Body Odor, Birth Marks, and Tonsils – PediaCast 019

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Topics

• Body Odor
• Birth Marks
• Ears
• Tonsils

Transcription

Announcer 1: This is PediaCast.

Announcer 2: You're listening to the Trypod Network. What's on?

[Music]

0:00:27.3

Announcer 1: Hello! Moms, dads, grandmoms, grandpas, aunts, uncles, and anyone else who looks after kids. Welcome to this week's episode of PediaCast. A pediatric broadcast for parents. And now direct from Birdhouse Studios, here's your host Dr. Mike Patrick Jr.

0:00:43.4

Dr. Mike Patrick: Hi, everyone and welcome to this week's edition of PediaCast. This is Sr. Mike coming to you from Birdhouse Studio and I'd like to welcome everyone to the program this week. A quick explanation, the next few episodes are going to run a little bit shorter than our show has been running. And the reason for that is because I have a family vacation between Thanksgiving and the middle December. But I still wanted to be able to get these shows out on a regular basis. Still planning on releasing a new one each Monday. And that means that I have to do a lot of work in the beginning before we leave for vacation in order to get all of these episodes done and wrapped up and ready for you to enjoy.

0:01:23.1

All of these are going to be question and answer episodes. That was the easiest for me in terms of getting ready before vacation. So I'm just basically going with the questions that you guys have asked over the last couple of weeks, and there's been lots of them. So I've had plenty of opportunity to incorporate those into these few episodes.

So today's episode, we're going to talk about four topics and that's how we're going to do each of these. About four topics or so per program. And today's topics are going to be body odor; actually I had two people ask about that. We're going to talk a little bit about a couple kinds of birth marks and then there's a specific ear problem that we're going to address and then we're going to wrap things up this program and talk about enlarged tonsils.

Even though I have all the information prepared and ready for these next few episodes, feel free to go ahead and e-mail in any questions that you have. You can also use the voice line or contact us through the webpage. That would be fine as well. And then in January we'll be able to get the questions that you're asking now out into the program. So again the website, www.pediacast.org and click on the Contact link, you can reach me that way. You can also e-mail mike@pediacast.org or use the Skype line at 347-404-KIDS.

0:02:51.2

Reminder, the information presented in PediaCast is for 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, call your doctor and arrange for 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.

0:03:17.4

OK. Let's go ahead and get right on in to the first question. This one actually again, two people asked this. One, Maria from Gainesville Florida says, "Hello, Dr. Mike. How early do boys start puberty? My seven and a half year old is starting to have an odor to him after about a day or so after a shower or bath. I was wondering if it is too early for those hormones to start causing problems. Love your shows. Sincerely, Maria."

And then we also had a message from Laura from Taunton Massachusetts and she says, "Dear, Dr. Mike. Love your show. I've heard the Manic Mommies talk about you and saw your name on a gather group response, so decided to check out the PediaCast. Kudos to you for such a well organized, informative, and parent-empowering program. My question is about body odor. What are the mechanisms that cause body odor and are there ages or situations that body odor could indicate a medical problem? And I'm thinking in particular about pre-pubescent children."

0:04:17.5

All right. Well thank you to both Laura and Maria for your question. By the way, if my voice sounds a little bit shaky, one of the bad things about being a pediatrician is you're around sick kids all day. So I don't get sick nearly as often as I did when I was a resident, when you first start doing this. But you know still about once a month or so in the winter time I get a little cold. But you know I've learned just to work through it. I don't complain much. So you have to bear with me if I have to clear my throat a couple of times.

0:04:47.8

OK. In terms of puberty, you know there's a wide variety of what is normal in terms of when puberty starts and usually it's going to be somewhere in the range of ages nine to fourteen. You know somewhere around there. At a lot of times it follows family patterns so if a lot of the girls and boys in a particular family go through puberty or start the changes when they're nine or ten years old, in other families you may not see even the beginnings of puberty until more like eleven or twelve years old. And then usually by about fifteen or sixteen, everybody's there. So there is a huge range of what's normal.

