Milk, Pregnancy Spacing, Psoriasis – PediaCast 293

Join Dr Mike in the PediaCast Studio for more Answers to Listener Questions! This week’s topics include milk consumption (which type and how much?), pregnancy spacing, immunizations (how many are too many?), and guttate psoriasis.

Topics

  • Milk Consumption

  • Pregnancy Spacing

  • Immunizations: How Many are Too Many?

  • Guttate Psoriasis

Links

 

Transcription

Announcer 1: This is PediaCast. 

[Music]

Announcer 1: 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 to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the campus of Nationwide Children's Hospital on Columbus, Ohio. It is August 27th, 2014, PediaCast episode number 293. We're calling this one Milk, Pregnancy Spacing and Psoriasis.

It's a Listener Edition of the program we have lined up for you this week. So these are the topics that you guys came up with. We're just taking questions that you guys have written in and giving you some answers. So, it, really, I think one of my favorite episodes that we do. I like going through the research and giving you some practical twist to the research and kind of putting in terms that everybody can understand. And, of course, I really enjoy interviewing pediatric experts as well. But these Listener Questions shows where we get to answer your questions, these are the ones that are near and dear to my heart. I mean, this is really why I started PediaCast in the first place back in 2006.

0:01:33.5

So I'm really excited about this show, get some more of your questions answered. And stay tuned, if you have a question, I'll let you know how to write in. It's really an easy thing to do and we'll try to get your question on our next Listener program. 

So, it's been kind of slim pickings in shows this summer, I do realize that. 

[Laughter]

Dr. Mike Patrick: Most of the year, we have shows about every week. Every month or two, we'll skip a week. But this summer, the shows have been little fewer and farther between so I thank you for your patience with that. 

I have taken a couple of weeks of vacation. We also had a big move. We built a new studio. There's now a new PediaCast studio. I'm not sitting in familiar surroundings at this point. The old studio was up against an external wall and had a big old window and the window actually cause the glare on my screen. And the guests who were here, we were staring at the window in the afternoon, it usually had sunlight streaming in. 

0:02:37.8

And for some reason, the air-conditioning in that room, too, just didn't work quite well and it was always blazing hot. So it came to pass that they wanted the office for an administrative type person anyway because there's someone new coming in and they wanted a window. And I'm like, "Yeah, you can have your window." 

So we got a new interior office and it is just peachy. I'm really loving it and took the opportunity to add another microphone. We actually have four mics now, so we can really do a roundtable discussion. And in fact, our next – I think it's our next one – Guest Show, we actually do have three guests lined up. So that should be a fun one coming up here soon. So, all that to say that it's been a summer, been spending time with the family, vacation, getting the studio moved and I appreciate your patience with that. 

0:03:30.4

All right, what are we talking about today? Well, again, we're answering your questions. Milk, milk consumption, so mom wants to know which kind, how much. There's so many opinions out there and different advice from different doctors. How does one make sense of it all? I tend to take a practical approach on these matters. So we'll talk through that. When do you transition to milk, which one should you pick and how much should you give? We will discuss it. 

And then, pregnancy spacing, what is the ideal amount of time to wait between pregnancies? What risks are involved with rushing things sooner and what about waiting too long? Is that possible? So, I'll have the answer for that. 

And then, the immunizations, how many are too many at one time? It's a quick and easy question to which I have an equally quick and easy answer. Yeah, it won't take long. And you probably already know what my answers are going to be but I will back it up with some evidence and some reason. 

0:04:24.8 

And then, finally, guttate psoriasis, what in the world is that? We'll define the condition. We'll talk about the cause. Believe it or not, strep throat is a common trigger. I'll take you down quickly to the cellular level and show you what's going on and then we'll explore treatment options and strategies to deal with the itch. So that's coming your way as well. 

Don't forget about our 700 Children's blog at 700childrens.org. We have a recent article on how to prevent ear infections while swimming. So be sure to check that out. 

