Magnets, Twitching, Poop – PediaCast 219

This week on PediaCast… Join Dr Mike in the studio for the latest pediatric news and answers to listener questions. This week’s topics include kids in the kitchen, magnet dangers, teaching kids to be persistent, infant self-gagging behavior, twitches and tics, baby poop, blood types and RhoGAM.

Topics

  • Kids in the Kitchen

  • Magnet Dangers

  • Teaching Kids to be Persistent

  • Infant Self-Gagging Behavior

  • Twitches and Tics

  • Baby Poop

  • Blood Types and RhoGAM

Links

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, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is episode 219, 2-1-9, for July 18th 2012. We're calling this one Magnets, Twitching and Poop.

You can probably figure it out that we have a News and Listeners Show coming your way today. I mean, when we have such diverse topics as magnets and poops in the same episode we're probably not interviewing someone; no we're going to answer your questions and speaking of the questions, I really want to thank all of you. The questions have just been rolling in and we're going to answer four of them today and we'll get to all the topics here in just a couple of minutes, but we're going to get to four of them. We have lots of News and Listeners Shows still coming your way in the coming months, so don't let that dissuade you. If there's a topic that you'd like us to talk about or you have a question for us on the program let us know. And in a couple of minutes we'll tell you exactly how you can contribute to the program by asking a question of your own.

01:38

Also I want to remind you that A Healthy You and 22q is a conference that's coming to Nationwide Children's Hospital in September. We mentioned this last week and I sort of put the teaser out there what is 22q. And then I went on to say that it was too long of an answer and so I couldn't answer, we'd need a whole program to explain exactly what 22q is all about. And I got to think it wasn't really fair to give you that kind of a teaser without at least giving you a little bit more information.

22q is short for 22q11.2 deletion syndrome. It's a genetic syndrome that involves chromosome number 22 and in particular a really small microsegment of chromosome 22 is missing and depending on exactly how big that microsegment is it can result in heart defects, cleft palate, hearing loss, kidney problems, growth delay and other issues. It's actually a fairly common disorder, it affects 1 in every 3,000 live births. That makes it almost as common as Down syndrome.

Now, you may be saying well, if it's as common as Down syndrome I may have heard of that but I've not heard of 22q. It's kind of a new name and so in the past it sort of paraded around as different diseases, but now we know they're all really the same disorder and that's why we've come up with the name 22q. Things that it's been called in the past include DiGeorge syndrome, Velocardiofacial syndrome, conotruncal anomaly face syndrome, Opitz G/BBB syndrome and the Cayler cardiofacial syndrome just to name a few.

03:23

So why all these different names? Well, in the past, genetics syndromes were previously categorized by these specific sets of signs and symptoms that you see. So in all the kids with these particular signs and symptoms we would call it this and we knew that it had a genetic component because of the inheritance pattern that would see. But we didn't know exactly where on the DNA the problem was occurring.

Well we've gotten better at examining DNA and now we know that all of the previously described disorders that I mentioned that we now call 22q, we know that all of those really are just different names and expressions of the same disease, because the same part of the chromosome is affected and just depending on exactly how much is affected gives you the different symptoms which we called different diseases back in the day.

So we've come up with the new name to describe all of them and that name is 22q. And as you can imagine kids with 22q have lots of issues. We're talking they could have heart problems, problems with the palate, which is the roof of the mouth, ears, kidneys; they can have issues with immunity, development, speech, feeding, nutrition. And so with all of these issues these are pretty complex kids who need a multidisciplinary team of experts and parents and caregivers of these kids really need lots of education and this particular conference seems to do just that. It's aimed at parents and caregivers and those affected by 22q.

Speakers include experts in Allergy, Behavioral-Developmental Pediatrics, Cardiology, Education, Endocrinology, Genetics, Psychiatry, Reconstructive and Plastic Surgery, and Speech and Language Therapy. The conference is happening September 22nd 2012 from 8AM until 4:30PM here on the campus of Nationwide Children's Hospital in Columbus, Ohio. And if you want to know more information how you can sign up just go to the link in the Show Notes at pediacast.org.

05:19

Speaking of 22q, we have an entire episode of PediaCast dedicated to the disease that's slated for September 12th. So if you want more information about 22q, you don't necessarily have a kiddo with the disease, but you just want to know more, it sounds interesting, you can stay tuned for that.

All right. What are we talking about today? Kids in the kitchen, does helping prepare food make kids better eaters? We're also going to talk about the dangers of magnet, you may be surprise at what dangers lurk not only when you ingest magnets, but if you get them too close to the body in certain kids it could be a problem, so stay tuned for that. Also, teaching kids to be persistent, what is the father's role and why is it important that kids learn to be persistent? And then we're going to answer your questions on infant self-gagging behavior; twitches and ticks; baby poop and blood types and the rhogam shot. If you're an Rh-negative mother you know all about the rhogam shot. Why do you get it? We're going to explain it. All coming your way in just a little while.

06:21

If you have a topic you'd like us to talk about, or you have a question for the show just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

Also, I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org.

And with all that in mind we're going to take a quick break and we will be back with News Parents Can Use right after this.

[Music]

07:35

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

Getting kids to pass up junk food in favor of healthier fruits and veggies has led to many a mealtime meltdown for parents everywhere. Now, researchers from the University of Alberta offer a simple solution: give your kids an apron.

A province-wide survey of Grade 5 students in Alberta, Canada suggests the best way to get your child to eat healthier foods and actually enjoy them is to have them help with meal preparation. "Kids who like fruits and vegetables tend to eat them more frequently and have better diets," says Dr. Yen Li Chu, lead author of the study and a fellow in the University of Alberta School of Public Health. She goes on to say that the study result show encouraging kids to get involved in meal preparation could be an effective health promotion strategy for schools and parents.

The study was published in the journal Public Health Nutrition and involved the survey of students in 151 different schools across Alberta to learn about kids' experiences with cooking and food choice. Nearly one-third of children reported helping with meal prep at least once a day; another one-third said they helped one to three times a week. A quarter of children helped once a month and 12.4% avoided the kitchen completely.

