Multiple Fevers, Molluscum Contagiosum, Tongue-Tied Babies – PediaCast 282

Join Dr Mike in the PediaCast Studio for more answers to listener questions. This weeks topics: multiple fevers, ear tubes & swimming, molluscum contagiosum, pasteurization, tongue-tied babies, and the poison plants of summer!

Topics

  • Multiple Fevers

  • Ear Tubes & Swimming

  • Molluscum Contagiosum

  • Pasteurization

  • Tongue-Tied Babies

  • Poison Ivy

  • Poison Oak

  • Poison Sumac

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's a pediatric podcast for moms and dads this is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We're in Columbus, Ohio it is episode 282 for March 26, 2014, we're calling this one Multiple Fevers, Molluscum Contagiosum, and Tongue Tied Babies. I want to welcome everyone to the show we have a listener program lined up for you this week so listener questions and we do have some good ones. I always get excited when I put out a call for questions because the usual fashion you guys follow through and send them in.

0:01:10.1

We haven't had a listener show in several weeks, our last couple have been interviews but I knew it was time to get back to the basics and see what questions you the audience has for me. So we'll get to the specifics of those in a few minutes. Spring is here at least on the calendar and after the winter we've had I cannot wait to get outside and enjoy some warm weather. The trees and plants are beginning to wake up just noticed some new sprouts on the magnolia tree in our front yard and have a couple of blooms. I'm hoping that we don't get any more freezes at this point but we'll see.

0:01:59.2

Anyway the trees and plants are beginning to wake up but that is also going to include poison ivy, poison oak, and poison sumac for those of you in the south eastern portion of the United States. For my final word this week even though it's early spring I'm going to do a primer on the poison plants of summer how to recognize them, how to prevent the rash, how to treat the rash, a little history, a little science so that's coming your way at the end of the program. If you're like me and dreaming of summer that discussion will definitely put you in the mood if you think it's too early in the year to talk about such things that's fine. Just make a note on your mobile device poison ivy, PediaCast 282 into the show and then when you or your child starts itching you have an easy reference and take a listen after the fact. I want to remind you about our blog 700childrens.org. We have our first blog series and it includes a heartfelt videos.

0:02:57.8

Little Blake is a baby born with spina bifida, we spent five months documenting key moments in the life of Blake and his family sort of reality TV Children's Hospital style. So be sure to check in with mom for family on the 700 Children's blog really well done and something you want to share with your family and friends. Marijuana for epilepsy, it's another good read to see what our experts have to say and it might surprise you or maybe it won't. Take a peek and judge for yourself and again the blog address is 700childrens.org. This week's line-up Multiple Fevers. Listener has a family of seven and fevers have been running around the house for the last six weeks. Two kids sick here another two kids sick there, then mom and dad gets sick then the first kid with the fever gets another fever, then dad has a fever again. What illnesses can a family pas back and forth and what can you do to stop the madness, that's coming your way. 

0:04:00.6

And then ear tubes and swimming, so again spring is coming and the swimming season will be coming soon behind it. Is it safe to go back in the water after ear tubes are placed through the ear drum? Does your child need to use ear plugs? And what about diving and swimming under water, is there a difference between swimming pools and lakes? What about baths and showers? And here's a tough one, what if one ear, nose and throat doctor tells you one thing and another one tells you something different? We don't mind answering the tough questions on PediaCast so we'll bite and stay tune for the answer. And then Molluscum Contagiosum, that's a mouth full. It's a common skin problem i children in fact I bet someone in your house has had it. What is Molluscum Contagiosum? What causes it? How do you get rid of it? A listener wants to know so we'll consider that. And then pasteurization, I talked about raw milk in a previous PediaCast. I even run a blog post about it over at 700childrens.org. 

0:05:01.4

A listener agrees she doesn't want her family exposed to the dangers of raw milk so she wants to know if low temperature pasteurization is a good idea? I'll let you know and we'll talk about the different types of pasteurization including vat pasteurization, high temperature short time pasteurization, higher heat shorter time pasteurization, and ultra-high temperature pasteurization. So what's the difference in these different procedures? Are they safe? And do they affect the protein content and nutritional value of the milk? So that's coming your way. I'll give you a hint, pasteurization does alter the proteins but does that affect nutrition in your body's ability to digest the milk? We'll explore those questions together. And then tongue tied babies. Babies born with a cord of tissue connecting the bottom of the tongue to the floor of the mouth what problems can this cause and how do you fix it? And a mom wants to share her journey with a tongue tied baby in an effort to spare other parents of the drama and frustration her family endured at the hands of medical professionals.

