Mosquito Bites, Laxatives, Homemade Baby Food – PediaCast 258

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Join Dr Mike in the PediaCast Studio for more answers to listener questions! This week’s topics include mosquito bites & meningitis, the dangers of laxative use, obstructive sleep apnea & sleep studies, vaccine reactions, homemade baby food & botulism, and gluten-free summertime cooking.

Topics

  • Mosquito Bites & Meningitis

  • Laxative Dangers

  • Obstructive Sleep Apnea

  • Sleep Studies

  • Vaccine Reactions

  • Homemade Baby Food & Botulism

  • Gluten-Free Summer Cooking

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. It is 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's episode 258 for July 10th, 2013. We're calling this one "Mosquito Bites, Laxatives and Homemade Baby Food."

Of course, we've got lots more coming your way and we'll get into the entire lineup in just a moment. First, I do want to welcome everyone to the program. And I hope everyone in my American audience had a great Fourth of July week with your family. We had, I guess I'd call it an interesting week, to say the least.

And since we're all family here in PediaCast, I'll share. Because I think you'll appreciate the story and I'm sure many of you out there can relate to our adventure, if you want to call it that. Many of you know, our family likes to do things together and to stay active. And as I talked about the last couple of months, we've really gotten into roller skating as a family, both outdoor and indoor.

Well, we happened to be in Cincinnati for a few days. My 16-year-old son and my 18-year-old daughter, along with some of my daughter's college friends, they headed to Kings Island and enjoy the ride and attend a two-evening concert event. So, my wife and I, we wanted to give the kids a little independence but we wanted to be close by for my 16-year-old as well. And we decided to incorporate a roller-skating palooza into our trip, with a tour of five different skating rinks over a four-day period.

Call us crazy, I know. But we were excited, like kids, about this. So, rinks number one and two were actually in Central Ohio just prior to our road trip to Cincinnati. And in fact, the night before we left, my wife and I — along with our kids — we attended a special Michael Jackson skate, which is a lot of fun in three solid hours of skating.

0:02:22

So we get to Cincinnati. Rink three is in the morning. We break for lunch and we head to rink number four for the afternoon. Now, by this time, as you can probably imagine, we're a little tired. And we pull into the parking lot and the place is busy, as evidenced by the five daycare vans and the school bus. But we aren't deterred, because we are in a mission at this point.

So, we spent two hours dodging little kids. But we're having fun and we're exercising in the process, right? Also, some quality husband-and-wife time together. So this is a good thing. Although, skating a total of seven hours in a 24-hour period, it's taken a toll on our 40-something legs. So we sit down for the hokey pokey, we jumped back in for the corner game. And as it turns out, despite of the little kids, we ended up in the winning group.

So, that was exciting. We're sitting in a carpeted mushrooms eating our prize, Twizzlers. And I mentioned to my wife that I'm pretty beat. Is she ready to go and check in to our hotel? She says yes, but how about a couple of cool-down lapse first. Now, mind you, this is her idea. I really want to point that out.

So we head back out on the floor. We're moving super slow and we're about 20 feet out on the wood when our wheels, the ones on her skates and the ones on my skates, they just barely nudged one another. Now, a pretty good skaters… I've been skating since I can walk and my wife just started a month ago, but she's progressed nicely, and under normal circumstances, this would not be a problem. But her legs are pretty much spaghetti at this point.

My wife loses her balance, her skates slip out in front of her and she goes straight down, with her left arm extended behind her. All of her weight comes down on her outstretched left wrist. Yup, you know where there is going. Turns out I forgot to teach her the all important skill of tucking and rolling when you hit the ground while roller-skating.

0:04:19

So she falls. She says very matter-of-factly, "I broke my arm." To which I reply, because she was so calm and because my wife is the consummate kidder, "You did not break your arm." Except she did break her arm.

And we're in unfamiliar city. Our kids are off at a busy amusement park. Our luggage is still in the trunk. And I had no idea where the nearest hospital is located. So good times, we made our way to an emergency room. And we had a very real taste of modern medicine from the patient perspective, which taught me a few things. You know, I may have some new empathy for families which had not been fully realized prior to this experience.

So, it turns out she did a real number on her wrist and she required surgery when we got back to Columbus. And she's now the proud owner of a titanium plate and screws. And she lovingly refers to this as her bionic arm. She blames her primary care physician who told her that she needed to exercise more.

[Laughter]

Dr. Mike Patrick: And her first question to the ortho doc though was "When can I skate again?" The answer is three months, which she wasn't so happy about. Honestly, I thought she'd chuck the whole thing and put her skates on eBay. Although, she is eager to hit the wood again, although not literally this time. We have to practice on tucking and rolling before we head back out.

The kids, in case you're wondering, they did not get totally abandoned in the park. It all worked out. Of course, they're practicing their tucks and rolls in the living room. That's a requirement before we head back out on skates. So that's quite the sight but I don't want them learning the way their mother did.

So that was our Fourth of July week. Exciting times, never a dull moment around here. All right, hopefully yours wasn't quite so adventurous.

So what do we have lined up for you this week? Mosquito bites — what diseases are associated with mosquitoes? How common are they? What signs and symptoms should you be on a lookout for? And what's the best way to treat and prevent mosquito bites? That's all coming your way.

0:06:14

Laxatives — we have a listener in Ecuador who wants to get the word out regarding the dangers of laxatives. What exactly are laxatives? How do they work? Why are they dangerous? Is there ever a place for their use? And what are some safe alternatives for the treatment of constipation? We'll answer those questions.

Another mom has a daughter with Asperger's, which is a form of autism. And her daughter is having some daytime issues, which may be related to obstructive sleep apnea and she has some questions about the results of a sleep study, the role tonsils and adenoids play in obstructive sleep anea. When should those things be removed? What role does CPAP play? And is it likely that sleep apnea is even the cause of her daytime issues? Also, how important is it that a sleep study be done at a children's hospital as opposed to a community facility? So, we'll explore all those questions coming up.