In general, children preferred fruits to veggies. But children who helped with cooking showed a greater preference for both. The data also showed that kids who did meal prep and cooking were more confident about the importance of making healthier food choices.

Dr. Paul Veugelers, co-author and Canada Research Chair in Population Health at the University of Alberta, says, "Getting children to eat healthier food promotes bone and muscle development, learning and self-esteem."

He says, "Good food is important for us. It keeps weight gain away and more important than that, it keeps chronic disease away." Dr. Veugelers adds, "The overarching objective of our work is to lower the burden of chronic disease in our society. And a healthy diet is right at the top."

Dr. Yen Li Chu said the results underscore the value of getting kids interested in mealtime activities in the home, but added there could be room for schools to get involved, too. She says, "You can go into schools and have cooking classes and cooking clubs to help them boost their fruit and vegetable intake and make healthier choices."

Though the survey dealt with Grade 5 students, Dr. Veugelers says, "The lessons are equally applicable to older youth, including college students. For many college-age kids, it may be the first time they leave home, the first time in their lives they're responsible for their own diets, there are lessons here for them too, to form groups and take turns cooking, and pay attention to good meal preparation."

So, it's a great concept and the life application isn't limited to Albertians. Is that what you call folks from Alberta? I'm sure I'm going to get email back letting me know. What do you call yourself if you live in Alberta? So, it doesn't just apply to those folks, this applies to all of us, from a young age getting your kids helping in the kitchen is important. And according to this study it may increase their consumption and enjoyment of fruits and vegetables, but more than that it's great family time and they're learning valuable life lessons as well. And those cooking classes in clubs in college that's another great idea.

Of course one word of warning is in order, you have to supervise your children very carefully when they're helping out in the kitchen. Kitchens contain lots of dangers including knives and glassware and hot liquids and possibly poisonous substances under sink and elsewhere, so be careful, but give it a try.

11:03

Speaking of words of warning, we recently talked about the dangers of batteries in your home, that was back in episode 213. That information came from a study conducted here at Nationwide Children's Hospital and published in the journal Pediatrics. Well, researchers in the UK have responded to our study by adding some comments in the British journal Lancet. You got to love this, researchers talking to one another through scientific journals at each side of the Atlantic Ocean. I don't know, for some reason that just strikes me as a little funny.

OK. So what did the UK researchers say? Well, they want to point that button batteries aren't the only danger and that parents should also be careful with small magnets. It's a point well taken. Magnetic toys are growing in popularity, but so is the accidental ingestion of magnetic elements among children. In their letter, again published in the Lancet, British doctors highlight the dangers of swallowing magnets and advised parents to take extra care that their children do not accidentally ingest them.

In the letter, Dr. Anil Thomas George and Dr. Sandeep Motiwale of Queen's Medical Center, part of Nottingham University Hospitals in the UK, report two separate cases in the last 18 months of children needing surgery in order to remove swallowed magnets. In both cases the children accidentally swallowed magnets from a toy. In the first incident, an 18-month old child swallowed 10 small magnetic spheres and in the second case, an eight-year old child swallowed two two-centimeter long magnetic strips. I don't know, spears would be bad too.

12:37

Both children experienced mild stomach pain and doctors found the magnets lodged in their digestive systems. Normally, small objects, which are accidentally swallowed by young children, are able to pass through the digestive tract without causing internal damage. However, when multiple magnets are swallowed they can become attracted to each other and trap internal soft tissues between them which can cause fistulous to develop. Fistula is an abnormal connection between soft tissues inside the body and it can lead to serious illness if left untreated.

Dr. George explains, "We are particularly concerned about the widespread availability of cheap magnetic toys where the magnetic parts could become easily detached. Parents should be warned of the risk of magnet ingestion, particularly in small children. We believe that improvement in public awareness about this risk will be key in preventing such incidents."

Although similar concerns have been raised in the United States and Canada, this is the first attempt to raise magnetic awareness in the UK. Dr. George goes on to say, "While we understand it may be impossible to prevent small children from occasionally swallowing objects, we would highlight to parents the potential harm that could arise from multiple magnet ingestion. We would advise parents to be more vigilant and take extra care when giving their children toys that may contain magnets small enough to swallow. We would also welcome an increased awareness of this problem among toy manufacturers, who have a responsibility to alert parents to the presence of magnets in their products."

So, hear, hear to our colleagues across the pond. And parents everywhere around the globe the take how is this, keep small magnets away from your kids and seek help right away if you think he or she may have swallowed one or two or three or four. The danger we're really talking about here is swallowing more than one magnet. But what if your child only swallows one? Well, I'd say maybe you only know that they swallowed one magnet, maybe they swallowed another one and you just don't know it. It doesn't mean there's only one magnet in there, there could be more.

14:34

So, even one small magnet could be dangerous if it gets into the airway or stuck in the esophagus. So, even if it's only one magnet make sure that you seek medical health. And you know what, let's broaden that, if your child swallows anything they shouldn't, whether it's magnets, batteries, whatever, seek medical help or the very least call your doctor.

All right. One more warning about magnets and this one is not for ingested magnets but instead, magnets that get too close to the body. Researchers at the University of Michigan have found that Apple iPad 2, I know, I know, say it isn't so, but when I first read that I thought oh no, what's coming? Apple iPad 2 can interfere with settings of magnetically programmable shunt devices, which are often use to treat children with hydrocephalus.

So, let's pause here for just a moment. Hydrocephalus is your body is making too much cerebral spinal fluid and if you have too much of that fluid in the brain it increases pressure inside the skull and that can cause brain damage and can become life threatening. And so kids with hydrocephalus have a shunt in place that diverts some of their cerebral spinal fluid down into their abdomen to the abdominal cavity where the body can just absorb it and there has to be a valve and this is all inside the body. So, this tube that goes from the brain down to the abdomen it actually is underneath the skin. But there's a valve in place that controls how much fluid is diverted because you don't want there to be not enough fluid diverted and you don't want too much fluid to be diverted, you want it to be just right and that is controlled with a valve.