0:06:07.6

See I told you we have some good ones today. And then we'll wrap things up with a final word on the poison plants of summer which somehow includes a reference to Capt. John Smith in Pocahontas. I want to remind you if there's a question that you have, or you like to suggest a topic, or point me in the direction of a new story or journal article it's very easy to get in touch just head over to pediacast.org and click on the contact link. Also I want to remind you the information presented in PediaCast is for general educational purposes only we do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to 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. Alright let's take a quick break and I will be back with answers to your questions right after this.

0:07:03.9

[Music]

Dr. Mike Patrick: Alright we are back and first up is Geraldine in Israel, Geraldine says, "Hi Dr. Mike greetings from the Holy Land. We are a family of seven and for the last six weeks different family members often two or three at a time have had fever. Some family members have had fever two or three times during this period. Sometimes it's just fever, other times diarrhea or a mild sore throat is present. We've been to our family doctor and he says it's a virus so basically there's nothing to do. It's really frustrating, last week it was my husband, three daughters and me. Today my husband and one of my daughters have a fever again. Is there something we could do? Thanks a lot for your time, love your show, cheerio, Geraldine." 

0:08:14.9

Well thank you for the question Geraldine. That does sound frustrating but it's also a common scenario especially during the times of year when school is in session. Fever is a by-product of our immune system at work which is why we see fever with a viral and bacterial illnesses and why we sometimes see fever following immunizations. Now there are other things that can cause fever things that are not necessarily contagious but they are not common. So when we see multiple fevers in the same home affecting different family members we often say the family members are passing something back and forth. This is more common during the school year or when you have young ones in day care because your children are in close contact with other children and they are sharing viruses and in some cases bacteria.

0:09:00.8

And they are bringing these pathogens home and sharing them with siblings and parents. And that's why we see more contagious illness during the school year, it's not from the cold or the weather, it's because of school. Can you pass these contagious illnesses back and forth, and if so how do you break the cycle? That's Geraldine's question in a nut shell. Well in the case of viral infections things like the common cold, influenza, croup when a virus is the culprit which is what Geraldine's doctor believe is going on. When a virus is the culprit you don't really pass the same virus back and forth and that's because once we're sick with the virus our immune system remembers that virus and revs up to stop the virus and its tracks the next time that virus shows up. Of course this is assuming a normally operating immune system. Your daughter may bring a virus home from school, give t to dad, but it's unlikely that dad is going to give it back to the daughter who first gave it to him because she has developed immunity against that particular strain of virus.

0:10:04.2

So why is everybody in the house getting sick over and over again? Well because you're probably dealing with a bunch of different strains of virus. You have five kids Geraldine what if each one brings home a different strain of virus from school or day-care? So you have virus A, B, c, D and E all running around your house. Now each person is only going to get sick with each virus one time and some members of your family may have immunity against one or more of these strains because he or she was sick with that strain last winter. So it's unlikely each person will get sick five times but each one may get sick three times and in a family of seven that's 21 separate illnesses and if each illness last an average of 7-10 days, couple days of fever then feeling viral for a few days you do the math. It may take a bit longer than six weeks for everything to work its way out right? And this is a common scenario when school is in session especially in large families.

0:11:03.6

So what can you do about it? Well in this case prevention is the best treatment. Try not to bring the viruses' home from school or day care which may be near impossible in the first place and try not to spread the virus to other family members. Now how do you do that? Good hand hygiene is a great start and wash those hands like crazy, or you sanitizing hand gel often, don't shake hands, or hug, or wrestle with classmates or family members during viral season even if others appear well they might be contagious day or two before their symptoms begin so assume everybody is a potential source of infection and keep your distance. Also wash your hands or use hand gels after touching things other people touched like phones, and door knobs, and television remotes to name just a few. Don't drink after others, don't share utensils all those good hygiene principles our mothers taught us, there are a reason for those rules. 

0:12:01.2

Now if that sounds difficult, it is which is why viruses spread like wild fire during the school year. Another form of prevention, make sure the entire family gets their flu shots each year that will protect you from some strains of the flu which can be a severe illness with complications like asthma exacerbation and pneumonia. It won't protect you from other viruses or strains of the flu that weren't in this year's shot. So you'll still going to get sick despite getting a flu shot but you're less likely to have a severe viral illness with potentially life threatening complications. I hear this complaint a lot, "Last time I got a flu shot I was sick all winter long," yes but you weren't sick with the flu. Did you end up in the hospital with pneumonia? No you didn't so the flu shot did its job. So get those flu shots each year and every year even if you're frequently sick during the winter following your last flu shot. So Geraldine if these are viruses running around the house you have to wait until each person has had each one and that may take a good while. 