0:05:28.9

Now in terms of the body odor question, it's actually; it doesn't really have a lot to do with puberty itself. What causes body odor is sweat and what happens with the sweat is skin bacteria breakdown the components that are in the sweat and then the bacteria breaking down those, those things is what actually causes the smell.

There's different kinds of sweat glands and the Apocrine sweat glands, those are the ones that make sweat that's 90% water but then it has about 10% of other things in the sweat. And it's those things that actually the bacteria breakdown and then that's what causes the smell. Now when you go through puberty, it is true that you start to have more development of the Apocrine sweat glands so that you have more of those and there's more of that kind of sweat which again has about 10% of other stuff in it that the bacteria can break down. So in littler kids, there's fewer of the Apocrine sweat glands and the type of sweat that gets made is much higher percentage of water so there's not much for the bacteria to breakdown in those.

0:06:46.7

And then of course the Apocrine sweat glands are concentrated in the armpit area and down in the groin area and so that's places are a little bit smellier than others because that's the kind of sweat that gets made there.

Now interesting enough, Asians sweat just as much as other races but they have less Apocrine sweat glands and actually, roughly 50% of Korean people have no Apocrine sweat glands at all. They just have the type of sweat glands that make mostly water and only about 10% of Japanese folks have Apocrine sweat glands. So that means that they really don't have much body odor at all because they don't have the kind of sweat that has stuff in it that bacteria can breakdown. And actually since 90% of Japanese men don't have these kind of sweat glands at 10% due, it's interesting that long time ago Japanese men with body odor, so that 10% that has the Apocrine sweat glands, they were actually exempt from military service one time.

0:07:52.3

Now what about diet? It is also true that certain foods can make you sweat more; so caffeine, hot drinks, also hot, spicy foods; things with garlic in them, cumin, also alcohol, these are all things that can make you sweat more. So if you have those Apocrine sweat glands, then as you eat those kinds of foods, you're going to sweat more than the bacteria are able to breakdown that's in the sweat. Also there are certain types of food that actually some of the chemicals in the food itself, as they're broken down do get excreted in the Apocrine sweat. So that you can have a bit of a garlicky smell or a cumin smell. That sort of thing associated with you because some of the molecules that have that particular smell get into the sweat itself. So diet can also have an effect.

0:08:51.3

There's also diseases that can make you smell a certain way, in particular, diabetes, especially insulin dependent diabetes; if they have a condition they are making a lot of ketones and they can then have ammonia actually in the blood and then that ammonia gets excreted in the Apocrine sweat. And then that can make them have a little bit of an ammonia smell or acetone smell associated with them. That's going to be mostly though after puberty. So if you have a littler kid who doesn't have a lot of Apocrine sweat glands, they're not going to have that smell quite so much. Also diseases, you know fever can make you sweat more, so that can be associated more with body odor.

Just like certain foods, can make you have a specific smell, also certain drugs can also have some of the chemical be excreted into the Apocrine sweat gland. 'Cause that's just one way that your body does get rid of some, what it considers toxic chemicals. And then also there are some drugs that can make you sweat more so that then you can get more of the Apocrine sweat that way too.

0:10:05.8

Also anxiety can make you sweat more which then can lead to increase body odor and of course heredity also takes its toll. Not just in terms of how many of those sweat glands you have but just how much sweat that you make anyway.

Now one other thing I came across in looking through this, in quickly researching this topic, because there were some parts of it that I didn't know myself. The question becomes, body odor, now we sort of consider the bad thing, but you have to remember that a long time ago before hygiene was known to be as important as it is in terms of keeping illness away. That it was sort of socially acceptable to have a body odor associated with you. And sometimes even it was a status symbol to smell a certain way. I come across this in the office sometimes. You have a kid who doesn't smell very pleasant and you kind of think down on the family, "gosh, are they neglecting their children?" But you know we are looking at this sort of thing from what is culturally acceptable today. And it's funny because you think, "oh they're not washing, they're negligent, it's very unhealthy," and yet you know a hundred years ago everybody lived like that. So sometimes we do make some judgments that, maybe it's right, maybe it's wrong. I'll let you decide. I'm not going to go there today.