And I did mention, if you like to get your question on the program for one of these answers-to-listener-question episode, it easy to get in touch. Just head over to pediacast.org, click on the Contact link. I do read each and every one of those that come through, and we'll try to get your question on the program next time we do one of these.

0:05:11.5

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

All right, let's take a quick break and I will be back with answers to your questions right after this. 

[Music]

0:06:12.6

Dr. Mike Patrick: OK, we are back and first stop is Jennifer in Colorado Springs, Colorado. Jennifer says, "Hello, Dr. Mike. I've been a listener of your podcast for a few months and I recommend it to all of my mom friends. I appreciate your information and your opinions on the various subjects presented. I have a 22-month-old child and I'm so beyond confused on the appropriate consumption of milk. Between my pediatrician and the pediatricians of my friends, I have gotten too many different views on the subject of milk to know what I should believe. I currently limit my child's milk consumption to about 24 ounces of whole milk daily which, of course, is pasteurized, and I appreciated your advice on this matter in a previous podcast. My child loves milk so much that we tend to limit it to breakfast, lunch, dinner and before bed with the teeth brushing afterwards. Otherwise, he'd have it on milk diet and would never eat anything.

0:07:01.9 

"My question is concerning the type and amount of milk that is recommended. My pediatrician is old school and is probably 70 years old. He recommends whole milk or 2% at least 24 ounces of milk, including other dairy products. However, several of my friends' pediatricians recommend no more than 24 ounces of milk and suggest 2%, not whole milk. And finally, another recommendation was that giving milk itself wasn't really necessary as long as dairy is in the diet. Oh, and another pediatrician that was giving a speech on diet said he would never give his child cow's milk, only almond milk. I personally give this opinion little value. I am so confused and would like to know what the American Academy of Pediatrics, or you, have to say on the subject."

Well, thanks for writing in, Jennifer. Really appreciate you trusting me to make sense of all of these options and opinions that you're hearing about, which I think I can do. First, you did mentioned pasteurized milk and thank me for previously talking about pasteurization. Thank you, Jennifer, for mentioning that. Regardless of which type of milk you use and we'll get to that, or how much milk you use – and we'll get to that too – it is very important that you use pasteurized milk, not raw milk from the farmer down the road. 

0:08:21.0 

And for those of you out there who may have missed our conversation on the dangers of raw milk pasteurization and the science behind the various methods of pasteurization, be sure to check out PediaCast episode 277. That one covered the dangers of raw milk. And Pediacast episode 282, that one discussed pasteurization techniques. So be sure to check them out. 

OK, so with that important safety tip out of the way, let's get to the heart of Jennifer's question. Why is there so many different pieces of advice from so many different places regarding the type of milk you should give your kids and how much milk they should drink. 

0:09:00.0

Let's actually start with when. When is the best time to transition to milk from infant formula or breast milk? Well, traditionally, we say 12 months is a good time. Well, why not sooner? Well, prior to 12 months, babies don't digest cow's milk as completely as they digest breast milk and infant formula. The nutrients are kind of locked up into the cow milk and the body just doesn't digest it and process it as well, so the availability of those nutrients and cow's milk prior to 12 months isn't as good as it is with breast milk and infant formula. 

Also, cow's milk does not have enough iron, Vitamin C and other nutrients. It's designed for baby cows, not baby people. And so, during that first year of life, baby people need a lot of iron because they've got a lot of brain growth going on. And they also need a lot of Vitamin C, they need the right fats, they need other nutrients. And so, it's really important to have the infant formula or breast milk prior to 12 months of age. 

0:10:09.2 

Also, cow's milk has too much protein and certain minerals, like calcium and phosphorous, which can be harmful to still developing kidneys. So, you've got not enough of some nutrients, too many of other nutrients. So prior to 12 months, we say no cow's milk. 