0:13:04.1

Now in the meantime you want each sick person to have plenty of rest and fluids and as we've mentioned here before, if any individual in the family has a fever that's lasting more than a couple of days in a row or is associated with concerning symptoms, things like a severe head ache, stiff neck, difficulty breathing, severe abdominal pain, vomiting, blood in the stools, strange rashes, anything that causes you concern then that person should see a doctor to verify that it's only a virus. Now having said all of that there are some bacterial infections that family members can pass back and forth unless everyone is treated with antibiotic at the same time it is possible to keep passing the illness back and forth. And examples include strep throat and Geraldine you did mention sore throat so you do want to make sure strep is not the culprit. Pertussis especially when there are un-immunized folks in the family, some skin infections like MRSA or methicillin-resistant staphylococcus aureus all different name for the same skin condition that can be pass back and forth and certain types of pneumonia can be pass back and forth as well.

0:14:11.9

Bacterial infections that aren't contagious for those who are interested things like ear infections, sinus infections, certain other types of pneumonia although underlying viral infections can lead to these bacterial infections and that underlying viral infection can be contagious. So brother and sister may get sick with the same virus but if each goes and develop an ear infection they each develop their own ear infection as a complication of the respiratory virus they shared, they didn't share the ear infection, ear infections are not contagious but the underlying viruses that can lead to them are. So I hope that helps Geraldine. Bottom line, if fever last more than a couple of days, or it is accompanied by concerning symptoms, see a doctor even if several viruses are running around the family. If your doctor says it's a virus, you're right there's not much you can do. Rest, fluids, fever reducers and watch for signs of complicating bacterial infections which your doctors will advise you to do.

0:15:08.7

As always thank you for the question Geraldine, I really appreciate you writing in. OK next up is Whitney in Dallas, Texas. Whitney says, "I've been listening to your show since before my niece was born about four years ago and now I have a kid of my own. I really appreciate you providing an evidence based resource for pediatric medicine, there is so much pseudoscience out there and I just don't have the time to research everything. Anyway here's my question, my daughter will be one towards the end of March, we plan to take her swimming this summer but she has ear tubes. The surgery was performed in November after she was on her forth ear infection in less than three months. Everything went perfectly she's been ear infection free since. I'm not sure if ear plugs are necessary or not, if not I would prefer to save the money in hassle. Her E.N.T doctor says the general consensus is not to use ear plugs however he likes to recommend them. 

0:16:02.0

His reasoning is water normally can't get through the ear tube and pass the eardrum into the middle ear space. That seems to make sense but anything going against common recommendations needs to be researched especially since I don't have a long term trust build up with using this particular doctor. What does the research say on benefits and risks of using or not using ear plugs after ear tube insertion? Thank you, Whitney." Thank you for the question Whitney. This is not an easy question to answer which is why your E.N.T doctor hedged. Here's what we want to know if we were designing a study and we're talking about kids who have the little plastic ear tubes with a hole in the middle of them through the ear drum so it helps to ventilate the middle ear space. And we've talked about how these tubes work before on the program so go back to past episodes and look up ear infections if you want to know more about the function of ear tubes. 

0:16:57.2

So here's what we want to know if we were designing a study to see if it's OK for water to enter the ear tube. First does water entering the ear canal actually get through the ear tube and enter the middle ear space. Second, if water does enter the middle ear space, can that result in the ear infection? And third, does it matter what kind of water we're talking about? So is there a difference between bath water, shower water, pool water, lake water and does it matter if a child is splashing on the surface of the water, or diving in, or spending lots of time under the water. So in order to know how to advice a family we really need to know the answers to these questions. SO what has research shown us? Well as it turns out research has produced some mixed results. We have some studies that shows surface swimming and general bathing do not result in significant water going through the ear tube into the middle ear space and surface swimming and bathing without ear plugs does not result in an increased incidence of ear infections. 

0:18:03.3 

On the other hand we have other studies which shows surface swimming and bathing do result in water entering the middle ear space which does result in a small but statistically significant increase in ear infections. So we have conflicting results and both are from well-designed studies published in well-known peer reviewed journals. So here's why your E.N.T doctors hedging on the answer the consensus is you don't need to use ear plugs for surface swimming or bathing because the risk is low but your E.N.T doctor knows that risk is not zero. He doesn't know what your risk tolerance is. So he's going to say use them that way if you don't and your child gets an ear infection after swimming it's not his fault, I get that really I do. What about diving or spending considerable time under water? In this case more doctors will advise that you go ahead and use the ear plugs. Water under pressure seem to have a greater chance of flowing through the ear tube and into the middle ear space that's a thought anyway although we don't have any good research to back us up on that. 