I hope that answered your question in a satisfactory manner.

0:11:43.6

Let's go ahead and move on to our next question. And this one has to do with birth marks. The question comes from Mollie. She says, "Hello, Dr. Mike. My husband and I have been parents for a little over seven months and we really enjoy PediaCast. We especially like your mini reviews of the current scientific literature related to the topics you discuss. Thanks. Here is something we have been wondering about. Our daughter has two birthmarks that appeared a month or two after her birth. A tiny strawberry mark on her thumb and a quarter size light brown mark on her belly. Her doctor looked at them and told us not to be concerned about either one, but to contact him if any additional marks appear. Interestingly, my husband has a strawberry mark on his finger and I have a light brown mark on my torso. Could you tell us about the different types of birth marks, what causes them, are they inheritable? Why are multiple marks reasons for concern? Thanks for any information and keep up the great podcasting. Mollie."

0:12:49.7

OK. You know there are several different types of birth marks. So I'm just going to address the two types that Mollie asked about.

The first one are the strawberry marks. Now these you've probably seen before. They're called hemangiomas as the medical term for them. And they're basically made out of a collection of blood vessels that's just under the skin. They can range in size from tiny dots that are sort of in a cluster together or they can even be more coin size. And I've even seen them as big as a golf ball or even bigger then they can bulge out and actually cause a little bit of disfigurement associated with them. Now the natural tendency of these is that they increase in size usually until babies are about a year of age and then they slowly regress after that until they're about school age and then you may not see them much at all.

So there are lot of adults who when they were kids had pretty prominent strawberry marks and then by the time that they're adults they're very faint, you can barely see them, and then sometimes you can't see them at all.

0:13:57.5

Now particularly with the big ones, I get a lot of parents that ask, "Can't you just take them off?" Well the problem with that, is that the surgical removal is going to leave a scar and that's going to be there the rest of your child's life. Whereas if you just be patient and give it some time, these things are going to fade away and it probably will not be very noticeable at all by the time that they're teenagers. So sometimes just patient waiting is really the best way to go.

The other thing is because these are made out of a collection of blood vessels, if you remove them, there is the chance that not only you will have a scar, but if you leave some of the cells behind in doing the surgery, they can grow back. So that's another reason to sort of hold off usually on getting them surgically removed. There are of course exceptions to that. If you have one of these and it has a tendency to bleed really often, and that's rare. You know hardly ever does that happen 'cause they are pretty deep in the skin. But every now and then you'll get a superficial one and it can have some bleeding associated with it. And if that's happening over and over, then it may be a good idea to go ahead and try to get that taken out.

0:15:07.5

The other thing and this is really another one that's very unusual, but sometimes you'll see they'll become so big that the actual hemangioma itself has sort of a cavity inside of it, this is called a Cavernous Hemangioma. And the problem with those is that they can be associated with the blood actually clotting inside the cavern and then that can also throw little blood clots or thrombis, they're called. And that can have some very significant problems associated with it. But again those situations; bleeding and the Cavernous Hemangiomas, those are rare. Those are the kind of things that individual pediatrician might come across once every several years. So it's not common at all. Most of these really just get a little bit bigger till your baby's about a year old and then they fade away after that.

0:15:59.5

Now in terms of some specific locations, if you have these hemangiomas, especially the ones that are going to be sort of the tinier ones and a cluster of dots, if you have that in the lower back in the midline, so sort of between the hip bones, where the top of the hip bones are right over the spine, in some cases, now again this is one of those things where you take a hundred kids who have some strawberry marks in the middle of their lower back, 99 of them are going to be just fine. But there is that small chance that that can be associated with a tethered spinal cord; which is a type of birth defect where the spinal cord has some connections down there. So as the baby grows lengthwise the spinal cord starts to get stretched because it's attached and then that can cause leg weakness and problems with putty training and then incontinence later on.