Vaccine reaction — babies who get vaccine often have soreness, redness and mild swelling at the injection site. They may be fussy, they may have a fever. What's a parent to do for these symptoms? Should they get Tylenol or can Tylenol diminish the vaccine's effectiveness? So, those answers are coming your way.

And finally, homemade baby food, is it safe? Could it lead to botulism? Speaking of botulism, what is that? What are the symptoms? Why is it such a concern for babies? And is this a real risk or just overblown hype to keep baby food companies in business? We'll clue you in all those details.

And then, at the very end of the program, summer grilling season is in full swing. But what about those folks with celiac disease or gluten sensitivity? We'll end this week with a final word on enjoying your summer barbecue gluten-free.

So, that's all coming your way. Like I said, we have a jam-packed show for you this week. Remember, if there's a question that you would like to ask or you have a topic suggestion for the program, it's easy to get in touch. Just head over to pediacast.org and click on the Contact link. And I do read each and every one of those that comes through. And hopefully, we'll be able to get your question on the program.

0:08:10

Dr. Mike Patrick: Also, I want to remind you the information presented in every episode of the program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals here on PediaCast. 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 some of your questions right after this.

[Music]

All right, you know, I see a lot of kids with broken arms, broken bones of any sort, when I worked in the emergency department in our Urgent Care centers. But I never had to deal with a broken bone at home before. So this is interesting. No cast though since it was internally fixated. But I can definitely commiserate with families out there who deal with broken bones.

All right, our first question this week comes from Mary in Florida, "The granddaughter of a friend, seven years old, has multiple mosquito bites on her arms, legs and face. Can this be a potential hazard for meningitis? What should we be watching for symptom-wise?"

Well, thanks for the question, Mary. It's a good one. In the spirit of transparency, my regular listeners will recall a few months ago, my aunt wrote in with a question about video games and ADHD. And I laughed and I said, "Hey, aunt Karen, you could have called me." Now, I did include my aunt's question in the show because it was a good one and because she's family.

0:10:11

So that brings us to Mary in Florida. It turns out that's my mom.

[Laughter]

Dr. Mike Patrick: Yeah, my mom writes in with a question. She doesn't call on the phone with her friend's concern for the granddaughter. She uses the PediaCast contact page instead. Huh, wow golly gee willikers.

Now, I know some of you are like, "What? He hasn't gotten to my question yet. Now, he's answering his mommy's question?" But look, many others out there, I know, are saying "Wait a minute, my kids have a bunch of mosquito bites and you're telling they can get meningitis from these? I want to hear the answer." So, that's what I'm going to do, because it is a good question and because it's my mom. I mean, what would you do if you were in my shoes?

So here goes, mosquitoes bite animals, including humans and consume blood. And if they bite one animal with a certain blood infection and then bite another animal, they can transmit that blood infection from the first animal to the second. Now, the animals we're talking about are vertebrates and as I mentioned, man is among them. So mosquitoes can transmit disease from animal to men and from one person to another.

So what sorts of diseases are we talking about? Because there are just specific ones, it's not just any disease. And how commonly does this occur?

Well, let's start with the diseases. The first, and one that affects the most people worldwide is malaria, which kills about two million people each year. Other diseases that can be transmitted by mosquitoes include Yellow Fever, West Nile virus and various encephalitis viruses, including Japanese encephalitis, La Crosse encephalitis, Eastern Equine and Western Equine, California encephalitis and Saint Louis encephalitis.

Now, there are other diseases that can be transmitted by mosquitoes, but these are the most common ones. So, just how common is this that a disease could be transmitted by a mosquito? Well, that depends. The likelihood of you getting a particular disease from a mosquito bite depends on the prevalence of that disease in animals in your area. In other words, if lots of animals, including humans, have the organism that causes the disease in their blood, the more likely it is that the mosquito that bites you will have some of the offending organism to pass along.

0:12:17

So how do you find out if there are particular diseases prevalent in your area? Well, that depends in where you're located. So here in the United States, a good place to check for that sort information is your state and local health departments. They keep track of local infections in humans and animals and if there is a concern, they'll release warnings. You can usually find these warnings on their website and sometimes, they're broadcasted in other media like radio, television and newspapers. If you haven't heard any warnings and you're concerned, you can always visit their website or call them to check.

Now, with regard to foreign countries, the CDC or Centers for Disease Control and Prevention, their website is a great source of information to let you know what mosquito transmitted infections may be an issue in specific international regions. And they also have prevention recommendations for folks who plan to travel to those areas.

OK, so let's get a bit more specific. What about mosquito bites in the United States of America and in particular, Florida, where my mom is worried about her friend's granddaughter? Well, fortunately, we don't have to worry about malaria or Yellow Fever in the United States. At least, not at this point in our history. Malaria hasn't been a problem in the US since around in the 1950 and Yellow Fever hasn't been on the mainland since the 1820s. Now, that does not mean that these diseases couldn't make a comeback. They could. But for now, malaria and Yellow Fever are not a concern.

West Nile virus on the other hand and the various encephalitis viruses I mentioned, these things are a concern for certain areas of the United States. And again, your local health department will have more information for your specific area.

Now, before we get to symptoms, I do want to point out another important consideration. Just because a mosquito is harboring an infectious organism — which by the way, the mosquito is acting as a vector here, so transmitting an infection from one animal to another and not being infected itself — so just because a mosquito is a vector for an infectious organism, this does not mean the transmission rate is a 100%. So you can be bitten by a mosquito harboring an organism and transmission may not occur.

0:14:24

Also, transmission does not automatically lead to disease. So you can be bitten by a mosquito harboring an organism and the disease-causing organism may actually go from a mosquito into your blood, but that doesn't mean that you have 100% chance of getting sick. There's a very good chance that your immune system will kill the organism.

And because of these facts, the vast majority of mosquito bites, even in areas where a disease is found, the vast majority of mosquito bites do not lead to disease. But it is possible. So we want to pay attention to warnings, follow prevention advice and be on the lookout for symptoms of transmitted disease.