0:19:09.1

And when we don't have good research to back us up we draw on our experience, what we do know to make a recommendation. In the case of lake water intentionally exposing a child's tubed ears to dirty lake water for the sake of science, that's not a study likely to pass an institutional review board. So we have to again call upon our experience and general established knowledge in order to make a recommendation which in the case of lake water I think the overwhelming consensus would be stay out of the lake but if you must go in use ear plugs if your child's going to be splashing around in the lake or the ocean for that matter. So to sum up Whitney consensus which just means a majority of E.N.T specialist would dictate that ear plugs are not necessary for surface swimming, or bathing, or showering unless the kid's going to let the shower spray goes straight inside his ear canal every time.

0:20:00.8

But ear plugs are probably a good idea if your child's going to be diving, or spending lots of time under water, or swimming in dirty bodies of water. Now that doesn't mean the risk of going ear plug less is zero when you're surface swimming or bathing, but for most families the risk is acceptable again if we're talking about surface swimming or bathing. So I hope that helps Whitney and as always thank you for writing in. Next up is Tiffany in Oregon. "Hi Dr. Mike I took my son for his four year well check-up and asked his pediatrician about this little bumps that he has on his right knee and right elbow. She told me they are most likely molluscum contagiosum. They looked like they would pop if I squeeze one but my son is quick to veto that. What does this cause from and will it go away? Thank you, Tiffany in Oregon." Well thank you for writing in Tiffany as always it's appreciated.

0:20:58.1

SO let's tackle molluscum contagiosum. As we move through this discussion I'm going to compare molluscum contagiosum with warts because they're both skin conditions caused by a virus. Now in the case of warts the virus is a human papilloma virus and this causes skin cells to multiply resulting in a benign tumor of the skin. SO the wart is made up of a pile of skin cells that have been hijacked by the human papilloma virus. In the case of molluscum we're dealing with a different virus, a poxvirus and the virus doesn't causes skin cells to multiply like we see with warts instead the poxvirus shares its genetic material with the cell causing the cell to form a characteristic lesion within the skin and these lesions are flesh colored or pearly dome shaped papules or bumps and they usually range in size from one to five millimeters so they're small but they can be as large as one centimeter so kind of the head of a tack those would be the bigger ones. 

0:22:02.3

And then you generally see central umbilication or dimpling in the middle on the top surface of that bump. So lesions are generally small, smooth, flesh colored bumps with a tiny dimple on top. The center of the dome is filled with a waxy core which is extra cellular. So it's not inside of the cell, it's between cells and this waxy core is filled with the pox virus. Now compare that to the wart virus which continues living inside the cell. So once the poxvirus hijack the cell and turns it into a virus making and papule making machine it exits the cell along with its newly made virus bodies and lives inside this waxy core along with collagen which is a protein and a lipid rich substance which is taught to protect the virus from immune system recognition. SO the virus infects the cell, instructs the cell to make more virus, instructs the cell to form this lesion, instruct the cell to make a protective substance and then the virus lives the cell and hangs out in this safe haven where the immune system has difficulty recognizing the virus as a foreign invader. 

0:23:13.8

It's pretty cool when you look at it from the viruses' point of view and they have a cool gig going here but of course it's not so cool for mom and dad. These lesions can spread from one kid to another and to different areas of the same kid which makes sense because they're caused by a virus. And they last a long time usually several months to a couple of years, why? Because the immune system has trouble recognizing that the virus is there. On the other hand they don't last forever. So eventually the immune system figures out the problem, fights the infections and the virus, and the lesions go away. Not only that these lesions are less likely to return because the immune system now has memory so the next time this poxvirus enters the immune system zaps it right away usually if the immune system's working correctly. 

0:24:02.6

And this is why molluscum is much more common in young children compared with older children, teenagers, and adults who had molluscum lesions at some point in their past and they're better protected. So we know it's viral, it can spread but it also goes away on its own eventually. So the next question, do you need to do anything about it? Well there's not a right or wrong answer here, you have to take each case on its own merit. If there's only a few lesions and they're hidden by clothing, the child's not messing them I'd say leave them alone , let the body do its thing. On the other hand if they're really spreading, you've got 20-30 lesions or more, your child's picking at them like crazy, maybe they're getting secondary skin infections right and left then it's easier to say, yeah let's do something about these things. Of course most cases are near extreme, they typically fall somewhere in the middle and what to do about them comes down to a decision between mom and dad possibly the child and your doctor.

