bottle to prevent spitting, throwing that rice cereal out would be the first thing I would do. If the baby's on soy formula, soy formula is famously constipating, I'd pull them off soy formula. 

After that, I will oftentimes add a little bit of extra water to a baby's diet. Two to three ounces a day will sometimes be enough to soften the poo. And believe it or not, sometimes, we use a little diluted fruit juice to soften that poo. The sugar helps hold water in. 

The American Academy of Pediatrics recently recommended no juice under 12 months of age as part of the standard diet but we do use it sometimes for constipation. 

Dr. Mike Patrick: Because in that case, you're not really using it for nutrition. You're really using it as a medicine, even though it's just juice. 

Dr. Bryan Vartabedian: Kind of, yeah. It has this osmotic effect where it holds water in the colon. So that's absolutely right. 

Dr. Mike Patrick: And we do have a podcast that we did, all about constipation. That was Episode 292. So parents who are interested in  learning more about that, you can check that out again in the Show Notes for this Episode 378 over at PediaCast.org. 

And then, what about diarrhea? What is too loose and what are some causes of that? 

0:28:13

Dr. Bryan Vartabedian: So it's interesting if you look back in the research literature, you'll find the past 20 years, you'll find several different definitions of diarrhea. So as it turns out, even experts can't come up with a firm decision on what constitutes diarrhea. So probably the simplest way to think about is poop that's of decreased consistency and increased frequency compared to what your baby's used to. So runnier poop and more frequent poop, we would constitute as diarrhea. 

The reason diarrhea becomes so important is the fact that again, as you'll learn in the book, a lot of poo is water. And the more poop the babies had, the more water they lose and babies can become dehydrated very, very quickly. So high up at the poo stage, we want to watch out for dehydration very, very carefully and make sure they get attention. 

Dr. Mike Patrick: Yeah, absolutely. And really, the treatment of diarrhea is going to depend on what the cause is. So again, if you're concerned that your baby's poop are too loose so that they're going too often, definitely something you want to talk to your provider about. So they can let you know, is this normal or not normal. And if it's not normal, what could the causes be? And then, kind of treatment flows from there. 

Dr. Bryan Vartabedian: Yeah, exactly. That's right. 

Dr. Mike Patrick: In terms of food allergy, this is also something that has gotten a lot of press. Talk a little bit about the symptoms of food allergies and when that could be a concern for parents. 

Dr. Bryan Vartabedian: So the most common allergy that we see in the first year of life, of course, is milk protein allergy. And for the average baby, it start to appear obvious at four to six weeks of age. Or three to six weeks of age rather, where baby's going to have some blood in the stool, some mucus. Sometimes, scaly skin or eczema, and even sometimes, colicky behavior or spitting. 

0:30:08

So when the bowels are enflamed, we're going to see some of those symptoms that I just described. And so, this is treated typically with a formula that's broken down. We call it an extensively hydrolyzed formula. So the kind of  fools the immune system that we don't see the reaction that causes the milk allergy. 

And so, as we advance to the solid foods, we get into a different territory of allergy. And most of the first foods they eat, the babies typically don't stimulate allergic reaction, although there are circumstance where it can happen. But for parents of babies, milk protein allergy is the big  kahuna. 

Dr. Mike Patrick: And for other food allergies, we did PediaCast Episode 259. We talked all about food allergies. And so, we'll put a link to that in the Show Notes. And then, those who are interested in peanuts and early introduction of peanut allergen in the babies, we also had have some podcasts on that topic. And we'll put links to those episodes again in the Show Notes. 

Are there any ways that food allergies, and especially as we're thinking about milk protein allergy, anyway to prevent that? 

Dr. Bryan Vartabedian: Yes, it's a great question. Listeners probably learned from your other episodes, certainly when it comes to peanut introduction, where rather than withholding some of these proteins, we're introducing them earlier. In terms of other kinds of allergies, one of the best things that parents can do to ensure or to minimize the risk of food allergies is to breastfeed. 

Breastfeeding is associated with a lower incidence of later food allergies in children. So during the first year of life, that's probably one of the cheapest and best things that they can do. 

Dr. Mike Patrick: And that's because mom's eating a variety of foods and some of those proteins and allergens end up in the breast milk. So the baby's immune system is exposed to those early on. Is that the thinking? 

0:32:12

Dr. Bryan Vartabedian: I'm not exactly sure why it's the case, what the exact mechanism of it is. It's not exactly clear to me, but I know the association is pretty tight. 

Dr. Mike Patrick: And then, you had mentioned couple of times in our discussion, probiotics. Are those something that should be given to all babies? Are there certain situations where probiotics are beneficial? Should they never be given? So what are your feelings on those? And if you do give them, which ones do you give? 

Dr. Bryan Vartabedian: So that's a whole lot of questions, Mike. 

Dr. Mike Patrick: Yes. 

[Laughter]

Dr. Bryan Vartabedian: So when we think of probiotics, a probiotic is any living organism that we give that have positive effect in our health. What's so interesting about all this is the fact that if we just go back a generation or two, we were doing everything in our power to ensure that babies get no bacteria exposure. Yet, now, we're adding this to infant formula. We know it's part of their milk. 