16:15

Well, you can't just adjust the valve by turning a dial on it because this is something that's under the skin, it's implanted. And so doctors use small magnets that they put close to the body and depending on how strong the magnet is that changes the setting of the valve, that's how that's done.

So, the iPad 2 and the new iPad 3, they're just calling it the iPad, the newer one to the list as well, they don't call it a three; but you know what I'm talking about; these iPad 2s and 3s contain magnets that can change valve settings in the shunt if the iPad is held too close to the valve. Too close is within two inches. Such a change may result in shunt malfunction until the problem is recognized and the valve adjusted to the proper setting.

Patients and their caregivers should monitor use of the iPad to ensure no changes made to the valve settings. The results of this study we'd publish in the August 2012 issue of the Journal of Neurosurgery Pediatrics. The idea for the study first presented itself when doctors noticed that an iPad 2 seem to affect the programmable shunt in one of their patients, a four-month old girl with hydrocephalus. Three weeks after the baby had received the shunt she was examined for shunt malfunction due to a changed setting in the magnetically programmable valve that regulates the flow of cerebral spinal fluid.

17:39

The baby's mother stated that she had held an iPad 2 while holding the infant. Programmable shunt valve settings can be altered by exposure to magnetic fields. Indeed, specialized magnets are used by physicians to adjust the settings on these valves. Since in this case no other environmental factor could be identified that would have led to a shift in the valve setting. The authors decided to test whether the iPad 2 might be implicated because unlike the initial iPad the iPad 2 and 3 contain several magnets and is often used with an Apple Smart Cover, which contains additional magnets.

The researchers tested 10 programmable shunt valves with a variety of devices. They exposed the valves to an iPad 2 with and without the Smart Cover at different distances – less than 1 cm, 1 to 2.5 cm, 2.5 to 5 cm, 5 to 10 cm and greater than 10 cm – and each exposure to the magnets lasted 10 seconds. Overall, the valves were tested 100 times for each of the five distances during exposures to the iPad 2 with the Smart Cover attached and 30 additional times without the Smart Cover for distances less than 1 cm.

After exposure of the programmable valves to the iPad 2 and Smart Cover at distances between 0 and 1 c, the researchers found the settings had changed in 58% of the valves. At distances between 1 and 2.5 cm, the settings changed in only 5% of the valves and after exposure at distances between 2.5 and 5 cm, the settings had changed in only 1% of the valves. No change in valve settings were identified after exposure at distances greater than 5 cm.

And remember those 30 additional trials at distances of 0 to 1 cm with the Smart Cover removed, in those cases researchers found the settings had changed in 67% of the valves. Although no change in setting was found past the distance of 5 cm or about 2 inches, the authors cautioned that patients and caregivers should be made aware of the potential for a change in the setting of a magnetically programmable shunt valve if an iPad 2 or 3 is placed very near.

19:42

This is not to say the iPad 2 cannot be safely used in the general vicinity of patients with programmable shunts. A variety of magnets can be found in households today and the authors state the magnetic field strength of the iPad 2 lies within the range of these everyday household magnets.

So, this is not a reason to throw second-generation iPads out of your home, just don't put them within 2 inches of your child's magnetically programmable valve. And likewise, don't allow any other household magnets to get too close either. Dr. Cormac Maher, a pediatric neurosurgeon and lead author of the report says he hopes to raise awareness of this potential interaction through publication of this study.

So, if you have a child with a valve shunt and you have an iPad 2 or 3, you know the newer ones, or any other device at home with a magnetic field, be sure to keep the magnets at least 2 inches away from the shunt valve. And if you know someone who has a child with hydrocephalus and a valve shunt in place, kindly pass on this information to them. Of course, if your child has a valve shunt, regardless if there's an iPad 2 in the home or not and if they shows signs of shunt malfunction, things like headache, vomiting, irritability, poor feeding, etc., be sure to seek medical help right away.

20:50

All right. One more news story for you this week, this one involving fathers. Dads as it turns out are in a unique position to help their adolescent children develop persistence. These are the findings from a new study published in the Journal of Early Adolescence and conducted by researchers from the Brigham Young University's School of Family Life, after following 325 families for a period of several years.

BYU professors Laura Padilla-Walker and Randal Day discovered that with time, the persistence gained through fathers resulted in a lower delinquency rates and a higher engagement in school.

Professor Day explains, "In our research we ask 'Can your child stick with a task? Can they finish a project? Can they make a goal and complete it?' Learning to stick with it sets a foundation for kids to flourish and to cope with the stress and pressures of life."

Professor Padilla-Walker adds, "There are relatively few studies that highlight the unique role of fathers. This research also helps to establish traits such as persistence, which can be taught and key to a child's life success."

The researchers point out that dads need to be 'authoritative' but not 'authoritarian' in order to succeed. For instance, an authoritative dad clearly establishes himself as a person the child should respect and responds to the child's needs, whilst maintaining a nurturing home in which the child feels comfortable making mistakes and questioning rules. Authoritarian dads, like authoritative dads, also establish themselves as an authority, but with the major difference that an authoritarian dad does not respond to his child's needs and instead rigidly enforces rules and punishes the child.

The researchers established that the key to success is that children feel their father's warmth and love, that accountability and the reasons behind rules are emphasized, and that children are granted an appropriate level of autonomy.

The findings demonstrated that around 52% of the dads who participated in the study showed above-average levels of authoritative parenting, which influenced their children to become substantially more likely to develop persistence, which in turn led to improved outcomes in school and lower levels of delinquency.

Even though this study focused on assessing children between the ages of 11 and 14 years living in a two-parent household, the researchers believe that single parents could also play a role in teaching the benefits of persistence, and suggest that future research should be conducted.