Now, some babies are going to be fine with cow's milk before 12 months. You've all heard stories, Grandma says, "Hey, your mother was on cow's milk when she was four months old and she did fine." So you're going to hear stories out there, babies who do fine transitioning to cow's milk whenever. But other's won't. Some are going to develop severe life-threatening anemia or kidney failure. And since we can't reliably predict who would do fine and who won't do fine, risk-benefit analysis falls on the side of waiting until 12 months to make the switch.

0:11:02.6

OK, what if you go over 12 months? Well, in the case of breastfeeding, there's really no harm in going longer. But, at the same time, there aren't any convincing studies that you need to go longer. In the case of infant formula, it's more expensive than milk and no longer provides the benefit. So, there's no nutritional benefit to infant formula compared to cow's milk after about 12 months of age. So that makes it a good time to make the transition. Again, it comes down to risk-benefit where we include costs and inconvenience as a risk. Before 12 months, the meter points towards breast milk and infant formula, and after 12 months, it swings the other way. 

OK, so we make the switch at 12 months. Why cow's milk? Well, for starters, it's wildly available. It's relatively inexpensive, although the price does seem to be going up day by day. And, most importantly, the nutritional profile works for most kids. Of course, there are exceptions. You got kids who have cow milk protein intolerance. You got kids with lactose intolerance. And some children just may have different nutritional needs based primarily on underlying disease processes. 

0:12:17.5 

So most of these issues will already have declared themselves, so most parents are going to know prior to 12 months that they need to use a different product. But sometimes, families find out when they make the switch because that's when problems arise. Really, the best time to start talking about these with your doctor, about this transition is the ninth month well check-up. And of course, continue that dialogue at the 12th month and the 15th month visits as well.

If you need to use something other than cow's milk, your doctor will let you know. Some of the common alternatives, soy milk – and these products are typically fortified with the nutrients that growing kids need and they're lactose free and cow milk protein free, so they make a very nice alternative – goat's milk, sheep's milk, almond milk as you mentioned, rice milk. Those may be fine choices for some kids. Your child might need some nutritional supplementation if you go with those. So you only want to choose those with the guidance and support of your child's doctor. 

0:13:17.5 

And then, what about the toddler formulas? The formula companies, they don't want you switching to milk. They want to keep you as a customer. And so, there are some toddler formulas out there that you can buy. But they really don't offer any significant nutritional advantage over cow's milk. And so, it really comes down to are you willing to pay the extra costs of that. 

OK, so let's reign it back into cow's milk here. The next question becomes do you use whole milk or 2% milk and how many ounces do you give at a time? Well, here's where the confusion really rolls in. And I'm going to make a profound statement that I hope will explain why there are so many recommendations floating around. Here it is: what's right for one kid isn't necessarily what's right for another. Cookie-cutter medicine doesn't work. You've heard me say that before and I'll probably say it again. 

0:14:17.6

You really need a pediatrician or a family doctor in the driver seat who recognizes that strict guidelines in this situation aren't going to work. Here's what's important, you want your child to be growing well and you want your child to be healthy. Now, for some kids, that means whole milk and for others, it means 2% milk. So, how do you know? Well, you get your doctor's advice. And you keep up with your well check-up visits at 9 months, 12 months, 15 months, 18 months and 24 months so that your doctor can keep up with your child's growth and health. 

Whole milk is probably best for kids who are growing as expected on their growth chart, while overweight babies would probably do better with 2%. Traditionally, we said "Use whole milk until they turn two. And then, at two, switch to 2%." And again, that's fine if you're just going to use a rigid guideline. But really, what you need to do is look at the kid, look at their growth chart and figure out do they need the extra fat calories or not. And so, for some kids, you're going to do 2%; for other kids, you're going to do whole milk. 