So that's something that some pediatricians, depending on where you live and what the standard of care in your area is. In some places the usual management is just to expect and observation. You know you watch him and if they start to have any kind of problems associated with putty training or incontinence or constipation or lower leg weakness, then you get an MRI to look for a tethered spinal cord.

0:17:19.3

In some areas the standard of care is just to do the MRI, and in some places they can do an ultrasound too to check for this. But it really depends on what resources you have available at your local children's hospital. Some radiologists feel comfortable doing ultrasounds and searching for those, others you older the ultrasound and the radiologist always says, "Well I don't see a tethered spinal cord, but if you're really worried about it, get an MRI."

So when I talk about how things are different in different areas of the country, all doctors have malpractice in the back of their minds. And in terms of how you're judged in what you do, as PediaCast goes on we'll talk about these kinds of things more. 'Cause I just want to be blunt and honest with parents. I think what ends up happening is you're really compared to how other doctors in your neck of the woods practices. So if other doctors get MRI's in six month olds and you have a baby that has these spots and you don't do an MRI when they're 6 months old, and they have a tethered spinal cord and something bad happens, you're going to get sued for malpractice because you didn't follow the standard of care that is present in your community.

0:18:30.1

Now on the other hand, looking on the flip side of it, let's say that the standard of care is to wait and other doctors in your area do not do MRI's but they just wait but you go ahead and you're very conservative and you do an MRI and then the baby has to be sedated to have an MRI done and then if something bad happens during the sedation, then you could get sued because the standard of care in your area is to wait and you unhindered the MRI and that put the baby at risk for the sedation part of it.

So you know it's one of these, sometimes there's no winning. All right but I'm getting off topic aren't I?

The other thing about strawberry marks; when they're on the foreheads sometimes they're called Angel Kisses. And when they're on the back of the neck, sometimes they're called Stork Bites. So just a little bit of trivia there for you.

0:19:17.6

OK. The other one, the light brown marks, these are called Cafe Au Lait Spots; and Cafe Au Lait I think that's like milk and coffee. So you think the color of coffee and you put a little milk in it and it gets that light tannish color. That's how it got its name. These are basically oval areas of increased pigmentation in the skin. They can be various sizes. They can be located just about anywhere in the body. These are not the same as Congenital Nevuses or moles that babies are born with which are a little bit of a darker color and then often times have some hair growing in them. And we'll talk about those in another episode on down the road here.

0:20:00.5

But right now we're just talking about the round, flat ones that are like a light tannish color, and these are gain called Cafe Au Lait Spots. Now these are really the ones that the pediatrician was saying, "If any more of them appear, make sure you let me know." These are the ones where that's important because if you have a lot of these, then it can be associated with a condition called Neurofibromatosis which is a disease; it's actually the Elephant Man Disease. But that was in extreme and unusual case of Neurofibromatosis.

Basically they are benign tumors associated with peripheral nerves that you get, these Neurofibromas they're called. And when you have a lot of them and they get really big, they can pinch off the lymphatic flow which you think of lymph nodes, in addition to blood vessels you have a whole lymph system and if those get blocked off then you can get edema or swelling in the extremities. So with the condition like in the old movie, The Elephant Man he basically had Neurofibromatosis and the Neurofibromas got so big that they cut off the lymphatic flow and then that leads to massive swelling in the extremities.

0:21:15.9

But again that's unusual. Most people who have Neurofibromatosis, it does not progress to anything like that. Neurofibromatosis can be associated with all sort of other things, but since our talk right now is not on that, I'm not going to go there, but at some point we probably will. 'Cause we have lots and lots to talk about. So in any case the light brown marks or the& Cafe Au Lait Spots, they aren't anything really to be worried about if you just have a couple of them, but if you have a large number of them then you do think about some other diseases that can be associated with that.

0:21:48.6

All of these things both the Hemangiomas and the Cafe Au Lait Spots can be seen showing up in family patterns. For instance my mother has a Cafe Au Lait Spot on the back of one of her calves and my son has one in the exact same location, so it's kind of interesting. So you know that that had to sort of come through the genetic route in terms of that.