0:25:01.0

Now I tend to be more conservative with these things. If they're not causing a problem leave them alone, let the immune system do its thing. I know it may take several months to a couple of years, they're going to go away before you get married and the reason is this, the reason that we typically say weigh if you can. The treatment options that are available are not necessarily benign. They can cause pain and they can cause scarring so why create new problems when the things are going to go away eventually on their own. On the other hand there are times when you must deal with them. Skin infections, cosmetic issues, other kids making fun of them, decrease quality of life kind of stuff then sometimes you just have demanding parents who wants the bumps gone. So let's talk about our options for getting rid of them. First is a method called enucleation. I like this method, you don't want to try it at home because you can introduce infection and you can spread the molluscum to other areas of the skin if it's not done correctly. So your doctor will open the lesion and express the core. 

0:26:06.1

And they typically don't come back once this is done although they can. Disadvantages to enucleation, a pain although you can numb the skin first with a topical agent. Scarring especially if your child keeps picking the skin afterward and there is the possibility of introducing surface skin bacteria into the skin and causing skin infection. Also reoccurrence of the molluscum is possible because you just express virus on the nearby skin so you definitely want to use proper technique with doing enucleation. Then there's topical agents, things we're going to put on top of the skin in order to make these things go away. Some examples tape stripping to remove outer layers of epidermis although this may also cause spread of the virus in nearby skin. Liquid nitrogen, so freezing the lesion. Now this doesn't work as well as it does for warts because the virus is not living in the cell. 

0:26:58.7

Liquid nitrogen kills cells not necessarily the virus which is a big deal if the virus is living in a cell. The poxvirus isn't living in a cell but cells are required to maintain that waxy core so this does sometimes work. Then there are blistering agents which are acids usually applied by a dermatologist, they require multiple weekly applications and can cause pain and scarring. And then there's some home agents that can be used, retinoid like Retin A this requires daily applications for couple of weeks is generally a good option for that. Then the next way to treat is with a systemic agent or something by mouth. Now this is kind of interesting. Cimetidine also known as Tagamet is an H2 blocker used to reduce the production of stomach acid and generally use to treat gastroesophageal reflux. But it's thought to somehow stimulate the immune system to better recognize the virus. The exact mechanism is unknown and this was probably first seen anecdotally, I don't know the specifics, maybe a doctor notice the association. 

0:28:04.1

You treated some patients for acid reflux and their molluscum goes away. One uncontrolled study showed resolution in nine of 13 patients over a two month period which was barely statistically significant and the authors recommended controlled studies with larger sample sizes which to my knowledge have not been done. Treating molluscum with Tagamet is not an official indication to use the drug so Tagamet's use in treating molluscum would be considered off label. And when we're talking about kids do we give a drug off label to treat a condition that is relatively benign with the evidence that the drug works as marginal at best, that's not for parents and doctors to decide together. So bottom line Tiffany for kids with uncomplicated cases most of us say leave them alone, they'll go away in time, time meaning a few months to a couple of years. On the other hand if a child is suffering because of the molluscum we do have some treatment strategies available.

0:28:58.7

So I hope that helps and thank you for the question. Next up we have Mary in Columbus, Ohio, Mary says, 'Hi Dr. Mike you said you don't believe we should drink raw milk and I agree now after reading and listening to your opinion. There is the option however of drinking milk that is pasteurized at low temperatures around 150 degrees Fahrenheit. This is a significantly lower temperature than milk is now routinely pasteurized at. What do you think of drinking milk pasteurized at these lower temperatures?" Thank you for the question Mary, it is a good one. So lower temperature pasteurization also known as VAT pasteurization is safe as long as it's done correctly. Now there are many methods of pasteurization basically the higher the temperature used the shorter period of time the milk needs to be exposed to that temperature in order to kill micro-organisms. So VAT pasteurization heats the milk to a 145 degrees Fahrenheit and it keeps it there for 30 minutes. 

0:30:05.3

Most big production dairy operations don't use this method because it slows down production and in fact here on Ohio Hartzler dairy to my knowledge is the only dairy that uses this. You do need some controls to make sure you're doing it correctly and if the milk coming out of the process isn't contaminated by microorganisms. So if the farmer down the road is doing homemade, low temperature pasteurization I'd be somewhat leery. On the other hand if you're purchasing low heat pasteurized milk from a reputable dairy in a reputable store I think you're fine because those quality and safety controls are more likely to be in place. By the way how does this low temperature pasteurization compare to other types of pasteurization? Again for VAT or low temperature pasteurization, we're talking a 145 degrees for about 30 minutes. There's also a type of pasteurization called high temperature-short time pasteurization or HTST and this is where the milk is heated to 161 degrees for 15 seconds. 