0:15:23.8 

I know, this is called common sense, which in an evidence-based world, where most of us doctor types live and where most of you in-the-know parent types live, is sometimes hard to consider. But when it comes to nutrition and growth, there's just too many variables in the box to make a 'one size fits all' plan. Genetics plays a big role on how calories are processed. Amount of physical activity your child has is another thing you have to think about. What other foods your child is eating and what kind of caloric intake they represent makes a difference. 

So you pick a place to start but you realize adjustments may need to be made. Personally, if you're going to have a rigid guideline, I think that 24 ounces of a day of whole milk is a nice place to start. Some kids are going to want more than that, which is fine as long as their growth looks good and they're healthy. On the other hand, if you go over 24 ounces a day, some kids are going to put on too much weight. Others may become constipated. Others may become anemic. Then, again, too little milk can also lead to anemia. Some kids may need more than 24 ounces a day to maintain good growth. Some needs whole milk to maintain good growth. Others need 2% because they already have plenty of weight on board. 

0:16:39.6 

So the right answer here is that there is no right answer that applies to every single child. And that, Jennifer, is why you were encountering so many different opinions. Here's my best advice – go with the flow. You know your 70-year old pediatrician may not be schooled in the most recent up-to-date ideas coming out of academic institutions. But truth be told, new ideas aren't always the best ideas. I mean, how many times had guideline changed only to be changed back to the way they used to be? Margarine was felt to be healthier than butter, until more research came along. 

Now, don't get me wrong. PediaCast is all about being evidence-based. But common sense is important, too, as is life experience. And your 70-year-old pediatrician has been around the block a good time or two, or three, or four. So if you like and trust your pediatrician, I'd listen to his advice, even if it doesn't match up exactly with what someone else is telling you, even that someone else is me, or even the American Academy of Pediatrics. 

0:17:38.2

Certainly, you don't want someone who is every single thing, they're like, "No, I don't believe that." I mean, that's a red flag. But on certain topics, if what they're telling you, if they can give you a reasonable explanation of why they feel that way, which I bet a 70-year-old pediatrician could easily do, I think you need to trust him. But that's my opinion. 

So I hope that helps, Jennifer, and as always, thanks for the question. 

0:18:06.0

All right, next stop is Tracy in Chino Hills, California. 

By the way, I got to get this off my head. And I've been thinking about this since I've been going through that last question. I made a comment about a quarter of the way through where I was talking about iron and I kind of linked it to brain health. And really, it's the fat intake that's really important for brain growth. The iron is important for red blood cell production and you don't want kids to get anemic if they're not getting enough iron. It bugged me enough that I thought about, "Do I need to stop this?" But I just kept going and then, I guess my guilty conscience convicted me and I had to set it straight. 

So anyway, that's just the perfectionist in me. OK, I'm not even going to cut this out. Let's move on. 

So Tracy in Chino Hills, California says, "Recently, I visited my OB/GYN because my husband and I are planning on having another child. My son is 13 months old now. The doctor said the World Health Organization recommends waiting at least two years before having another baby and says there is an association with autism for having children too close in age. I've never heard of this before and was wondering what your thoughts are. 

0:19:15.9

"On another note, when I took my son to his one-year doctor appointment, they said he will be getting six vaccinations. I was surprised as I have an eight-year-old and don't recall there being so many. I support vaccinations, however, six of them at one time seems a bit excessive. I chose to give him some at the visit and return several weeks later for the rest. My pediatrician just keeps repeating that the American Academy of Pediatrics says it's fine. Why give so many at one time?"

All right, thanks for the questions, Tracy. Let's tackle them in order here. First, what's the ideal amount of spacing between pregnancies which translates into the ideal amount of spacing between your kids in terms of their ages? There is some evidence-based information available on this which is what the World Health Organization is using when they make their recommendation of waiting two years between pregnancies. 