Professor Padilla-Walker concludes, "Fathers should continue to try and be involved in their children's lives and engage in high quality interactions, even if the quantity of those interactions might be lower than is desired."

So dads and when dads aren't around, moms, help your kids set goals and help them to complete those goals, that's the bottom line advice from the researchers at Brigham Young University. The expected results, kids who learn persistence have fewer behavioral problem and better academic success.

All right. That concludes our New Parents Can Use this week. We are going to take a quick break and we'll come back to answer your questions right after this.

[Music]

24:19

All right. We are back and this is I think one of my favorite parts of the doing this show. It's important to get the news out there and covering research topics and doing the interviews, it's all important, but as a pediatrician, getting parents' questions answered is probably the most rewarding thing that we do, at least in my opinion. And so we've got four great questions here for you today and let's get right to it.

The first one comes from Vichel in Olathe, Kansas and Vichel says, "Hello, Dr. Mike. About 10 months ago my wife and I became proud parents of a beautiful girl. She is generally very playful and well-mannered but she has one very annoying habit – she sticks her index finger in her mouth and continues to do so until she throws up. If we take or force her hand away from her mouth, she thinks we're playing with her and continues to do the same thing but with a big smile on her face. The only time she stops is when she's watching baby songs or eating. I'd much rather have her play with toys instead of watching TV. What can we do to break this habit of hers? I've been listening to PediaCast and spreading the word in conversation and through your posters ever since I came to find out about the show a year ago. Thanks for the great program. Sincerely, Vichel.

Well, thanks for the question, Vichel. This is actually a common issue with young kids and it's something my son did quite frequently at this age. So, why did they do it and how can you make them stop? Let's tackle the why first. Different reasons really for different kids, I think boredom is one, learning cause and effect – when I put my finger in my mouth it makes me feel like I have to gag and then I throw up and so there's kind of learning this cause and effect that doing this produces this result and it's reproducible. They can also use it as an attention getting device and as part of an obsessive compulsive type issue. So, we have to kind of figure out why they're doing it before you can create a plan for eliminating the behavior. So let's kind of go through each of these reasons why and talk about it if that's what it is, sort of a plan that you can do to eliminate it.

26:30

If it's boredom, they're just doing it because they're bored, distraction usually works. You just get their mind on something else and it sounds like in the past you've kind of use that a little bit. If you get her to watch a particular program on TV that is one way that you are distracting her or if you actually present her food to her it's a distraction. So, just something to get their mind on to something else often times works if it's boredom.

In terms of they're doing it because they're learning this cause and effect, and at that point if they're only gagging but they're not really vomiting every time, ignoring it may be the best thing to do, just let them see the cause and effect and then let them get bored with it and pretty soon they'll be off on a different but equally annoying cause and effect experiment. They may not be gagging themselves anymore, but now they're spitting on the floor so they can watch it go from their mouth and splatter on the ground every time; or they may drop their food from the highchair and watch the dog lick it up; or blowing raspberries in your face or yanking the glasses off of your face and tossing them to the floor.

I mean, life is a grand experiment at this age and although these things can be annoying, you're child's learning about the world around them and learning that actions lead to reproducible effects. So, they're like baby scientists and they're seeking evidence-based patterns of cause and effect. It's just kind of cool when you think of it that way. And if one particular behavioral pattern is really annoying you just wait it'll go away, but be warned, another is lurking in the shadows.

28:07

Now, what if they're learning this cause and effect but they're doing to the point of actually vomiting? Well, for a lot of kids that's the result that leads them to stop the behavior and explore elsewhere. Now I know, Vichel, that's not the case for your child, but I'm just saying if the reason the kid is doing this is because of that cause and effect thing and they actually get to the point that they vomit, a lot of kids they don't necessarily vomiting, the gagging is OK, but vomiting is not so much. And so often times for those kids when you actually get to the point that you let them vomit they'll stop that behavior and explore elsewhere because they don't like to vomit.

Now, what if they do like to vomit and they keep doing it? Well, now you have a bigger problem and distraction from the first sign that the finger is going in the mouth may work, not taking your child's hand away because you're not going to win that battle. Their hand is attached to their arm, which is attached to their body and it's always within reach of their mouth, right? But instead offer distraction with spoon, a finger food, a toy, a goofy song or dance, something to distract them from what they're doing.

What if that doesn't work? Well, if they're bent on making themselves vomit to the point they're making messes all the time and it's to the point that they're possibly not gaining weight well and really affecting the quality of life in the family, at that point you're dealing more with an obsession compulsion type of issue. And that is likely to require professional help to really come up with a coping plan. And I'd start with your pediatrician, but he or she may need to refer you to a behavioral specialist or a feeding disorder clinic if they're doing it to the point of vomiting and they're doing it so much they're not getting enough nutrition and they're not gaining weight and it's really interfering with their quality of life.

29:54

All right. We've tackled all of the whys except for one and the reason I saved this one for last is because it's probably the one that you're dealing with, Vichel – using self-gagging as an attention getting device. And why do I think this is your child's issue? The hint really is that big smile on her face when you respond to her and she puts her finger right back in her mouth.

For these kids, if they're doing it to get your attention, if they're doing it to get a rise out of you, for these kids completely ignoring them when they engage in that behavior, even when they vomit as long as they're not choking and turning blue, even when they vomit completely ignoring them is your best bet.

And then when they're done with the behavior then engage. Or better yet, try to anticipate when they would start the self-gagging behavior and engage them at that point. So, if it's always when they're in their highchair and they're waiting for their food to be presented to them that's when this happens, get their food all ready and the moment you point them in the highchair present their food.

So, try to anticipate when they're likely to do this and change what you're doing so that it doesn't happen. And then if it does start to happen, ignore it, that's really your best bet. Of course, even though you're ignoring them you're still secretly paying attention in case safety concerns become an issue. You don't want them choking on their vomit and turning blue. You still have to pay attention to them, but you don't want to let your child know that you're paying attention. But in the end you have to outsmart them.