0:31:10.0

Then you have high temperature pasteurization which is just the old fashion industry standard. There's various techniques basically the milk is heated to somewhere between 191 and 212 degrees Fahrenheit for anywhere from one second to 0.01 second and basically the higher the heat, the less time it needs to be exposed. And then we have ultra-high temperature pasteurization, pretty much the opposite of VAT pasteurization and the advantage of this is it leads to milk that has a much longer shelf life and this is where you heat the milk to 280 degrees Fahrenheit for two full seconds. Now I should point out all of these methods when performed correctly kill micro-organisms and render the milk safe to drink. But what about nutrients? Do high temperatures, do they change the nature of vitamins and enzymes in the milk? That's the million dollar question many parents want to know.

0:32:07.9

And the bulk of research out there right now suggests that all of these strategies from VAT pasteurization on up to ultra-high temperature pasteurization, the bulk of research suggests that all of these methods maintain the integrity of milk nutrients. Now what exactly does this mean? Because it is true that all forms of pasteurization from VAT pasteurization on up to ultra-high temperature pasteurization, it is true that all forms of pasteurization will de-nature proteins. Now what does that mean? Well proteins are a strings of amino acids and denaturing just means that the protein falls apart into smaller strings of amino acids or into individual amino acids. So think of a pearl necklace if you're going to denature the protein you're going to cut between some of the pearls, sometimes you're going to cut between each and every pearl and end up with individual amino acids. 

0:33:08.6

So yes, pasteurization denatures proteins. It doesn't destroy them but it does start to break them down. Now what else denatures proteins? Stomach acid and digestive enzymes denature proteins. These websites that scare parents into thinking pasteurized milk is less nutritious, what they fail to understand is that proteins and enzymes that are present in raw milk, they're not going to enter your blood stream as full proteins and full enzymes and they're not even going to make it down toward you would expect them that they're going to be working. They're not going to get help you break down lactose, stomach acid and digestive enzymes break these proteins into smaller proteins and amino acids which were then absorbed in the intestine and taken up into the blood stream. 

0:34:00.7

So pasteurization including the low temperature kind simply starts the job your body is going to finish. I hope that helps Mary. Bottom line and I've said this before, raw milk is not safe, pasteurized milk which has been processed properly from low temperature on up to ultra-high temperature is safe and nutritious as long as the source is reputable commercial dairy farm. Don't drink milk from farmer brown down the road, just not a good idea. OK next up Ashley in Raleigh, North Carolina. Ashley says, "Dear Dr. Mike I started listening to your show when I was pregnant with my first child last year. I was hoping you could go back to a subject you covered in show 151. My daughter was severely tongue tied at birth but it wasn't discovered until she was four weeks old. My daughter was breached and born by C section. I had a lot of trouble getting her to latch on and stayed an extra day in the hospital to work on breast feeding. I saw several lactation consultants and they blamed the difficulty on my anatomy and being unexperienced."

0:35:02.2 

"I was so frustrated, I was only able to get her to latch on without help from a nurse one time over four days. When I had to leave the hospital I was scared, my daughter was screaming from hunger and I couldn't feed her. Thankfully I had bought a double electric pump and was able to give her some milk through a bottle the first day home. I went to my pediatricians' office the next day to get some help, I work with the lactation consultant in the practice. She mentioned that my daughter could be tongue tied but didn't think that was the case. I was eventually able to get her to latch on but it hurt badly, she was biting me and leaving me bruised. After going back multiple times and trying everything the consultant knew she came to the conclusion that my daughter had uncoordinated tongue patterns and would never be able to breast feed. She told me that I have tried hard and she'd feel OK with giving up, I was heartbroken. I had a good milk supply but couldn't get her to nurse. Even though she did nurse she wasn't eating well from a bottle either. I went to the hospital for a breast feeding class and asked the teacher for advice. She recommended that I see a pediatric dysphagia specialist that has had success with babies who have breast feeding." 