0:20:05.5 

So limited research and these are small retrospective studies where they look at small amount of people and they look back, these are not large prospective studies which have more validity. So limited research has suggested that a pregnancy within 12 months of giving birth is associated with an increased risk of the following – so if you get pregnant within that first year after giving birth – there's an increase risk of one, placental abruption, which is a peeling away from the uterine wall of the placenta and that may be life threatening to the baby and to the mother. 

There's also an increased risk of what's called placenta previa. This is where the placenta partially or completely covers the cervix, so that's where the baby would normally need to get out. The placenta is covering that. And this is a risk if the first birth was by C-section and get pregnant again within a year. And placenta previa is associated with an increased pregnancy and delivery complication rate. 

0:21:12.0

And then, number three, if you have a pregnancy within one year of giving birth, you have an increased risk of autism in the second-born child. Limited research also has suggested that a pregnancy within 18 months of giving birth is associated risk of uterine rupture in women who attempt vaginal delivery following a previous C-section. Having a pregnancy within 18 months of giving birth also has an increased risk of having a baby of low birth weight, a baby who is small progestational age and a pre-term labor or pre-term birth. 

So, yes, limited research suggest that you should probably wait at least 18 months. And just to play it safe, the World Health Organization extends that to 24 months because of a concern for autism, as well as the other problems that I've mentioned. 

0:22:04

OK, so why has Tracy – and probably many more of you out there – why have you not heard about these risks? Well, you know, they're small retrospective studies. There hasn't been a large landmark study to back up these claims. On the other hand, I would give the findings a bit more credibility because they make sense. Pregnancy depletes a lot of nutritional stores, making less nutrients available for subsequent babies until moms body has a chance to replenish her nutrients. Those nutrients are needed for baby's body and brain growth, so it makes sense that if mom's nutritional stores are depleted, you have a higher risk of poor body and brain growth. So we see things like low birth weight, small progestational age and possibly autism. 

Pregnancy also takes a toll on the uterus. It needs time to recuperate as well and so we have an increased risk of these placental abnormalities I mentioned and pre-term birth if pregnancies are spaced too close together. Now, keep in mind that an increased risk is not an absolute risk, right? There are plenty of parents out there who pop one kid out after another and everybody ends up just fine. You just need to know you're taking a risk. Your family may have different planning needs with regard to the timing of your children and there are ways to deal with depleted nutrient stores.

0:23:29.6

So, the point here is, once again, where are you on the risk-benefit meter? Does your family planning need to have kids close together outweigh the small risk? And if does, you want to talk to your OB/GYN, make them part of the conversation. And, of course, sometimes, these things aren't planned. It's within the first year and what do you know, you're pregnant again. You just need to know the risks are there and to make sure you and your doctor are doing everything you can to minimize additional risks and to watch for the development and subsequent complications and problems. 

0:24:04.0 

By the way, studies also suggest you can wait too long between pregnancies. If you wait five years or more between pregnancies, you have an increased risk of pre-eclampsia which is high blood pressure and protein in your urine during the second half of your pregnancy. You have also have an increased risk of low birth weight, small progestational age and a pre-term birth. The reasons for these findings aren't as readily apparent but they had been observed nonetheless. 

So it seems ideal spacing between pregnancies which correlates to years between the ages of your children is between two years and five years. Now, my wife and I have two kids. They're two and a half years apart which fit nicely into these recommendations. But I have to confess, Tracy, like you, I didn't know these finding back in the day. In fact, that day was before these finding had been made. And in fact, these aren't super duper strong findings. 

With regard to autism, you'll find that some kids who fall outside of this pregnancy spacing guidelines do have autism. But there are plenty more who are between two years and five years between kids who do have autism. So, there's a lot more at play than just this. 

0:25:14.4

All right, let's move on to your second question, is six immunizations at one time too many? No. Six immunizations at one time is not too many. You knew that was going to be my answer, right? There's absolutely no credible scientific evidence to suggest a maximum number of immunizations at one time. Now, we care about discomfort. Really, we do. And there are many combination products on the market today to limit needle pokes. 