So what specific diseases do we worry about, from mosquito bites in Florida, the ones out there right now, this summer, 21013? The West Nile virus, Saint Louis encephalitis and Eastern Equine encephalitis. These are the three current concerns, so let's talk about them.

West Nile virus causes disease in birds, humans and horses. Eighty percent of people infected with the West Nile Virus have no symptoms and fully recover. So their immune system kills the virus, no harm done.

Now, the 20% who do developed disease, typically we see mild flu-like symptoms — so fever, mild to moderate headache, and fatigue. And these symptoms last a few days and then they go away. Less than 1% of people who get West Nile virus — so this is an uncommon event — less than 1% developed meningitis and encephalitis. And when this happens, possible symptoms include fever, severe headache, stiff neck, vomiting, seizures, paralysis and coma. Irreversible brain damage is possible and death is possible, too.

0:16:08

The very young, the elderly and those with weak and immune systems are most at risk. And, unfortunately, there is no specific medical treatment for this, just supportive care. Although it's still important to see your doctor because there are other causes of meningitis and encephalitis that are treatable and the supportive care might just save your life.

By the way, those who aren't up to speed with the terminology, encephalitis just is a fancy way of saying infection of brain tissue and meningitis is infection of the membranes and fluid that surround the brain and spinal cord.

OK, so what about Saint Louis encephalitis? Well, this one primarily infects birds but can infect humans as well. Again, most human infections are not apparent, with either no evidence of disease or just mild flu-like symptoms. The immune system kills the virus, no harm is done. But like West Nile virus, the few people who do get diseased, their symptoms can be severe and may include fever, severe headaches, stiff neck, vomiting, seizures, paralysis, coma and death. And again, we do not have an effective treatment when this happens, just supportive care.

OK, what about Eastern Equine encephalitis. Well, this one is more common than West Nile and Saint Louis encephalitis. It also infects birds, humans, and also horses. Now, again, most of the time immune system zaps the virus but severe disease is possible with fever, severe headaches, stiff neck, vomiting, seizures, paralysis, coma and death — all possible, just like the others.

Now, about one-third of those with severe disease die and the remaining two-thirds are often left with severe neurological impairment. Again, there's no treatment and no vaccine to prevent the disease in humans, although there is an improved vaccine for horses.

Children and teens under 15 years of age and folks over age 50 are most at risk for severe disease. According to Department of Health reports, an average of one or two human cases of severe disease each year, with the range of zero cases to five cases every year since 1957.

0:18:09

So the bottom line, these things are possible but even when we talk about the "more common" ones, there's only a handful of cases each year. The symptoms again to watch out for fever, severe headache, stiff neck, vomiting, seizures, paralysis and coma. Flu like symptoms come first — so fever, muscle aches, fatigue, mild to moderate headache. But keep in mind, in any particular person, even someone with multiple mosquito bites, flu-like symptoms are more likely to be caused by run-of-the-mill respiratory virus and not one of these encephalitis viruses.

And in the rare cases symptoms are caused by an encephalitis virus, there's really not much you can do. There's no specific treatment. You still want to see your doctor in case the symptoms are caused by something else, something you can treat. But the end of the day, all we can really offer with regard to treatment is supportive care.

So what about prevention? Well, that's your best bet since there's no real treatment. And the best way to prevent mosquito-acquired encephalitis is, you guess it, by preventing mosquito bites. So, avoid mosquito-infested areas especially at dawn and dusk. And if you can't avoid them, be sure to cover up and use insect repellant which contains DEET.

One other tip when you go back inside, wash your clothes, and wash your body parts sprayed with the DEET-containing insect sprays with soap and water.

What do you do for the insect bite themselves? Well, 1% hydrocortisone cream, it's anti-itch. That can be applied a couple times a day just to help with the itch. It's over the counter.

You do want to watch for infection. Kids tend to scratch these things and can break up on the skin. And then, just a normal skin bacteria can actually can cause infection of the mosquito bite. If they do break open the skin but there's no sign of infection — so no tenderness, redness, swelling drainage, that sort of thing, fever — if there's none of that but the skins broken open from their scratching, you can apply an antibiotic, over-the-counter antibiotic ointment, like a triple antibiotic ointment, like Neosporin, that kind of thing on the broken skin, a couple of times a day until they're well-healed. And for itchy can also do Benadryl, also over the counter, just as needed for the itch.

0:20:10

But you do want to touch base with your doctor. These are just some suggestions. I'm not telling any specific person this what you need to do. Touch base with your doctor if your child is having a problem to make sure it's not something else. Maybe it's a disease that causing these bumps and not mosquito bites or maybe they're getting infected. So definitely get in touch base with your doctor.

So, I hope that helps and thanks, mom, for asking the question. Be sure to pass the info on to your friends. And please, next time, just pick up the phone.

[Laughter]

Dr. Mike Patrick: All right, next up is Carla. A little further away, she's in Ecuador. She says, "Hi, Dr. Mike. Let me start by congratulating you on a wonderful podcast. There is a lot of traffic in Quito, Ecuador and the only way to avoid tension headaches as a consequence is to listen to your show."

I don't think listening to PediaCast is the only way of preventing tension headaches, Carla. But I do appreciate your vote of confidence.

Carla goes on to say, "I was listening to your over-the-counter medicine podcast and learned a lot. However, I was hoping you could expand a bit more on laxatives. People have very little understanding on the terrible effects that laxative dependency can have in a person's life, taking years to recover. Can you educate your listeners on reasons for dependency, the mechanism of action of different types of laxatives, and alternative options for constipation therapy? Also, parent should be aware of how predominant laxative abuses with bulimia and how to notice signs that your kid maybe a victim.

Thank you. Once again, your faithful listener, Carla."

Well, thanks for the questions, Carla. Always appreciated. So, let's talk laxatives — what exactly is a laxative, what are they used, how do they work, why are they dangerous, what are the alternatives and what's up with laxative abuse in those with bulimia. I think we can cover all these for you.