OK. Let's go ahead and move on to question number three. This comes from Haley in Durham North Carolina and Haley says, "MY daughter is constantly complaining about her ear bothering her. It doesn't hurt but she said that when it's really quiet, especially when she is trying to go to sleep, it sounds like wind rushing by or like a train in her ear. I also have the same problem. I have tried to talk to my doctor about it but they always just say that it's because draining properly. This has recently started to bother my daughter so much; it keeps her awake at night. Have you ever heard of this? If so, does it have a name? I appreciate all the help you can give me for my family and for myself. Thank you, Haley."

0:22:52.2

All right. Now again, in terms of addressing specific situations, it's difficult to do that and really not proper in the form of podcast and that's because I can't look in the ear and see what it looks like. But I can tell you that from the way your doctor is describing it as because it's not draining properly, I'm assuming that what your doctor is saying, is that there is fluid behind the eardrum and when that fluid is infected fluid and pus, we call that in Acute Otitis Media or a ear infection in the middle ear space, and we usually treat that when we think it's a bacterial cause with an antibiotic. When you have just some clear fluid that's there over a long period of time, we call that a serous otitis; and that just means that there is clear fluid behind the eardrum that is not draining.

0:23:43.3

This is a difficult situation because it used to be that we would think that there was an increased risk of that clear fluid turning into an acute ear infection. And sometimes we put kids; this is 10 years ago or so, on antibiotics everyday for a low-dose of the antibiotic daily to try to prevent that fluid from turning into an infected ear infection.

What we used to do is with the antibiotics, but we don't do that so much anymore because of all these resistant bacteria that we're getting with overuse of the antibiotics. It also used to be that when kids had this fluid behind their eardrum that lasted for several months but not getting infected, sometimes we would send them to the Ear, Nose and Throat doctors and get tubes put in, in order to drain that fluid and to keep it re-accumulating.

0:24:38.0

Now the issue with that is, there's always risk when you have surgery; there's risk with the anesthesia, there's risk with bleeding, there's risk that the tube can become infected, or you can get scar tissue around the tube that can lead to later hearing loss. I'm not anti-tubes in ears, don't get me wrong. There's definitely a place for them, but you always have to look, is what you're doing, does the benefit of it outweigh the risk? And for ear tubes and just the clear fluid that we're talking about, with the serous otitis, it may be that the benefit that you get doesn't really outweigh the risk that can be involved with putting ear tubes in.

0:25:19.4

So what kind of problems can you have with this fluid? Some people would say, if you have constant fluid behind the eardrum, does that affect your hearing to the degree that speech can be delayed? And there have been several large studies that looked at kids who had chronic serous otitis would have this chronic clear fluid behind the eardrum, and they do have a little bit of hearing loss when you have that fluid there. So they looked at a large group of kids who had the fluid and they just left it there over the course of two or three years. And then they had a group of kids who had the chronic fluid for months on end, they put the ear tubes in, drain the fluid and then they looked at both groups to see if there was any difference in speech development. And what they found was there was no difference.

0:26:11.4

So even though you have a little bit of a hearing loss associated with this chronic fluid being there, it's not to the degree that speech is impaired. OK and usually it's not really all that uncomfortable either. But you can get sort of a low-level background noise when you have that fluid in there. And as Haley described it, sort of like the wind rushing by or a train in your ear, particularly at night because then it's really quiet, there's no background noise and you're much more in-tune with that noise, so you do have that.

I suppose that if it were my patient and I had a kid who had chronic fluid that was not going away and it was bothering them so much that they couldn't sleep at night; I mean it really was interfering with their life, so the next day they were tired or they were grumpy because they weren't getting a good night sleep. You know in that case, in consultation with the parents say, "Well maybe we should get the opinion of an Ear, Nose and Throat doctor."