You have to think like a baby, which is easier for some of us than others. All right. I hope that helps, Vichel. Thanks for the question.

31:30

Let's move on to twitches. This comes from Alicia in Tennessee and Alicia says, "My eight-year old has started blinking his eyes, twitching his nose like Bewitched and clearing his throat like he is sick all the time. He's a very healthy boy who's aside from tubes in his ears has never been a sick kid. When I asked him about this, he says he doesn't know why he does it and sometimes I don't think he even notices it.

So, Alicia, I'm going to point out again as I always do, for all of these things when you have a question it's fine to write in and get some more education on it, but primary thing you want to do is see your doctor. You want to see your doctor so they can really tease out more of the history, do a physical exam and give you their opinion. So having said that, Alicia, based on what you're saying with blinking his eyes, twitching his nose, clearing his throat, these sound like ticks.

And ticks are stereotypical voluntary movements that involve the same set of muscles. So, stereotypical in that whatever the motion is it's always the same, voluntary. They do have control over it, it's not involuntary. And blinking the eyes, twitching the nose, clearing the throat these are all common ticks, common, stereotypical, voluntary movements.

What causes them? Well, we know that there's a behavioral component and we know that because those ticks tend relieve stress and they're often exacerbated or made worse during times of stress or heavy concentration. And so you have a kid who's really thinking about their homework and maybe they're a little stressed over it and they're really concentrating and you'll see those ticks come out more. Or in stressful situations you'll see them come out more.

And we think what happens is that instead of focusing on the stress suddenly the child focuses on the need to have this tick and then by actually doing it it helps to relieve the stress and makes them feel a little bit better. This is sort of the entrance level into obsessive compulsive types of behavior. So, you're obsessing about something, in this case the tick, and then you feel compulsed to do it and that's the action. So you think about it, you do it then you feel better. And so this is kind of early on obsessive compulsive type stuff where you think about it stress builds and the action follows it relieves the stress.

33:56

Now, does that mean that you have to do something about it? We're going to get to that. So, just kind of pause with me for a moment that there is this behavioral component to ticks. There's also a chemical component to ticks. We know that certain drugs, especially drugs that stimulate the central nervous system, can make tick expression worse. So if you're already kind of prone to having ticks, you're child may actually have them more when they're on a central nervous system stimulant, things like ADHD drugs like Adderall, Concerta, Ritalin, Vyvanse, caffeine, these kinds of chemicals can make ticks worse and so we know that in addition to their being a behavioral component there's also a chemical component involved.

We also know that ticks are common. They affect up to 20% of kids at some point during childhood. We also know that they tend to come and go and most often they tend to be mild. So, in 20% of kids they'll have the tick then it goes away, a few months later it may come back then it goes away. And tends to be mild, it doesn't really interfere with their life.

OK. So what do you do about this? Well, definitely you want to talk to your doctor, because again you need that complete history, you need the complete physical exam with an emphasis on a neurological exam just to make sure that there's not something else going on. If the history and physical are otherwise normal and your doctor is convinced that the behavior is a tick, treatment often times just ignoring the behavior will eventually make it go away.

Again, it's 20% of kids have this at some point or another, in most kids they're mild and in most case they just go away on their own. If you focus on it, if you really talk to your kid about it all the time, then the focus is back on the tick, so then they think about it more, do it more, it becomes more of a stressful situation. Now they're not only stressed out from whatever is stressing them out, but they're also stressed out because they have these tick and they can't seem to make them go away, oh, but I just did the tick, now I feel better. And so focusing on it usually does not help. Your best bet is just ignoring it and most of the time it'll go away on its own.

36:01

Now, when do you want more help than just what your pediatrician can provide? What's the reason for a referral and where would you get referred to? So, things that would make you as a primary care doctor want to refer for ticks concerning history, if there's a family history of severe ticks, if there are severe symptoms where they're shouting out obscene words and when it starts to become more of a severe symptom tick disorder where it's interfering with your life, then we start to call that Tourette syndrome.

Also, there are some seizure disorders like partial complex seizures that could kind of masquerade as a tick and brain lesions, brain tumors could cause a particular problem and especially then you're going to have more than likely have an abnormal physical exam when you really do the neurological exam. So, if there's anything concerning in the history or in the physical, then your physician may want to make a referral.

And if the tick is persistent, it's lasting a long time, it's starting to interfere with your child's quality of life, maybe they're getting made fun of it at school, they don't want to participate in certain activities because they're embarrassed about the tick, so if it's really affecting their quality of life and it's persisting or there are concerning things in the history or concerning things on the physical exam, then it's time to do a referral to get more help.

And again, where do you go? A couple possibilities – pediatric neurology, especially if there's a concern for something other than ticks like a seizure or brain lesion based on the history of physical or they're having severe symptoms. And a pediatric neurologist may do an MRI, an EEG, do an exam and possibly put your child on medication for it if it's particularly severe.

Another possibility to go is behavioral health such as psychology or pediatric psychiatry. This would be a little more appropriate if it's still mild symptoms but there are still quality of life issues. So, the history and physical really aren't concerning, it just seems like a normal childhood tick type thing but it is affecting your child's life and they need to have some more tools in their hands in terms of dealing with this, you know biofeedback type stuff or possibly medication.

So, behavioral health and pediatric neurology are kind of where you want to go if there are concerns, but be assured that there are a lot of kids who have this up to 20% of kids, certainly not all of them need the referrals and most of the time it's mild and comes and goes on its own. It exactly what happened in our case.

38:34

All right. Let's move on. Alexandra in Buffalo, New York says, "Hello, Dr. Mike. I am a first time mom and I've been listening for months since I first found this podcast on iTunes. My son has poop issues every now and then and it seems to cause him discomfort. He pushes until his face is red. I understand that as babies get older, their poop gets more like adult poop. In the beginning I was breastfeeding and his poop was like normal baby poop – mashed potato-like. Then when I stopped breastfeeding and started him on formula, his poop was getting harder. I used and have had to use recently Karo syrup until I discovered yoghurt for babies up until the last few weeks his poop is getting hard again and sometimes too hard and he starts crying. I know sometimes introducing new foods can be the reason, but is there anything that I can give him to help him poop better? He's still on formula as well, do you have any suggestions. Thanks, Alexandra.