First, let me catch some folks up to speed. PediaCast 223 was our safety of over-the-counter medications episode and we covered fever reducers, cough and cold medicines, antacids, wart remover, topical antibiotics and antifungals, anti-itch creams, teething gel, diaper rash treatment, head lice shampoo, motion-sickness medication, many others. Again, PediaCast 223 over at pediacast.org if you wanted to take a listen to that. We did mention laxatives, but we didn't provide much details. So, let's do that now.

0:22:22

Laxatives are used in the treatment of constipation. Unfortunately, the term is often used to describe any treatment for constipation including a bulking agents like fiber, stool softeners or osmotic agents like fruit juice and MiraLAX — which even has 'lax' in its name — and lubricants like mineral oil.

However, those of us in the medical world, most of us have a tighter, stricter definition of the word. And we use the term 'laxative' to describe agents that treat constipation by stimulating smooth muscle of the intestine to contract and push stool along. So these are going to be substances like senna which is in the brand Ex-Lax and Bisacodyl which is in the brand Dulcolax, and there are others. Again, these work by irritating and stimulating smooth muscle in the intestine to contract and move the stool along.

So what's wrong with that? Well, as it turns out, chronic use of stimulant laxatives can lead to the smooth muscle of the bowel becoming dependent upon their presence. In other words, without the presence of the stimulating chemical, the smooth muscle of the intestine mostly sits idle and you have to continue the stimulant laxative to get the muscle to contract. So, you become dependent on the laxative and if you stop taking it, the constipation may get worse — often worse than it was to begin with. And the longer you use this, the more of them you need to produce the same effect.

So, as Carla mentioned, this can become a very serious and spiraling problems. Having said that, there is a time and place for stimulant laxatives. For the intestine that is not used to them, they work quickly and can be very effective. So, they are a tool in the constipation toolbox but we must be careful with them and they are best to use for a short periods of time and under the strict supervision of the doctor.

0:24:11

Now, as Carla points out, laxatives are also commonly abused by those with eating disorders, most notably bulimia nervosa. And they're popular in the situation because of the rapid onset for those attempt to purge their vowels. But what the abusers soon find is that they need to use the laxatives more and more in order to have normal bowel movements.

So, Carla makes a good point for parents. If your teens are buying and using laxatives, you need to start asking questions. And for more information on eating disorders including the bulimia nervosa and laxative use, be sure to check out PediaCast 249. PediaCast 249 on eating disorders.

So what are safe alternatives to stimulant laxatives, ones you won't become dependent upon and ones that aren't as potentially dangerous? Well, we mentioned them at the beginning of our discussion. The bulking agents, so like dietary fiber bran, psyllium which is in Metamucil, and methylcellulose, which in Citrucel.

How do these work? Well, more stool bulk means more stool movement within the large intestine in and out of the body. So, the more bulk there is to the stool, the easier it is for the muscles and the intestine to move it along.

Then, there's the osmotic agents also known as stool softeners, and they work by providing undigested particles that reach the large intestine. And then, water is drawn in by osmosis across the semi-permeable member that is the intestinal wall. Remember, a water moves from where there is less particles to where there is more particles. So, by increasing particles in the large intestine, water moves in and that increases the water content of the stool. And by doing that, we can make thick dense stool easier to move.

And the examples of these includes apple juice and prune juice where sorbitol is an undigested sugar that provides those particles. Prunes also contain fiber as well, and MiraLAX, which contains Polyethylene glycol — which is chemical that, again, does not get digested. And so, these particles end up in the large intestine and they draw water in. And even though MiraLAX has the term 'lax' in it, it is not a stimulant laxative.

0:26:27

Polyethylene glycol, by the way, that sounds like it's a terrible thing. Like "I don't want polyethylene glycol on my kid." But it actually is safe and if you ever heard of GoLYTELY, if you ever had a colonoscopy or you know someone or a parent or a grandparent that had a colonoscopy, they probably drank something like GoLYTELY the night before. And that did so much bigger dose of it, it just cleans out the bowel by acting as an osmotic agent and softening up the stool in a very large way, when you want to use it in that sense.

By the way, combining a bulking agent and an osmotic agent is nice, because we get large but soft stools that are easy for the intestine to move. I also mentioned that lubricating agents, things like mineral oil which makes the stool slippier and easier to move.

So these things are better first line in daily treatments for constipation. Actually, the best first line daily treatment is a simple change in diet, which of course aren't always simple in kids or grownups. Who don't want to change their diet? But a diet change will often help with an intake of more fiber and fruit and less fat.

Of course, even with dietary changes and things like bulking agent and osmotic agents and lubricants, sometimes stubborn constipation needs something more, like a stimulant laxative. But again, by the time you and your child needs that, you should be seeing the doctor and letting them supervise the use of these laxatives.

Another important point — constipation in some cases is a byproduct of another disease process. So persistent constipation should not be something you treat on your own, anyway. You really do need to see your doctor.

So I hope I did you proud, Carla. And thanks again for writing in from Quito, Ecuador and for raising awareness.

0:28:09

All right, let's move on to our next question. This one comes from Melissa in Washington State. "We recently had a sleep study performed on our six-year-old. She was seen in an adult clinic and the techs had trouble getting her to cooperate when applying the sensors. She's on the autism spectrum and I feel pretty confident saying they had never dealt with a child on the spectrum before. She flat out refused her sensors that had tiny tubes going into her nose. The doctor wanted her to sleep for as long as possible, but the tech accidentally woke her while trying to adjust something.

When we followed up with the sleep doctor, he said she stopped breathing seven times in an hour. He said her tonsils were not enlarged but he wants to remove them anyway. Her dad and I feel like we were being placated, "We'll do a surgery so you feel like we're helping you." We went back to our PCP and asked for a referral to Seattle Children's for a second opinion."

PCP, by the way, is primary care physician.