0:27:15.4

Maybe in your case, I said the ear tubes would help that go away because that fluid being there is interfering with the quality of your child's life. On the other hand if it's not infected, it doesn't hurt, we know it doesn't interfere with language development and you just hear a train in your ear and the wind rushing by, but you're still asleep within 15 to 20 minutes. In that case then, it's probably you're just going to have a little noise in your ear for a few months and then it'll probably go away. And in that case I would say, "Nah you're probably better off just leaving it alone."

One other thing I want to mention real quick, and that is another way to try to treat the serous otitis in the past has been to try to use like decongestant type medications like Sudafed or antihistamine medicines like Claritin. And I suppose they have a role in some kids, especially if they have an allergic component to all these. But for the most kids, that's not going to help very much and probably not worth while doing.

0:28:18.0

You know quick trial on some Claritin if it's an allergic thing that's causing this fluid to be there but you know and then something else to consider too and again this is me not being able to look in the ear to see what it looks like. Instead of the fluid behind the eardrum, another thing that could cause these kind of symptoms is if you have some allergy symptoms and mucous that's blocking the Eustachian tube which is the little tube that connects the middle ear space to the back of the throat. And its job is to equalize the pressure on both sides of the eardrum. And if that tube is clogged off with mucous because of allergy symptoms, then, it's not really a humming or a wind or a train sound, it would be more of a popping and crackling sensation in the ear, like if you're going up and down on the mountains or going up and down in an airplane. That kind of feeling.

So if you have that rather than the noise, then that could be in the Eustachian tube issue and mucous in the back of the throat from allergies could do that. So in that case, some Sudafed or Claritin; those kind of medicines may help you out.

0:29:25.1

OK. I hope that answered your question well enough. Let's go ahead and move on to our final question for this episode. This comes from Andy in Grand Blanc Michigan. Oh boy, that Ohio State Michigan game is, I'm recording this on a Friday, and it is tomorrow. So by the time you guys listen to this you'll know who won. But I'm going to still say, "Go Bucks."

All right. Andy says, "I've been enjoying your podcast during my long commute to work two days a week. Thanks. However I almost had to turn it off when you mentioned going to an Ohio State Game. I work at the University of Michigan and much of our family has attended U of M. Yikes. Guess I'll listen anyway." That's all right, Andy. I'm going to answer your question so; you know I could say, "Oh she's from Michigan. Let's just move on to the next one." But I'm not going to do that.

Her question is, "Tonsils or enlarged tonsils have been blamed for lots of things lately including sleep disturbances, ADHD, etcetera. An article in a recent issue of parent's magazine discussed this, what is your take on it all? Also another small suggestion, the interlude music doesn't really seem to belong in a podcast about children. Perhaps something more fun and upbeat."

0:30:41.1

You know I like the interlude music, but if there's more out there that agree with Andy, e-mail me. I'm certainly up to changing the interlude music if a lot of you don't like it. On the other hand if you like it, let me know that too and we'll just see what the crowd says and go with that.

Now in terms of this parent's magazine article, I want to mention right off, I did not read that article. So if I say something different, well that would be interesting. So let me give you my take on tonsils.

First of all, tonsils really get a bad rep and you got to think about what tonsils are. Tonsils are basically type of; they are in the realm of the lymph tissue. So the role of the tonsils, it's a location where the body fights infection. And the mouth and nose are big openings and bacteria from the environment and viruses and all these things come in to the mouth. And basically your tonsils are your body's first defense against invading organisms.

0:31:46.9

So they're going to get infected a lot because they're doing their job. And if the tonsils weren't there, then those invading organisms, whether they be bacteria or viruses are going to be more likely to go up the Eustachian tube and cause an ear infection, to go up into the sinuses and cause a sinus infection, or go down the trachea into the lungs and cause pneumonia. So even though kids get tonsils that are infected often, it's because those tonsils are doing their job and they're keeping that infection out of the ears, the sinuses, and the lungs. So that's why kids get tonsils a lot.