But for me, looking at all the evidence involved and having practiced medicine, pediatric medicine, and giving kids immunization for the last 20 years and we've talked through the evidence many times in the past, for me, the benefits of immunizations far outweigh the risks. Look, your immune system is built to handle exposure to lots of foreign proteins all at the same time. In fact, your immune system thrives with this opportunity. 
 
0:26:12.5 

Let me asked you this, how many foreign invaders does your child's immune system encounter every day in day care centers or at school? What about when they fall in the mall and scrape their knee or when they have dental work done? What about when they pick a piece of popcorn off the floor and it's been longer than five seconds and you can't stop them before they pop it in their mouth? What about when they forget to wash their hand between going potty and eating lunch? What about when they pick their nose and eat it? 

So our bodies are exposed to thousands of foreign invaders every single day. Six more are not going to make a difference. A hundred more are not going to make a difference. A hundred more are not going to make a difference. Personally, if I was your child's immune system, I'd be insulted that you think I can't handle six at one time. "Come on, you can do better than that. Throw me something I can work with here," that's what I'd be saying. Then, again, I'm passionate about protecting my kids from the things I'm still able to protect them against. 

Were you expecting a different answer, Tracy? Probably not. But at the end of the day, I'm glad you asked it. Thanks for writing in. 

By the way, if you're interesting in hearing the history of the MMR-autism fiasco, including names and accusations, be sure to check out PediaCast episode 251. I give you all the details in the course of that particular episode. 

0:27:27.1 

All right, let's move on. Faith in Highlands Ranch, Colorado. Well, this entire show is west of the Rockies. Faith in Highlands Ranch says, "Dear Dr. Mike, my oldest daughter was diagnosed with guttate psoriasis nearly three years ago. The children's pediatric dermatologist said it was brought on by a case of strep throat. However, since that time, it has continued to worsened. The doctors prescribed several different medications including Vitamin D cream, steroids and a liquid for her scalp and has recommended she get a lot of sunlight exposure. Despite following the doctor's specific directions for application of the medication, we haven't had success clearing my daughter's skin. She continues to have patches all over her body. She's very uncomfortable, scratches and rarely sleeps through the night.

0:28:14.2 

"The specialists at our children's hospital has given several different treatment plan since my daughter's diagnosis, none of which seemed to work. I'm beginning to feel hopeless that we will not find anything that will put this disease at bay. I know we can't get rid of it but if even if we could get it mostly clear, that would make a world of difference. It plagues our household day in and day out and our daughter is so sick of the creams and ointments," I can't blame her, "and the liquid for her head just hurts, burns.

"I'm beginning to wonder if she needs a significant diet shift. She eats a substantial amount of fruits and veggies, very little meat, she doesn't like fish. I've taken her off of milk because of some digestive issue but she will have almond milk on her cereal. She'll eat Morningstar griller instead of hamburgers, but she does have a sweet tooth. So we're doing our best to limit her sugars. 

"Please, please, please give me some advice. I'm doing everything I can to fight for her. Please help. Many, many thanks. Faith." 

0:29:10.9

Well, thanks for writing in, Faith. I really appreciate you sending me the question. I honestly can just hear your frustration in this. I totally get that. And I do, I understand your frustration. Let's talk about guttate psoriasis and I think in doing so, we'll answer your questions and paint a fairly clear picture of what's going on. 

So, psoriasis in general is a chronic skin condition characterized by patches of skin in which cells build up rapidly and form thick dry scales, often described as silvery. Not always a helpful description because one man's definition of silvery may differ slightly from another's. These lesions or plaques are itchy and sometimes painful. And they come and go – waxing and waning over a long period of time. 