"We are waiting for that appointment and feel like we should have just gone there in the first place. Do you think our daughter could have thrown off the study by not cooperating and possibly having sensors placed not quite right? And is it common to remove tonsils and adenoids even if they're not enlarged?

She's impossible to wake for school. Will this level of apnea do that or is this an autism thing? She technically has Asperger's. The sleep doctor's other recommendation was to require a nap everyday during school until she grows out of this.

We'd love to hear what you think. I know for my comfort, we're doing the right thing, getting a second opinion. But do you think we really need one? Thanks, Dr. Mike. I've been listening since the beginning and love the show. Melissa."

Well, thanks for the questions, Melissa. You bring up some great points. Let's talk about the relationship between tonsils and adenoids and obstructive sleep apnea. And we'll talk sleep studies, too. Actually, let's talk about obstructive sleep apnea first.

By definition, obstructive sleep apnea occurs when the airway is obstructed during sleep, usually by enlarged tonsils and/or adenoids. And, because the airway is obstructed, your child has difficulty breathing. He or she may actually stop breathing for a few seconds and we call this apnea. The apnea results in a decreased oxygen in the blood — so, decreased oxygen saturation — and that wakes your child up to a degree and your child repositions the airways, so he or she can breathe again. And then, your child goes back to sleep.

0:30:25

Actually, if we want to get really technical, it's probably not the decreased oxygen in the blood that actually causes your child to wake up. It's probably more an increase in CO2 which you want to breathe out. OK, we won't go there.

So, that's obstructive sleep apnea. And that apnea-wake-reposition-go back to sleep cycle may occur several times a night or even several times an hour. Now, it's important to point out, this waking up, as I mentioned, is to a degree. I mean, your child may or may not wake up fully. Most often, they just wake up enough to reposition their airway and reposition may be subtle. Your child may not be aware of waking up, but it's enough to disrupt normal restful sleep. And if there's enough disruption of normal sleep, this may result in your child feeling tired the next day. They may experience difficulty concentrating. They might have behavioral issues, very much like the symptoms of ADHD.

So if we find kids with enlarged tonsils and/or adenoids and if we verify obstructive sleep apnea with a properly performed sleep study and if your child has daily life disrupting problems which we believe might be caused from the sleep apnea, then we have an indication to remove tonsils and adenoids.

But there are a bunch of if-then statements here, right? And it sounds like Melissa's doctor has been working through these if-thens. Melissa's daughter is having daytime problems. Perhaps she snores at night, but snoring doesn't automatically mean obstructive sleep apnea, so he orders a sleep study. And it's here that we hit stumbling block number one. Melissa is concerned that the sleep study wasn't done appropriately and she wants another one done at a children's hospital.

0:32:07

Well, I think this is a valid concern, Melissa. It is possible the results are inaccurate if the study wasn't performed properly. And having it repeated at a facility with lots of experience in children certainly sounds like a good idea to me.

Now, for those of you in a similar situation, I do want to point out, there are plenty of community based programs, ones that aren't exclusively pediatric but who still see a lot of kids, are comfortable seeing kids and perform stellar sleep studies on children. So, I'm, not throwing all community-based programs under the bus. However, if your mom radar is going off and you feel like something isn't quite right, getting a second opinion at a children's hospital is a fine idea before you rush into surgery.

OK, let's say you have you have the study repeated, and the obstructive sleep apnea is confirmed. It really does exist, which is likely in this situation. And your child really is having daily life-disrupting issues, but he or she does not have evidence of enlarged tonsils. What then? Well, you still want to see an ear, nose, and throat doctor because the problem may be the adenoids.

You can see the tonsils at the back of the throat when you look in the mouth but you can't see the adenoids. They're further up. So, if the enlarged, the tonsils may be normal but with enlarged adenoids, there may be benefit in removing them if your child has obstructive sleep apnea that is associated with daily life disruption.

Now, I want to point out here, getting the tonsils and/or adenoids, if they're enlarged, may or may not solve the problem. Often it does, but there may be another cause of the obstructive sleep apnea and there may be another cause of your child's daytime issues. There's no guarantee that getting tonsils and/or adenoids out is going to help. There's a good chance it will. Now, does that chance outweighs the risk of surgery? Well, that depends on your child's exact set of circumstances and your risk of tolerance. So it's something you have to discuss with your child's doctor.

What if neither the tonsils nor the adenoids are enlarged? What then? Well, obstructive sleep apnea may also be caused by a flexible airways. So supporting tissue around the airways are just less rigid. And if this is the case, then even normal-sized tonsils and adenoids might be enough mass to cause an extremely flexible airway to obstruct.

0:34:28

Now, in this situation, trying something like CPAP, or continuous positive airway pressure, at night. So, it's a mask which has air basically blown in. Having that continuous positive airway pressure, sometimes, that is what kids need so that they can avoid surgery and the CPAP helps. On the other hand, a lot of kids don't tolerate that mask. Although if they don't tolerate it at first, give it some time, because sometimes they'll come around and they will start to tolerate it, especially when they're certain to get more sleep.

So, CPAP might be something to consider before rushing off to surgery. I'm not saying your child needs CPAP, Melissa. But that may be a worthwhile conversation with your daughter's doctor especially if her tonsils and adenoids appear normal.

A final point to consider, your child's daytime difficulties might simply be from the Asperger's. Or obstructive sleep apnea, that might be the only cause. Or the daytime difficulties may be from the Asperger's but worsened by the obstructive sleep apnea, or the other way around. Or they may not be related either with the Asperger's or the obstructive sleep apnea. There may be another reason for the difficulties.

There's no magic test to tell us exactly what's going on. So you really have to filter everything — the results of the sleep study, the size of the tonsils and adenoids, the effects of CPAP if you give it a try, the effect of behavioral interventions, and the result of creative sleep strategies like a brief nap at school, if that's possible. We have to filter all of that through our risk-benefit meter with the help and guidance of your child's physician. And the more experience your doctor has in dealing with this sort of problem, the better equipped he or she would be at walking you down this road.