Now I have not seen any studies looking at this but I would imagine just based on, so this would be a hypothesis; it would be a good basis to do a study. I wonder, if you look at adults who don't have their tonsils and their incidence of sinus infections, ear infections, and pneumonia; I wonder if adults who don't have tonsils are more likely to have those things than adults who still have their tonsils. I think that would be an interesting study for someone to do. Maybe someone's done it. I've never seen it or come across it, but I think that would be an interesting one. That's one that I think would probably get published.

0:33:05.7

So that's their job, they get a bad rep. And those are the kind of things that would happen if you didn't have your tonsils. Now having said that, again you have to look at risk versus benefit. When do you want to remove tonsils?

The first one that parents say is they keep getting strep. Well if they keep getting strep and you are unable to get rid of their strep, because recurrent and especially untreated strep can lead to rheumatic fever which is very serious, not scarlet fever; that's just strep with a rash and a fever. I'm talking rheumatic fever which again perhaps in the future episode we'll talk more about that. But if you have recurrent strep that you cannot rid off, then that would be an indication to get your tonsils out. Now I will admit, the number of kids that I send to get their tonsils out because of recurrent strep, I could probably count on one hand in the course of a year. And the reason for that is usually you can get rid of strep if you treat it the right way.

0:34:08.6

And by the right way, you start with the Penicillin, if Amoxicillin doesn't work; it's usually not because the strep is resistant to the Amoxicillin. It's usually because you also have other bacteria in the mouth that are making a chemical that protects the strep. So you either have to use a higher dose of the Amoxicillin or use another medicine like Augmentin or Omnicef, those kind of things. Now Zithromax, we don't use so much in our area because there's a pretty high incidence of resistance of the strep to Zithromax unlike with Amoxicillin. So we don't use that unless we have to because your kid's allergic to just about everything else you can think of. And when I use Zithromax, I usually have them come back and re-check their throat swab. Just to be sure it did kill it.

Now another reason the Amoxicillin or Penicillins might not work is because your child could have a carrier state, which is when the bacteria are kind of in a dormant state and they're not actively reproducing. And the way that antibiotics work, often times they depend on the bacteria actively reproducing in order to do their job. So in the case of a carrier state with the strep, you have to use a different class of antibiotic to get rid of the carrier state. And often times that ends up being something like Clindamycin or Rifampin, is another one you could use. And then that usually takes care of that.

0:35:35.8

Now you also have to get rid of the sores, so that if you treat it; pharyngitis or tonsillitis with strep successfully, but someone else in the family is a carrier and gives it back to him, then they're going to keep getting their strep. So if you swab the whole family and anybody who's a carrier in the family, get them on an antibiotic so that you can get rid of the primary case.

You can also re-infect yourself through your toothbrush, so I usually have parents change the toothbrush after they have been on the antibiotic for a few days, so that they don't give the strep back to themselves through that mechanism. And then at school, don't share any drinks or food, 'cause if someone's a carrier at school, it's a little more difficult to get them treated. But as long as your child's not eating and drinking after him, it's going to be a little less likely that they're going to catch it that way.

0:36:26.7

So between correctly determining if it's a carrier state or an acute strep infection and then treating them with the right kind of antibiotic or locating the carrier in the family, making sure they're not getting it at school, and make sure that they're not re-infecting themself with their toothbrush; for the vast majority kid, you can get rid of strep by following that sort of little protocol there.

Now if you have a kid who you've done all those things and they keep getting their strep back, then they are at an increased risk from rheumatic fever and that may be an indication to get your tonsils out.

Now what about just size? You know my kids got big tonsils. If they're not causing a problem, then it's not worth taking them out. So if they don't have any problem swallowing, they don't have a sore throat, they don't have strep, they don't have signs of obstructive sleep apnea; which we'll get to in a minute; they're just big.

0:37:26.8

Tonsils like lymph nodes, once they're big, they're going to stay big for a long time. It takes a long time for them to shrink back down, if ever. So the way I look at it, is if you've had a lot of throat infections and the tonsils are still big but they're not causing any decrease in the quality of your child's life, then you're really best off just letting them be. Just let them be big and look at it as you got your doll-sized tonsils and your head's going to grow into them.