0:30:02.9 

Now, the description of guttate psoriasis gets a bit more specific. This type is most common in children, teens and young adults and these plaques of dry skin tend to be small and shaped like a drop of water. And since guttate means droplike, it's easy to see how this variety of psoriasis gets its name. The number of these patches vary from a few to many and they're typically seen on the trunk, arms, legs and scalp. The lesions are thinner and the scales finer than other forms of psoriasis. 

Sometimes, guttate psoriasis appears and goes away a few weeks later, never to return. Other times, it becomes a chronic problem. And if there's a family history of this condition, looking at the family course may help predict how your child's condition will progress, although that's not a guarantee. 

OK, so what causes this? Well, let's dive down to the cellular level quickly and take a look. So something triggers the immune system. And this something can be an infection, like strep throat in the case of Faith's daughter. But other infections as well including viruses, ear infections, skin infections; a skin trauma is another possible trigger including cuts, scrapes, bites and sunburn. A stress, an anxiety is another possible factor. And certain medications including lithium which is used to treat mood disorders, Inderal which is a beta blocker, used to treat high blood pressure among other things, and certain anti-malarial drugs as well. These are all can be triggers of this process. 

0:31:39

In kids though, the most common known trigger is strep throat. But it's not the strep bacteria itself that's causing the problem. Instead, in response to the strep bacteria, your body makes a type of immune cell called T cells like the letter T, which are involved in fighting invading micro-organisms. Now, unfortunately, these T cells, in the case of guttate psoriasis, go haywire. And here, we don't quite know the mechanism behind why they go haywire, we just know they do. 

OK, so what do I mean by going haywire? Well, they trigger other immune responses which result in dilation of blood vessels in the skin and migration of white blood cells into the outermost layer of skin. And the net result of all of these inflammatory activity is a localized and sped-up production of skin cells being made. 

0:32:34.9 

So the skin cells rise to the surface quickly over days, instead of weeks, and they start piling up, creating scaly plaques that itch. Of course, itching the skin makes things worse because they causes mass cells to release histamines which amplify the immune response and results in more inflammation, more skin production, more itching and it's what we'd call – and this is a technical term – a vicious cycle. 

0:33:02.7 

OK, so what do you do about it? Well, first you want to calm down the itching. I mean, that's one way to sort of break that cycle. And, really, you want to calm down the whole immune response. But you don't want to go overboard and shut the immune down to munch. Otherwise, you open yourself up for attack from other sources. You want your immune system operating, you just want to stop it from going hayward. 

OK, so the first order of business is to calm down the itching and the scratching so you can break that cycle I was talking about. Oral antihistamines like Benadryl help with the itch but they also make you sleepy and they can result in behavioral changes, let's put it that way, especially in younger kids. But if your child's awake and scratching through the night, oral Benadryl may be helpful. Of course, as always, talk to your doctor regarding specific treatments in specific kids. 

Keeping the skin moisturized may help with the itch, with thick greasy ointments, like Eucerin is one example, help lock in the moisture. Cool showers and ice packs may also do the trick. And teaching your child to gently pat instead of scratching and digging at the skin, that may be helpful as well. Besides controlling the itch, we also want to interrupt the underlying immune activity in skin growth and there are lots of strategies for doing this, including steroid creams, Vitamin D creams and controlled exposure to ultraviolet light as you mentioned. 

0:34:28.0 

Other options include topical retinoids – things like Retin A, which are Vitamin A derivatives – other immune modulators like Elidel is an example, salicylic acid products to promote sloughing off that excess skin. And the coal tar is a messy options but one that works for some people. And then, for severe cases, there are also heavy-hitting systemic immune suppressors like Cyclosporine, Methotrexate, Remicade among others. But these have lots more side effects and complication potential, so it's really important to think through the risk and the benefits before using them. 

0:35:02.8 

Here's the bottom line, if you aren't happy with how your child is progressing, you really need to be open about this with your doctor. By this time, you should be seeing a pediatric dermatologist, and here she needs to know that your child's quality of life is suffering. Now, that doesn't mean that your doctor can snap his or her fingers and make it all go away. If he could, he would have done it by now, trust me.