0:36:02

And that's why having a pediatrician and having these tests and evaluations and discussions at a children's hospital really come in handy. So at the end of the day, Melissa, I think you're doing the right thing with the second opinion at Seattle Children's.

So thanks for writing in and for listening since the beginning. That was back in 2006. I really appreciate your trust and support.

All right, let's move on to Pippa in Surrey, UK. "Hi, Dr. Mike. Did you know you have fans in the United Kingdom. I listen with interest to your show and I recommended you to my fellow Brit moms and dads. Thanks for your hard work. We really appreciate it.

My questions follows on quite nearly from your last episode. A friend recently told me not to give Calpol to my baby after her jabs as this would dampen the immune response mounted to the vaccine. Is this correct? And if my baby is grizzly and unwell after her jabs, what should I do?"

[Laughter]

Dr. Mike Patrick: Thanks for writing again, Pippa. Let me do a little bit of translating for my American friends. Calpol is similar to Tylenol, or acetaminophen, here in the United States. And jabs are shots. So should parents give Tylenol after shots? Would this lessen the immune reaction to the vaccine? And if so, what should you do for a fussy baby following their immunizations?

Although, I must say, Pippa, I do like the way you ask the question. Much better than my paraphrase.

There's really, Pippa, not an easy answer to this question. There has not been any study to my knowledge which looks at the absolute effect that pain relievers and fever reducers — so things like Calpol, paracetamol, Tylenol, ibuprofen, Advil, Motrin — any of these, there's no studies which look at the absolute effect that these medications have on the effectiveness of immunizations.

Now, having said that, we do have some evidence which leads to some concern about this possibility. Back in 2009, a study out at the University of Defence in the Czech Republic showed that the use of acetaminophen following vaccine does reduce the incidents of fever. And in this year, 2013, another study, this went out at Goethe University Children's Hospital in Germany showed the same thing. That acetaminophen reduces the incident of vaccine related fever.

0:38:19

So that's a good thing, right? I mean, we don't really want our kids to have a fever after a vaccine, so we give Tylenol. It goes down. The studies show yes, that's effective. So why is this concerning for vaccine effectiveness? Well, the reason we see fever following a vaccine is because fever is a byproduct of the immune system responding to the components of the vaccine. So, if we are blunting the fever, we are in effect blunting of dampening one aspect of the immune response.

But does that mean we are dampening the body's overall ability to form immunity. We really don't know. Now, personally, I think it's unlikely. But this is based on observations and not direct research. So what observations? Well, millions of children get fever reducers following vaccines. And if giving fever reducers cause vaccines to consistently and significantly fail, I think we would have made that observation by now. Also, we know when kids get natural illness, they often form protective immunity against the strain of organism that's making them sick, even when fever reducers are used.

So, I think it's unlikely that fever reducers significantly block immune development. And I think most doctors and scientists would agree with me on this. Otherwise, if they truly believe that fever reducers significantly block the immune response, wouldn't they call for banning their use altogether, even when kids are sick. Don't they want children with natural disease in post-vaccination to form immunity, to protect them from illness down the road?

Especially in the light of the fact that we know fevers are safe. Fevers in and out of themselves are not dangerous. And we've talked about febrile seizures here on the program and that it's more of the rate of the rise of temperature, not how high the fever actually goes that causes febrile seizures.

0:40:07

Now, on the other hand, what about the immunity we do form? So we know that even with fever reducers, we form some immunity to both natural illness and vaccines. But will that immunity be stronger and last longer if we didn't use fever reducers? It does make some sense, doesn't it? So what's a parent to do? What's a doctor to recommend?

Well, as always, without hard research to back with me up, I would take a practical approach. If my child was mildly uncomfortable or had a low grade to moderate fever, I'd hold off. I would try distracting my child. Maybe the brief use of an ice pack might help her swelling or discomfort at the injection site. I'd avoid snug clothes and layers and blankets which may raise my child's temperature further.

But what if my child's really fussy? Or what if he or she has a high fever following a vaccine? I would be a little concern that it might not be the vaccine that's causing that fussiness and really high fever and I'd probably want a doctor to see him. In that situation, your best bet really is to talk to your doctor. Think about the risks and benefits of using the fever reducer, and make an informed decision and don't look back.

There are some absolute rules, though. We don't want to use aspirin or acetylsalicylic acid in children or teens unless directed to by a physician for a specific medical condition because the use of aspirin can cause life threatening problems. Also, ibuprofen — so Motrim, Advil and the likes — is not recommended until babies are at least six months of age. You want to stick with Tylenol, or acetaminophen, Calpol, paracetamol until they're six months of age. So no ibuprofen until then.

So a great question, Pippa. Unfortunately, I don't have an equally great answer because the evidence is somewhat lacking. But hey, at least you can have an informed discussion with your doctor and come up with a plan together.

0:42:00

All right, let's move on to our final question this week. This one comes from Keanna in San Jose, California. "Hi, Dr. Mike. Our seven-month-old daughter started solid foods about six weeks ago and her first food was sweet potato. I have boiled, baked and steamed sweet potato for her, and subsequently frozen the pureed leftovers in ice cube trays so I can microwave one cube at a time for dinner. And she absolutely loves it.

But our pediatrician discourage us from making our own baby food, especially sweet potato and regular potatoes, due to the risk of botulism. Well, as it turns out, she hates the packaged foods. They're bland and lack texture. Well, at least, that's why I think she doesn't like them.

What is the risk of botulism with homemade baby food? Is there a method of food preparation, boiling, baking or steaming which will cut down on the risk? I'm also making steamed pureed carrots. Do carrots carry a lower risk of botulism, if any at all?

Thanks in advance. Keanna.

P.S., On another subject, is there any association with fluoride multivitamins and constipation. She got quite constipated after we gave her the first dose of fluorides, so I'm waiting to give the next dose to see if it was the cause. And I wonder if it was the fluoride or the other multivitamins in the mix. Maybe she'd benefit from a different mix. Thanks."