OK. Now if you have tonsils that are causing a swallowing difficulty because they're so big, first I'd have to question, is it really the tonsils doing that? Because for instance, with Mono's sometimes you just see huge tonsils and you wonder how they even have an airway? Those tonsils are so big. And even some of those kids don't really report too much difficulty swallowing, other than the fact that their throat hurts from the Mono. But you see some really big tonsils on well-checkups and kids don't even know their big and they're swallowing just fine. So if the only issue is trouble swallowing, you know and they're big, maybe I'd get an Ear, Nose, and Throat referral but I still would wonder if there are some other issue that's causing the difficulty swallowing.

0:38:35.3

Obstructive Sleep Apnea is a little bit different. And I think this is probably becoming the most common reason now that tonsils get taken out. Because we do know that if kids have true Obstructive Sleep Apnea; they're snoring a lot, and then that is waking them up because they stop breathing for intermittent periods during their sleep and then their oxygen and their blood dips down and then that wakes them up. If that's happening and they're not getting a good night sleep that can lead to depression fatigue, ADHD kind of symptoms. We do know that through research studies. So Obstructive Sleep Apnea can be a problem for some people. And for those folks if you get your tonsils out, it really does improve the quality of life.

0:39:16.9

Now, how do you know if they have Obstructive Sleep Apnea? Well what I do is send them to one of our local children's hospital. They have a very nice sleep lab. It's actually the one in Dayton; Dayton Children's. They have a nice sleep lab there and they basically watch these kids overnight, they have them hooked up to monitoring devices, they watch their oxygen saturation, they watch their EKG, their breathing. And they just record what they're seeing and if they have episodes where they're snoring and then waking up briefly, and those are associated with dips in their oxygenation, then you have the diagnosis of Obstructive Sleep Apnea. And then those kids, we usually do send to the Ear, Nose, and Throat doctors and have them get their tonsils out.

On the other hand if they're snoring a lot but they're not waking up, their oxygen level's not dropping, then that cannot be the reason that they're having depression anxiety, ADHD symptoms or whatever during the day. So if it's a snoring issue, and they're waking up everybody else in the house but they're staying asleep, then you leave their tonsils in because again it's not affecting the quality of that child's life. So therefore it's not worth the risk of the surgery of taking the tonsils out. And everyone else just have to get ear plugs if the person is keeping them awake from their snoring.

0:40:36.9

So again all this boils down to is, do you have a problem that's affecting your life? Is it worth the risk of taking the tonsils out to improve the situation? And so just enlarged tonsils in it of themselves or snoring in it of itself is not a good enough reason to go through the risk of taking tonsils out. Recurrent strep is, if it's really recurrent and you really can't get rid of it despite looking at all the appropriate issues involved and using the right types of antibiotics must be a reason, and true Obstructive Sleep Apnea that's documented with a sleep study would be another reason in my opinion.

OK so I hope that answered your question, Andy. And feel free to ask any more.

0:41:20.2

I'd like to thank everyone for listening this week. Gosh that it went longer than, where am I now? It went much longer than 20 minutes. I'm at 40 minutes in four questions. Sorry, folks. You get me talking you know. This is great because in the exam room, if I spent this much time in the room, my nurse would be breaking the door down, yanking me out of there because the waiting room is so full. So this is just fantastic, being able to answer questions into this much detail and the interactive. This is just a wonderful thing. I'm real pleased with it.

I'd like to thank everybody for listening and make sure you tell your friends and family about us. Don't forget our website at Pediacast.org. All the wonderful graphics there courtesy of Vladstudio.com, there's a link on the site to his site. Also, remember you can submit a question or comment, view the show notes, sign up for a newsletter, read the blog, all those things at pediacast.org. And if you like PediaCast, please spread the word by telling your friends, relatives, and neighbors about our program. You can download free promotional materials on the Poster Page of our website. And of course reviews in iTunes are also most helpful.

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

0:42:35.8

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