0:36:06.8

"As soon as the dysphagia specialist saw my daughter she recommended an E.N.T evaluation. I've made an appointment with the pediatric ear, nose and throat specialist and saw my pediatrician the same day for GURD gastroesophageal reflux related issues. I told my pediatrician about the suspected tongue tie and she felt that it wasn't that bad. She said getting it clip was optional and only if I wanted to have it done but when the E.N.T evaluated my daughter she said that tongue tie was a two out of four, one being the worst case scenario. She quickly trimmed under my daughter's lip and tongue and each cut barely bled. It made a huge difference but my daughter didn't know how to use her new found freedom. I've worked with the dysphagia specialist and my pediatrician different than the one I mentioned previously for the past five months to help my daughter learn how to use her tongue. She never learned how to nurse but she's getting breast milk through bottles and her eating habits are improving."

0:36:58.3

"I say all these because my daughter was one of those few cases where a tongue tie was causing eating and weight gain issues. It drives me crazy that several people miss the problem. The lactation consultants at the hospital never looked in my daughter's mouth, the lactation consultant at the pediatricians office missed how severe it was and didn't realize she needed to see a specialist. My former pediatrician didn't think it was worth correcting. Dr. Mike can you please explain to the practitioners in the audience what to look for when it comes to this issue. I would hate to see more families go through all these because of a lack of information. Sincerely, Ashley in Raleigh, North Carolina." Well thank you for writing in Ashley. You bring up a good point. You know there are certain factoids that get drilled into pediatricians as we train and one of those factoids is that tongue tied babies who are feeding well don't need to have the frenulum which is the strand of tissue that connects the bottom of the tongue to the floor of the mouth. If that frenulum is really broad and restricts tongue movement, if as long as they're feeding fine you don't need to have the frenulum clipped and slightly older children who are tongue tied as long as they're not having eating problems and they don't have speech problems they also don't need to have their tongue tying frenulum's clipped.

0:38:13.2

And we get so used to handing out this information during visit, after visit, after visit because we do see a lot of tongue tied kids who have no problems at all that we forget about the exceptions that poor feeding can be caused by tongue tied and speech problems can be caused by being tongue tied and these conditions might be improved or corrected by clipping the frenulum. Now notice I said might be corrected. Clipping the frenulum might not help the problem, there are other causes of poor feeding and speech problems and tongue tied kids that have nothing to do with their being tongue tied. I also want to point out that clipping the frenulum is not risk free. So Ashely in your case the procedure was a walk in the park but for other babies this is not the case and significant bleeding has been reported, and significant and prolonged bleeding that close to the airway can result in life threatening complications. 

0:39:07.8

So what's a doctor and parent to do? Clipping the frenulum doesn't guarantee of positive outcome and it have the potential to be harmful. On the other hand it might just solve everything. So this is where the practice of medicine is not exactly black and white. We need to give parents all their options and be frank with the risks and benefits and we need to help parents assess their risk tolerance level and we need to guide them in their decision making process without making the decision for them. Ashley I do want to point out if you had said that your baby had the tongue tie corrected and immediately latch on to the breast and the feeding problems were no more than I would say absolutely, that's a kid that I would say getting that tongue tied fixed the problem, the tongue tie probably was the cause of the problem.

0:39:57.1 

But the fact that it didn't correct things right away you could make the argument that even if you hadn't had the tongue tie clipped at that point with seeing the dysphagia specialist the feeding would've started to improve and so maybe the tongue tie will still just a coincidence and not the cause of the problem to begin with. There's really no way to know the answer to that question and if you had been in the situation where your child did have a complication and maybe aspirated or choked on blood and had a poor outcome I think you'd probably be writing a different email into the program. So just things to think about, parents once you make a decision and move forward, don't look back just move forward, work with what you have and like I say don't look back. There's really two sides of the story and I certainly understand Ashley's frustration and really do thank you for sharing your story, definitely sounds frustrating and I hope hearing it will help some moms and dads, and doctors, and lactation consultants, and ear, nose, and throat doctors in the future.

0:41:03.8

Alright so that brings us to a conclusion of our answers listener questions this week. I do want to thank those took the time to send in your questions and comments. Don't forget if you have a question for me, or you have a comment, or you want to point me in the direction of a new story or journal article. It's easy thing to do just head over to pediacast.org and click on the contact link. I do read each and every one of those that come through. Alright the poison plants of summer. I know it's early spring but I'm just chopping at a bit here to talk about a summer topic. So I will be back with a final word on poison ivy and the like right after this.

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0:42:23.3

Dr. Mike Patrick: Spring will soon be upon us and you know the signs, dad will fire up the grill, mom will find her green thumb, and your kids will fetch their ball in the weeds and the whole family will come down with an itchy rash. That's right the poison plants will soon be back and this year they promise to send 40 million Americans to the doctor. The three most common culprit's poison ivy, poison oak, and poison sumac are native to America and caught European explorers by surprise. Capt. John Smith wrote, "The poisoned weed is much in shape like our English ivy but being touched cause a redness itching and lastly blisters." Pocahontas could've warned him after all Indian warriors coated arrow tips with poison ivy and medicine men rubbed its leaves on infections in an effort to break open swollen skin. 