So, thanks for the questions, Keanna. Let's consider botulism first — what causes it, what are the symptoms, how do you treat it, what does prevention look like. Is homemade baby food a risk? And if so, what can you do to minimize the risk? Lots to cover, but it's an interesting topic and it provides an opportunity to share some really important information.

So what about botulism? The culprit here is a bacterial organism known as clostridium botulinum and this bacteria makes a substance called botulinum toxin. The toxin works at the cellular level causing muscle paralysis.

Now, as it turns out when it's used in targeted locations, botulism toxin is not always a bad thing. It's the active ingredient in Botox which takes away wrinkles, temporarily, when injected into facial muscles. And more importantly, the toxin is helpful for folks who have neuro-muscular diseases, things like cerebral palsy which result in increased muscle tone, because you can relax muscles and help with function by injecting Botox.

Now, you don't want botulism toxin running rampant, paralyzing muscles willy-nilly, right? I mean, you don't want paralyzed muscles used for swallowing and breathing. That's bad and can lead to death.

0:44:29

So, how is it that one becomes accidentally exposed to this toxin? Well, the most common way is home canning of food. And to understand why this happens, we have to take a closer look at the organism, Clostridium botulinum. Its natural habitat is the soil. Now, an interesting characteristic of this organism is that it form spores when it becomes stressed.

Now, what are spores? A spore forms when the bacteria encapsulate itself in a tough shell and becomes inactive. And the formation of spores is really a good news-bad news situation. The good news is the inactive organism does not make botulinum toxin. The bad news is, the spore is incredibly resistant to killing. And while boiling, baking and steaming may kill the active form of the bacteria — the one that's making the toxin — household cooking temperatures will not reliably kill the spores, they remain in the food.

So no big deal, the spores are harmless, right? It's the active bacteria that makes the toxin and they are easily killed in the kitchen. Well, not so fast. Eating spores is safe for most people. They tend to just pass through the gut and out in the stool. But canned food is another story. Canned food, particularly when the canning process is not done correctly, the canned food can become a hospital environment for the bacteria. So the bacteria may emerge from this spore and start making toxins again, which then accumulates in the canned food. And some poor soul comes along, opens the can, eats the food and dies. Not good.

0:46:06

So back to Keanna's question, she's not canning the home made baby food. She's freezing it. And freezing is not hospitable for Clostridium botulinum and so the bacteria is unlikely to emerge from the spores in the freezer and start making toxin. So, this is true. But at the same time, freezing does not kill the spores. Remember the spores are tough.

Also, remember I said the spores safely passed through the gut of most people, but most people does not mean all people. Turns out certain groups of people, namely, young babies and those with compromised immune systems, these folks have a higher risk of the organism emerging from the spore inside their intestine. Babies less than six months old have a particularly high risk but the risk is there for six-month-olds to 12-month-olds as well. Now, fortunately, after 12 months of age, the risk drops dramatically.

So, what do we see when this happens? Well, after eating the spores, the bacteria emerge in the intestine and start to make their toxin. It usually takes a couple of weeks before enough toxin accumulates to cause a problem. But then, these babies become weak. They start having trouble feeding. Then, they start having trouble breathing and if the condition is not recognized, they can stop breathing and die.

When it is recognized, these babies usually end up in an intensive care unit on a mechanical ventilator and fed through an IV until the toxin and infection had cleared. Which, as it turns out, can take several weeks, during which time they're prone to potentially life threatening complications like pneumothorax, pneumonia and sepsis. So it's serious business, and it's something you really want to avoid.

OK, so the next question becomes what food are risky? Well, think about the natural habitat of Clostridium botulinum, the soil. So produce that grows in and around the soil has the highest risk. So, things like potatoes and carrots. Yes, cooking kills the active organism but it doesn't eliminate the spores.

0:48:03

What about washing the produce thoroughly? Well, that will lower the risk of spores. But it doesn't completely eliminate the risk. And refrigeration, freezing and canning, they don't lower the risk either, because the spores survive these conditions.

Now, what about commercially available baby food, with potatoes, carrots, and other soil-grown produce, including sweet potatoes? The commercial process does kills the spores. But the conditions required to do this reliably cannot be recreated in the home kitchen.

As it turns out, another risky food for botulism is honey. Bees pick up botulinum spores while out collecting pollen and transport them to the hive. So honey is another potential source of the spores and should not be given to babies less than 12 months of age.

Now, many of out there are like "Seriously? Isn't this overkill? Are these just scare tactics aimed at keeping parents from making homemade baby foods and in the process, keeping commercial baby food companies in business? After all, we make our own potatoes and carrots all the time, so do our friends. We give our baby honey, so do our friends. We've never had a problem." 'Go organic. Grow it yourself. Boycott big business. Homemade baby food super power!"

And those of you saying that — and there are some of you saying that — you have a point. Lots of parents make homemade baby food and most babies have no problem at all. So, the presence of botulism spores on produce items is not a 100%. And if your baby is exposed, the chance of he or she getting botulism is not 100%. In fact, it's pretty low-risk. Botulism in babies is rare.

But it does happen. I've seen it. Most doctors who treat babies have seen it. And when we do see it, there are a couple of common threads. First, it happens the babies were fed high-risk foods. Second, the disease and its treatment seriously disrupt your life and it has the potential to kill your baby.

0:49:54

So how does this look in a risk-benefit filter? That's something you have to decide. There are many benefits to homemade baby food. But when you consider the risk, the very real possibility of botulism, that risk may not justify the benefit. So personally for me, that's where I am. I don't think the risk justifies the benefit. So I would stick with the commercial baby food when it comes to soil-based produce. And I would avoid honey until one year of age.

Now, your baby may not prefer the taste and texture of the commercial product. But they'll get over it. They'll eat it. It may take a bit more effort on your part. But that's OK, it beats the prolonged stay in the ICU. That's for sure.