But at the same time, if you don't speak up, your doctor won't know that your child is suffering. And it sounds like you've already tried lots of different plans and your doctor may have other plans in mind. I mean, it sounds like you've got a good doctor. Where you may need to go at this point is with some behavioral and psychological management of the stress and anxiety that's accompanying this chronic condition. 

We don't want to overlook that important piece of the puzzle. I mean, it is taxing on a child and on parents and on a family to be dealing with something like this. And in addition to treating the disease, you really also have to treat the stress and the anxiety. And I could just hear that in the frustration of your voice, Faith. And so, there I think you really need an addition to the medical treatment, maybe look into behavioral, psychological treatment as well. And your dermatologist and your pediatrician should be able to point you in the right direction there, just in helping to deal with this. So definitely, talk to your doctor if things aren't going as you had envisioned them to go. Doesn't mean they can fix everything, but at least give them the chance to try. 

0:36:34.4

With regard to diet, there isn't any conclusive evidence to suggest that food plays a role in a guttate psoriasis. So remember, this is a problem that waxes and wanes. So it's easy to make false assumptions when you try a food alteration. You do something different and the skin improves. Well, it might have improved anyway, since this is something that waxes and wanes. Still, not all kids follow the evidence-driven rule book.

So if you are convinced that a particular food always aggravates the condition and life seems peachy when you withhold that food, by all means withhold it, especially if your child continues to do well without it. But be sure to talk to your regular doctor about this, so they can figure out what, if any, nutritional substitutions need to be made to maintain good health. 

0:37:24.4

Hope that helps, Faith. I know I don't specific advice for your daughter other than to say keep the lines of communication open with your child's doctor and don't give up hope. 

All right, that does wrap up our Listener Questions for this week. Don't forget if there's a question that you would like to ask or if you want to point me in the direction of a news article or journal article or have a recommendation for a topic that we should be talking about on PediaCast, it's easy to get in touch with me. Just head over to PediaCast.org, click on the Contact link and write away, write in. Let me know what's on your mind. Pass your question and we'll try to get it on the show. 

All right, we're going to take one more quick break and I'll be back to wrap things up, right after this.

0:38:09.2

[Music]

Dr. Mike Patrick: All right, we are back and with just enough time to say goodbye. Again, the last couple of month's shows had been kind of slim pickings, I realize that. Vacations are over, the studio is moved. I think we're back on track now, so hopefully, we'll have shows on a more regular basis for you. And I do appreciate those questions, so keep those coming in. 

That does wrap up our time together. PediaCast is a production of Nationwide Children's Hospital. Don't forget, PediaCast and our single-topic short format program, PediaBytes, are both available on iHeartRadio Talk, which you'll find on the Web at iheart.com, in the iHeartRadio app for mobile devices. 

0:39:25.0

Our show archive which include over 250 programs as well as our Show Notes, transcriptions, Terms of Use and Contact page are available at the landing site, which is pediacast.org. Also, on iTunes, under the Kids and Family section of their podcast directory; and you'll find PediaCast on Stitcher, TuneIn, DownCast, iCatcher, Podbay and most other podcasting apps for iPhone and Android. Also on Facebook, Twitter, Google+ and Pinterest. And of course, we really, really really appreciate you connecting with us there and sharing, retweeting, repinning all of our posts, so you can tell your own online audience about our little show. 

0:40:00.9 

We also appreciate talking us up with your family friends, neighbors and co-workers. Anyone with kids or anyone who takes care of children. And as always, this is really important, be sure to tell your child's doctor about the program. So next time you're in for a sick office visit or a well-child check or a behavioral visit or an ADHD recheck, make sure you let them know about PediaCast if you haven't done so already. And posters are available under the Resources tab at pediacast.org.

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

[Music]

Announcer 1: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast. t time on PediaCast. 

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