So when we think about probiotics, we think of them from two perspectives. One is as a preventative means. We know that certain probiotic strains are associated with the prevention of community-acquired infections, for example. And then, we can use probiotics to treat conditions such as antibiotic-associated diarrhea. 

What's interesting is in Europe, probiotics are use prophylactically to prevent disease, whereas in the United States, we tend to be very reactive to conditions. We like to treat things after they happened. So in the United States, I can't make blanket recommendations for your baby being on a probiotic, but there are certain probiotic strains that have certain effects for say antibiotics and antibiotics use and colic. 

0:34:03

Dr. Mike Patrick: There's a lot of probiotics products that are available over the counter. This is probably not something that parents ought to choose one and just give with their baby without talking to the provider about it, would you agree? 

Dr. Bryan Vartabedian: Yeah, I would agree. And I think it's important to understand that we can't categorically say that all probiotics are safe in babies. We have to understand that certain probiotics strains have been proven over time to be safe in babies. Lactobacillus reuteri, lactobacillus GG are couple of big ones that had been heavily studied. These are the ones that we find in some of more common infant formulas that we use to treat antibiotic-associated diarrhea. 

But we want to stick with the bugs that our providers recommend. It's also important to understand this is a completely unregulated industry. And so, if you go to the standard health food store and just buy a baby probiotic, you don't know where it was made or what center, what the bacterial counts are, whatever. So it's very, very important to use reliable sources of your bugs. 

Dr. Mike Patrick: And your provider will have thought about this and know what they recommend to other families that have researched it. And so, that's going to be a terrific source of information as you're thinking about whether you want to use a probiotic, and which one that you ought to use. 

Dr. Bryan Vartabedian: Yeah, Looking Out for Number Two, my last chapter deals with some of the common probiotics and the ones that are safest for your baby to use. So make sure you check out Looking Out for Number Two. 

Dr. Mike Patrick: Great. And where can moms and dads find your book, Looking Out for Number Two? 

Dr. Bryan Vartabedian: Oh, they can find that wherever any amazing book is sold. So that would be Barnes & Noble, or Amazon, anywhere books are sold, you're going to find them. 

Dr. Mike Patrick: Yeah, and I love that you have a digital version for parents to have that option available. 

Dr. Bryan Vartabedian: Right. 

Dr. Mike Patrick: Great. Again, the book is Looking Out for Number Two: A Slightly Irreverent Guide to Poo, Gas, and Other Things That Come Out of Your Baby. 

0:36:06

We'll have links to the book in the Show Notes of this episode, 378, over at PediaCast.org. Also links to all the PediaCast episodes that we have talked about along the way. But lots more information in the book. So I would really recommend that moms and dads, anyone who takes care of kids, check that out. 

And thanks so much to Dr. Bryan Vartabedian, a pediatric gastroenterologist at Texas Children's. We really do appreciate you taking time out and talking to us today.

Dr. Bryan Vartabedian: Thank you, Mike, I really appreciate it. 

[Music]

Dr. Mike Patrick: We are back with just enough time to say thanks to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.

Also, thanks to Dr. Bryan Vartabedian, pediatric gastroenterologist at Texas Children's Hospital and author of the book Looking Out for Number Two, which we'll provide link for you in the Show Notes so you can find that book easily. He also blogs at 33 Charts. And we'll put a link to that location for you as well and his Twitter handle, @Doctor_V, with an underscore between Doctor and V. And we'll put a link in the Show Notes for that. So you have all sorts of ways that you can get in touch with Dr. V. 

Don't forget, you can also get in touch with us. It's really an easy thing to do. Just head over to PediaCast.org and click on the Contact link. Always appreciate comments and questions, topics. If you want to point us to an article, or a news story, or journal article, all great things, so head over to PediaCast.org because we would love to hear from you. 

You can find PediaCast in all sorts of places, wherever you find podcasts, so iTunes, Google Play, iHeart Radio, most mobile podcast apps. And of course, the landing site is PediaCast.org where we have our entire show archive, all of our Show Notes, our transcripts, our Terms of Use agreement and that contact page I was talking about.

We're also part of the Parents On Demand Network, which you can find at ParentsOnDemand.com. They also have an app and you can find all of our programs in there as well. 

0:38:29

We're also on social media, Facebook, Twitter, Google+ and Pinterest, and we really do appreciate when you connect with us in those locations and share our content with your own online community. 

And, of course, face to face is always really helpful. So next time you see your family, friends, neighbors, co-workers, anybody who has kids or takes care of kids, if you can let them know about PediaCast, really would appreciate that. Word of mouth is really how our audience has grown over the years. 

And that by the way include your child's doctor. So next time you're in for a sick office visit — maybe it's a well check-up, a school physical, or sports physical, maybe a medicine recheck — whatever the reason, just let them know that you found a evidence-based pediatric podcast for parents. And let them know they can find us at PediaCast.org, so they can share the show with their other patients and families. 

We also have a program for pediatric providers called PediaCast CME. That stands for Continuing Medical Education. Similar to this program, we turn the science up a couple of notches and offer free Category 1 Continuing Medical Education Credit for those who listen and participate. 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] 

0:40:05

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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