All right, let's move on to the multivitamin with fluoride question, as it relates to constipation. The culprit here is most likely the iron in the multivitamin mix. Fluoride is not known to cause constipation. So if your child is on a multivitamin with fluoride and is experiencing constipation, talk to your doctor. If your child is not anemic and is healthy and has a balance diet and is growing well, he or she may not need a multivitamin. Vitamin D supplements are still be important. Fluoride may be important, too, but they may not need the rest of that.

By the way, if you'd like to know more about fluoride supplements — when to start them, how much to give, is it safe, what are the risk of too much fluoride — be sure to check out the newborn basics edition of PediaCast. It was Episode 241. Basically, it is a primer for parents with newborns at home. Newborn basics, and we do cover fluoride and some detail on that. Episode 241 over at pediacast.org.

At the end of the day, taking away the multivitamin may not make a difference. The constipation may be there for a different reason, or no identifiable reason at all. So talk to your doctor, have your child examined, come up with a game plan from there.

And, as always, thanks for the questions, Keanna. They're always appreciated.

Speaking of questions, you probably have a question of your own. Or you might have two, like Keanna did. That's fine, I'm happy to hear them. Just head over to pediacast.org and click on the Contact link and ask away. I'll be looking forward to hearing what your question is.

0:52:08

All right, we're going to take a quick break and I will be back with the final word. We're going to talk about gluten-free grilling. That's coming up, right after this.

[Music]

Dr. Mike Patrick: All right, so tuck and roll, if you're falling. No matter what you're doing, whether it's roller-skating or something else, teach your kids. And you, yourself, practice it so it becomes muscle memory. Tuck and roll, no extended arms.

[Laughter]

Dr. Mike Patrick: OK, really, I'm not laughing.

Grilling out, particularly potluck style, can make gluten-free summer barbecues challenging for families living with celiac disease, wheat allergy and gluten sensitivity.

Mary Kay Sharrett, a registered dietician from the Celiac Disease Center at Nationwide Children's Hospital says, "When going to a cookout, parents with the child who's gluten-free need to make sure that cross-contamination has been avoided and that they read labels carefully, especially if gathering with a group who may not understand the particulars of a gluten-free diet. Be sure to take a gluten-free dish or two with you to the cookout such as a bowl of mix berries, baked beans, corn on the cob, or gluten-free potato salad. That way, you'll know your child will have something to eat."

Mary K. also suggest bringing a gluten-free bun with you to the cook-out or large piece of lettuce as a bun substitute. She also advises moms and dads to closely watch the condiments, read the labels and squeeze bottles aren't being used. Try to be the first in line to avoid contamination from knives that had touched gluten-containing bread. Families with experience eating gluten-free may want to offer to host the cookout to ensure all the details had been covered and to keep the experience safe.

0:54:17

Now, these precautions may seem extreme to those who aren't familiar with celiac disease. But keep this in mind, even left behind crumbs from gluten-containing food can be harmful for a child with a celiac disease if the crumbs mix with a gluten-free dish.

So, to grill safely, gluten-free, you should be mindful of these precautions: Ask if the meat is plain. Seasoning or soup mixes containing wheat may have been added to the meat. Check for marinade or sauces, these two may contain wheat, especially if they contain soy sauce. Some soy sauce can be purchased gluten-free but you must check the label. Also, watch out for marinades made with beer, which do contain gluten.

Check for meat substitutes like veggie burgers, which might look like the real thing, but can contain wheat. Wrap your food in foil when grilling. Wrapping your meat or corn on the cob in foil is crucial if you don't know if the grill has been cleaned, especially after marinades containing gluten had been used or buns had been warmed on the grill. Make sure the spatula only touches plain meat or vegetables because, again, cross-contamination with buns or marinades could be dangerous.

Mary Kay says, "The long-term effect of exposing someone with celiac disease to gluten is damage to the intestine. Some kids experience symptoms immediately, and as a result, many parents choose to eat at home in a controlled environment. But group cookouts are possible if you are cautious."

She does have some gluten-free summertime recipes for you over on the new Nationwide Children's blog. 700 Children's, that's the name of the blog. It's 700childrens.nationwidechildrens.org. I'll put a handy link in the Show Notes for this episode, 258, over at pediacast.org so you can find the recipes easily.

So a gluten-free summertime cooking and the new 700 Children's blog — and that's my final word.

0:56:00

Speaking of the 700 Children's blog, be sure to check that out. I'm one of the regular contributors and you'll find my post, "Does Sunscreen Cause Skin Cancer?" there as well. And, I'll also put a link to that post in the Show Notes over at pediacast.org for this episode, 258.

Coming up in a couple of months — or maybe, actually I think it's next month, in August — we do have a show scheduled with the director of our Celiac Program here at Nationwide Children's. And we're going to have a whole show on gluten and gluten-free, celiac disease and gluten sensitivity and all that. So, we look for that coming up sometime in August.

All right, I would like to thank all of you for being a part of the program today. Really appreciate your trust and your support. Just remember, iTunes reviews are very helpful. If you haven't done that, just take a couple of minutes, please, and write us a nice review on iTunes. It's very helpful.

Also, links, mentions, shares, re-tweets, re-pins on all your social media sites are helpful as well. We are on Facebook, Twitter, Google+ and Pinterest.

And be sure to tell your family, friends, neighbors and co-workers about the show. Most of all, tell your child's doctor. Next time you're in for a well checkup or a sick office visit, let them know about PediaCast. The posters are available under the Resources tab at pediacast.org, so they can hang those up and share the show with the rest of their patients.

We'd like to remind you one more time, the Contact link is available at pediacast.org if you'd like to get in touch with me. Just ask your questions or your comments, or show topics, suggestions. All those things are appreciated.

We also have a link to connect with a pediatric specialist for Nationwide Children's and this is for referrals and appointments. If you're interested, you can get right in touch and someone will be back in touch with you to let you know how to get a referral or an appointment ASAP. And again, that link is also in the Show Notes over at pediacast.org.

And until next time, this is Dr. Mike saying safe, tuck and roll, stay healthy and stay involved with your kids.

So long, everybody!

0:58:03

[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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