All right, Alexandra. Well, thank you for listening to the program and for asking for questions. There's a lot that we could say on baby poop and so I'm really going to try to focus on your particular situation, Alexandra, and just talk about when babies have a hard time pushing out their poop and it's hard when it comes out and not soft. You didn't mention how old your baby is, which is kind of important. So that's one thing that if I were seeing you, as your doctor I'd want to know and obviously I would be right there on the chart how old your baby is.

Also, it's important to know that difficult to pass hard formed stool usually is the result of not having enough water in the stool. And the intestine does a great job of absorbing water, but it's not leaving enough water in the poop and so you have to increase the water component in the stool to make it softer and easier to pass. Now again, we're assuming that the issue here is hard poop. There are also medical conditions that could cause babies, Hirschsprung disease is one that immediately comes to mind, but there are others that can affect poop. And so again, you definitely want to see your doctor and let them get the complete history, do a physical exam and give you their opinion.

40:42

But let's say they say, yeah, the poop's too hard, it's constipation, you need to get the poop softer. How do you do this? Increasing water intake usually does not work at least by itself. The reason is that the intestine is doing a great job absorbing water. So if you give more water, the intestine is going to absorb more water and you're still left with hard formed, dry, difficult to pass stool. So if adding water doesn't help, what will?

Well, you have to remember the large intestine, the inside lining of the large intestine is a semi-permeable membrane. And if you take your mind back to high school biology class and remember that osmosis is something that happens across this semi-permeable membrane where water flows across the membrane in the direction of less particles to where there is more particles.

So if we want more water to get into the large intestine to loosen up the poop, then we want undigested particles in the stool to draw water into the bowel lumen, the opening in the center there, and this will increase the water content in the stool and make the poop looser and easier to pass. Now, this is exactly what we do in older kids with constipation, we often use MiraLAX to accomplish this. MiraLAX is a powder, you put it in water, juice, mix it up and basically these undigested particles make it into the large intestine take all of these particles in the large intestine, more water then is going to enter the bowel through the membrane and by osmosis. And so you end up with looser poop and that helps you to go.

42:15

Now, in babies we usually try different strategy. MiraLAX would likely work and sometimes we do use it for babies if we have to, but often a little dietary adjustment is all that's necessary. So what can we use? Well, number one, Karo syrup is something that you mentioned and I would not recommend this for infants younger than 12 months of age and I'll tell you why here in a second. Karo syrup is actually corn syrup and it has undigested sugars that get down to the large intestine and draw water in by osmosis and helps in that way.

The problem with corn syrup though is that it may contain spores of a microorganism called Clostridium botulinum and that particular organism makes a toxin that causes paralysis and we call that botulism. It includes paralysis of the diaphragm and so babies can stop breathing and it can be life threatening. So you don't want your babies to have botulism. It's rare but it is possible and so a Karo syrup is not recommended for infants younger than 12 months of age. And the makers of Karo syrup they don't want you giving it to your babies, they say so right on their website.

Now, some practitioners still recommend it, but I wouldn't. I would not take the chance. The people who make Karo syrup don't want you doing it so just don't do it. If they're less than 12 months old don't use Karo syrup. By the way, the same is true for honey, we don't want babies less than 12 months of age to eat honey and the reason is the same, we don't want them to get botulism from the honey.

43:42

Incidentally, why is it OK once they're about 12 months of age? Well, the issue then is their immune system is better and they can take care of those organisms without the disease occurring. In other words, the organism can't proliferate in their body to the point there's enough toxin to cause a problem. So, once they're 12 months old they're usually OK.

All right. So, you can't use a Karo syrup, what can you try? Well, apple juice and prune juice are great options and you do want to use pasteurized apple juice or prune juice. Pasteurized there's a far less risk of C. botulinum pores. Now it's not zero percent, but it's much less likely. And pasteurized apple juice and prune juice have undigested sugars in it including fructose and sorbitol that make it to the large intestine and so again the water component of the stool is increased by osmosis.

And by the way, baby apple juice and prune juices are less likely to help, the baby kind. And why is that? Because the makers of the baby apple juice and the baby prune juice water it down to provide less of the undigested sugars. Why? Because they would give kids diarrhea and if your baby had normal soft baby poop and you got undigested sugars down to the large intestine that drew more water in it and it makes them even looser and so it can give your kids diarrhea. And so they add water to the apple juice or prune juice to dilute it out and it give them volume, they're getting less of the undigested sugar and it doesn't cause to loosen up your poop.

45:14

But in a constipated kid you want looser poop and so using the baby apple juice or the baby prune juice probably isn't going to help very much. So don't use the baby juices, just use full strength adult apple or prune juice that's been pasteurized, which most of the ones that are on the market have been unless you're getting a fresh, organic one. So you do want it to be processed at some point to make it safer.

So you don't want to use the baby kind and you don't want to take the adult kind and dilute it water, in other words make your own baby juice. So just use full strength adult apple juice or prune juice.

How much do you use? Well, you want to titrate it to get the stools where you want them. Usually for young babies a couple of ounces twice a day is a good place to start. Remember you're not using this for nutrition; you're using it as an osmotic stool softener. And there are some other options for osmotic stool softeners that doctors can use including milk of magnesia, MiraLAX like we talked about.

So you still need to see your doctor for this so they can do a complete history and physical exam that's still important to make sure that it is the right diagnosis and to come up with a plan for your child. I know in my own practice using apple juice or prune juice for babies typically does help loosen the stool pretty nicely for you. But there are some diseases that can do it and so it's important that your child sees your doctor and you talk about this in the exam room.