0:43:09.7

Physicians in the colonies learn something new and expanded the plants use to the treatment of herpes, eczema, arthritis, warts, ringworm, and rattle snake bites. Today we know the rashes is an irritating allergic dermatitis upon exposure the immune system revs up, attacks the plant oil and damages your skin. The few who don't react should still watch out sensitization can occur any time making a fool out of cousin Eddy when he rubs the leaves up and down his arm just to prove he ain't allergic. The offending substance in the oil is urushiol, it's a yellowish chemical inside the leaves, stems, and roots of the plant. Because the oil is inside, undisturbed leaves will not hurt you. However, if the plants become dry, insect-chewed, or otherwise damaged, the oil leaks to the surface where it comes into contact with humans and other animals. 

0:44:02.1

As it turns out, only primates are allergic. Dogs, cats, cattle, and sheep don't break out, but they can pass the oil to their human keepers. Clothing and tools also spread the oil, and since urushiol remains allergenic for years, unsuspecting spring gardeners can get the rash from last season's gloves and shovels. If you come into contact with poison ivy, you should wash well with plenty of soap and water. Unfortunately, this won't always prevent the rash because the oil bonds fast to human skin and is nearly impossible to remove within 30 minutes of exposure. This also means you won't spread the rash by touching affected skin or taking a bath. Poison ivy does have the illusion of spreading, but this is because areas with the greatest exposure break out first, and because thinly-skinned body parts react more quickly than thick skinned areas. Once you have the rash, it typically lasts 2 to 3 weeks as the damaged skin is replaced by new cells.

0:44:58.3

All you can do is treat the symptoms and prevent infection. For mild cases, over-the-counter hydrocortisone cream and oral antihistamine, like Benadryl, work well to control inflammation and itching. Topical antibiotic ointment may prevent bacterial infection when the skin is broken open from repeated scratching. If you have widespread rash, face or genital involvement, or signs of infected skin, it's time to see your doctor. In these cases, prescription steroids or antibiotics might be necessary. Prevention by avoidance is always best. All three poison plants have compound leaves, most commonly with three leaflets. My Grandma Bert used to say, "Leaves of three, let them be!… and she was right. The leaves are smooth and glossy, colored with a summer green that transitions to autumn shades of orange and scarlet. Poison ivy is a stout weedy vine that climbs trees east of the Rocky Mountains. Poison oak is larger, more shrub-like, and found west of the Rockies. Poison sumac grows in swampy areas of the Southeastern United States where it can reach heights of twenty feet.

0:46:04.5

IvyBlock, and other medications containing the chemical bentoquatam, prevents the rash by providing a barrier on the surface of exposed skin. It is available over-the-counter and approved for ages 6 and up. It should be applied at least 15 minutes prior to expected exposure and reapplied every 4 hours to remain effective. So get out there and enjoy spring. Fire up the grill. Tend the garden. Play ball. But don't forget my grandmother's advice. Otherwise, you might end up in the waiting room, scratching your itchy skin with those other 40 million Americans. And that's my final word. I do want to thank each and every one of you for taking time out of your day to be a part of the program. PediaCast is a production of Nationwide Children's Hospital. Don't forget PediaCast and our single topic, short format programs PediaBytes are both available on iHeart Radio Talk which you'll find on the web at iheart.com and the iHeart Radio app for mobile devices.

0:47:02.6

Our show archive which includes over 250 programs as well as our show notes, transcripts, terms of use agreement and contact page are all available at our landing site which is pediacast.org. We're also on iTunes under the kids and family section of their podcast directory. You'll find PediaCast on Stitcher, TuneIn, Downcast, iCatcher, Podbay, and most other podcasting apps for iPhone and android. We're also on Facebook, Twitter, Google Plus, and Pinterest. And of course we really appreciate you connecting with us there and sharing, re-tweeting, re-penning all of our post so you can tell your own online audience about our little show. We also appreciate you talking us up with your family, friends, neighbors, and co-workers, anyone with kids, or anyone who takes care of children. And as always be sure to tell your child's doctor about the program. And posters are available under the resources tab at pediacast.org. Until nest time this is Dr. Mike saying stay safe, stay healthy, and stay involve with your kids. So long everybody.

0:48:03.6 

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

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