46:35

All right. Let's move on to our final question, this one comes from Elizabeth in Round Mountain, Nevada. Elizabeth says, "Dr. Mike, I don't know if this is the right place for this question since it's more of a prenatal question, but figure I'd try." That is a good one. This is actually a good one, Elizabeth. "I have Rh-negative blood, actually it's A-. If I become Rh sensitized it can cause serious complications for future pregnancies. I have one child, a little boy, but I've had two miscarriages since. They were both before 10 weeks, but I still got a rhogam shot with the first miscarriage. Can you explain the complications sensitization can have on a developing fetus, how is it treated and are there any complications once the baby is born? Also, can a person become immune to the rhogam shot? Finally, I was curious about the genetics of blood types, are there dominant genes for blood type? My mother is A-, my father was O, three out of us four children are A- with one unknown; I am A-, my husband is unknown and my son is A-, there just seems to be a lot of A negatives. I appreciate you podcast tremendously, especially that it is evidence-based. Both my husband and I have a strong science background and the only thing more frustrating than people preaching and teaching opinions as facts are people who twist the facts to their own agenda. There are not enough people like you out there willing to teach others how to read and interpret scientific papers and to think critically. Thanks, Elizabeth."

48:02

Well, thanks for the kind words, Elizabeth, I really appreciate it. It's nice to know that what we're doing here makes a difference for people. So let's talk about blood types. A blood type is basically, and really there are lots of different blood types out there, the ones that we most commonly talk about are the A-B-O group, so you're either A, B, AB or O and Rh, either you're either Rh positive or you're Rh negative. And so we get A+, A-, B+, B-, AB+, AB-, O+ and O-. And so these are just looking at the A-B-O group and the Rh group.

And what determines all of these are proteins on the surface of red blood cells. So, you have red blood cells that carry oxygen around the blood, they have some proteins on their surface and based on what proteins you have is how we determine what blood type you have. And again, we're only looking at A-B-O and Rh here because those are the most significant ones. But there's really 30 different ways that you can type blood. So there are other minor proteins out there, but the A-B-O and the Rh ones are the ones that are most immunogenic, in other words, they're the ones that the immune system cares about the most and the ones that can create the most disease and so they're the ones that we talk about the most.

A, B, O and Rh are both genetically determined and in fact, they're autosomal dominant. You could draw a Punnett square, if you remember we've talked about this many times and if you don't know what a Punnett square is just Google Punnett square. Most of you though, if you took even middle school biology or life science, you've probably dealt with a Punnett square where you make a box of four squares and you put mom's genes on top, dad's genes along the side and then kind of mix and match to figure out what the possibilities are for the baby. So, if a parent has blood type A, they can either be AA or they can be AO.

And so if you line them up on a Punnett square, if you had two adults, a mom and a dad and they're both AA then all their babies are also going to be AA. But if mom and dad, one of them say O and the other one is AO, so they're both type A but they're expressing it as AO, then 25% of their babies are going to have O type blood. So, I hope that kind of makes sense to you. You can do that with the As, you can do that with the Bs. If you have AB, you're going to have an A and a B and if you have O blood you have OO. So either you're going to have an A, a B or an O, you're going to have two of them, one from your mom, one from your dad. They're dominant so if you have an A and an O then you're going to have blood type A. If you have a B and an O you're going to have blood type B. If you have an A and a B you have blood type AB.

50:54

And then you can do the same thing with Rhs, so you're either Rh+ or you're Rh-. An Rh+ can be positive-positive, both mom and dad and then everything's going to be positive when you run it through a Punnett square. Or they can be a positive and a zero or an O and if you had a mom or a dad who are both positive and O then 25% chance that they would have an O, 75% chance that it would be positive.

So again, you just kind of write down your Punnett squares, it's autosomal dominant, it's genetically determined. Those of you who don't care let's move on. Those of you who do, do the Punnett squares and you'll see what I mean.

So, the A, B, O and the Rh are the most important in terms of the immune system. And here's what happens with the immune system if there's a foreign protein that's foreign to your body you're going to make an immune response to it. You're going to make an antibody to attack and destroy the antigen and so let's say you are A-, then anything other than the A protein your body is going to think of as being foreign. So if a B protein comes in, so if blood type B is introduced into your body or any blood type that's Rh+, if you are A- the only thing you're going to tolerate is that A protein.

Anything else is going to cause an immune response and you're going to make antibodies that will attack the red blood cells that have those foreign proteins on them and then that can lead to fever, destruction of the red blood cells, which causes hemolytic anemia, the red blood cells are destroyed, they spill their contents including hemoglobin, which is toxic to organs like the kidneys and that can result in kidney failure and possibly death. And that's what we call a transfusion reaction and that's why we type blood and only transfuse compatible types.

52:46

Incidentally, if you're AB+ your body is used to the A proteins, the B proteins and the Rh protein and so you're what we call a universal recipient. So you could tolerate type A blood, type B blood, you could tolerate type O blood and you could tolerate whether it's Rh+ or Rh- because your body is used to all the proteins, the As, the Bs and the positive Rh. So you're the universal recipient, you can accept any blood.

If you are O- then your body is not used to any of the proteins. OK? You're not going to tolerate A, you're not going to tolerate B and you're not going to tolerate the Rh. And so you're what we call though the universal donor because your blood doesn't have any of those proteins in it and so there's no A, there's no B, there's no Rh, there's nothing that another person is going to have a significant reaction to and so you're what we call the universal donor. You could give your blood to anyone.

All right. So, with all that in mind let's turn our attention to the babies. Let's say if an Rh- mom, so she is not used to the Rh protein, she's not going to tolerate that Rh protein. And so if you have an Rh- mom and her first baby is Rh+. So in other words, they must have gotten the Rh+ from the dad because the mom is negative, but the baby is Rh+. Well, mom's going to make antibodies against the Rh protein.

54:15

Now, mom and baby's circulation is separate but a little bit of baby's blood can escape the fetal circulation and enter the mom's blood through the placenta and it's a small amount, mom is going to make antibodies against the Rh, but it's rarely a problem for that initial baby because it takes a little bit of time to make enough antibodies to cause a problem and it's a very small amount. But subsequent Rh babies, so the first Rh+ baby is fine, but subsequent Rh+ babies will now mom's blood is going to launch a large scale attack on the developing baby.

And remember one of the things that mom does give to the baby through the placenta is antibodies and so if mom now has antibodies against the Rh+ protein, because of that first baby that was Rh+, so that baby sensitized mom, she made now Rh+ antibodies. With the second Rh+ baby, those antibodies now are in full force, they go across the placenta, they attack the baby's blood and often times it just causes spontaneous abortion of the baby, but it can cause something called hydrops fetalis.

And hydrops fetalis is when you have severe anemia, oxygen delivery is important to the developing fetus, so if you have severe anemia the developing baby is not getting the proper amount of oxygen delivered to their tissues. Also, lack of red blood cells decreases osmotic tension in the blood. So remember water flows from more particles to less particles, remember from our constipation talk, the same is true across blood vessels.

And so if you don't have a lot of red blood cells you have less particles in your blood and so the water component of blood is going to flow out of the blood vessel and into unwanted places and in particular it can go to the subcutaneous scalp, the pleural areas around the lung, the pericardial area around the heart, the perineum around the intestinal organs. And so you get these fluid collections of what used to be the water component of blood that's in places it shouldn't be and that can result in organ malformation.

56:37

Again, spontaneous abortion of these kids is high, but if they do make it to term where the infant mortality is very high, it's a bad, bad thing that we want to prevent. So how do we prevent it?

Well, the answer is rhogam, which is a shot. The rhogam is human antibody against the Rh protein. So the idea is this, if you take an Rh- mom and you give her rhogam, then when the baby, if a little bit of an Rh+ baby's blood gets into the maternal circulation, those antibodies are there waiting, attack it, kill it and so the mom's body doesn't make her own immune response, doesn't make her own antibodies against the Rh because the ones that we provided mom through the rhogam shot do the job, attack it, so that she doesn't make an immunity against it.

So you have those antibodies already floating around ready to attack any baby Rh that enters an Rh- mom and destroys those cells so mom doesn't have an immune response and make her own antibodies. Now, what about those rhogam antibodies themselves? Well, as it turns out not very many of them cross the placenta, but if mom had made her own antibodies against it then a lot of them would have crossed the placenta and caused the problem for the baby.

57:52

So rhogam is given to all Rh- mothers regardless of the baby's blood type because you really want to give it before you even know the baby's blood type, because when that first cell with Rh+ on it enters in the mom, you want that rhogam working. So you always give the rhogam to Rh- moms regardless and that way they're protected and their subsequent babies are protected.

Rhogam would be expected to work the same with each pregnancy, so a mother wouldn't develop tolerance to it because this is passive protection, OK? Mom's immune system is not involved at all. In fact, we're providing this so that her immune system doesn't become involved in it. So I hope that helps, Elizabeth. I kind of glanced back to your question here to see if I missed anything. So we talked about why that's a problem for developing fetuses having those Rh antibodies, how is it treated or are there any complications. Once the baby is born there really aren't any complications.

Any of the complications that we see with hydrops fetalis are things that happen while baby's still developing inside mom. Once they're outside of mom, then it's not going to be a problem anymore. So, hopefully all that makes sense. It's kind of a complicated topic and I know that it did go a little bit better; we almost need to do a video podcast for this one to kind of draw a Punnett square so you'd see exactly what I'm talking about.

59:12

All right. So we've got all of our questions answered for this week. I do want to remind you that if you have a question for me it's easy to get a hold of me, just go to pediacast.org, click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS. 347-404-K-I-D-S.

All right. We're going to take a quick break and we'll be back to wrap up the show. Be sure to stick around, i want to tell you about a new podcast app from Apple and also there's not going to be a show next week and I want to explain why. So, stick around, we'll have those answers for you, right after this.

[Music]

60:14

All right. We are back to wrap up the show. Just a friendly reminder, A Healthy You and 22q Conference, don't forget if you are interested in that you can find the link in the Show Notes that'll point you to the right direction to find out more about the conference and to sign up for it.

Apple has a new free mobile podcasting app and it allows you to subscribe to shows on the fly, you can download and listen to new episodes without connecting to your computer. So this is brand new from Apple. It's called Podcasts, pretty simple. So if you go to the iTunes mobile store simply search for Podcasts and it's free. It's a pretty cool app to help you organize all of your podcasts.

All right. No show next week, I know the 4th of July we didn't have a show because the 4th ended up on a Wednesday, which was our usual release date for the program so we didn't do one. And we're taking a summer vacation to California as a family next week, so we won't be around to do a show for you then. But the following week we will have an episode for you so stay tuned for that, point of explain there why we're not going to be here next week.

61:18

Also, I want to thank all of our listeners for taking time out of your day and your week to be a part of the program, particularly those of you who have written iTunes reviews and/or clicked on 'this review is helpful' in the iTunes Store. If you know what I'm alluding to there you can tune in to the program a couple of weeks ago. And I do want to thank those of you took that call to action and went to the iTunes Store and either wrote a review or picked some that you thought were helpful. So I want to thank you for that.

Also, those of you who write in to the program, we really appreciate your input and participation in the show. Be sure to join our community by liking PediaCast on Facebook, you can also follow us on Twitter and tweet with hashtag #pediacast. You can also hang out with us over on Google+. Be sure to swing by the Show Notes at pediacast.org to add your comments to today's show.

We also appreciate you telling your family, friends and neighbors about PediaCast and don't forget to talk us up with your child's doctor at your next well check-up or sick office visit. We also have posters you can download and hang up wherever moms and dads hang-out. You can find them under the Resources tab at pediacast.org. One more time, pediacast.org Contact link or email pediacast@gmail.com or call the voice line 347-404-KIDS. 347-404-K-I-D-S.

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

[Music]

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

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