Infant Formula, Urinary Tract Infection, and Constipation – PediaCast 024

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  • Infant Formula
  • Urinary Tract Infection (UTI)
  • Temperature
  • Constipation

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Announcer: This is PediaCast.

You're listening to the tripod network. What's on?

[Music]

Announcer: Hello moms, dads, grand moms, grandpas, aunts and uncles and anyone else who looks after kids. Welcome to this week's episode of PediaCast, the pediatric podcast for parents.  And now, direct from Bird House Studios here's your host, Dr. Mike Patrick Jr.

00:00:45

Dr. Mike Patrick: Hi everyone and welcome to PediaCast, the pediatric podcast for parents. It's episode 24. This is Dr. Mike coming to you from Bird House studio and I'd like to welcome everyone to the program this week. This week on PediaCast we're going to answer some more listener questions, we're going to talk about how much formula infant should get, we're going to talk about urinary tract infections in babies. Also body temperature, what's the best way to take a temperature of a child and what's considered too high, what's considered too low, we'll talk about that and then we'll wrap things up with a little bit talk about milk and constipation. I had a listener who brings up a very interesting study and we're going to talk about that a little bit too.

0:01:24

So that's all coming up on episode 24 here of PediaCast, don't forget if you have a question or a comment that you would like us to address, you can get a hold of us at PediaCast.org and then click on the contact link and you can ask your question that way. Also you can email mike@PediaCast.org or call the voice line at 347404KIDS, that's 347404KIDS. Now before we get into our topics, I just wanted to mention here real fast, did anyone see the tiger video at Disney world? There was a family that was visiting Disney and there is a teenager who had his arm around tiger. And in the video it looks like tiger kind of just out of the blue, turns to the sides and lids this kid up on the cheeks. And of course there's been a lot of controversy over these and some people have called you know for the tiger to be released from Walt Disney world, it's craziness.

0:02:24

But if you look carefully at the video it does look like these kids messing with tiger in the back of the head so also, in addition to PediaCast write a column on the disk which is the largest unofficial guide to Walt Disney World that is online at wdwd.info.com and this week's column is entitled don't mess with tiger. And I'm going to put a little link in the show notes so if anyone is interested in hearing what else I have to say about this whole situation with tiger, hiding a kid at Walt Disney world then you may want to check out that link in the show notes.

0:03:04

Also I do want to mention too that, I said this in the last episode that I'm making the switch from PC to MAC but there are a couple of programs that I still really like the windows version better than the Mac version. My wife, one of those is quick in, the quick in from MAC doesn't have nearly as many features as the windows version does. And also, although I like compiling the podcast with the garage band doing the post production stuff for actually recording, I've really grown a custom to podcast station. So i was a little bit leery about moving to MAC just in terms of these couple programs I really like.

0:03:44

And this week I found parallels, now i know there's virtual PC and there's “Boot Camp”, and I did a little bit of research on the different ways that you can run a windows programs on an Intel based MAC. But I just want to say so far, I'm really happy still doing the free trial right now of parallels. So if you've made the switch to MAC, which I know seems like lot of people I know recently have been doing that but if there's still a windows program that you really have to have or really like, you might want to give parallels a try at www.parallels.com and we'll put a link on the show notes.

0:04:26

Alright, one more order business before we move on. I got a voice mail this past week and let's take a listen to that right now.

0:04:35

Erin: Hey Dr. Mike it's Erin from Manic Mommy, calling you about show 22. I think you did that show just for me because it's all about me, you know. Now but I'm so interested in everything you have to say about the chicken pox vaccine because my son has an egg allergy and he didn't receive it. Picky eater, cause both of my sons are and whenever you come back from the holidays you feel like you're a terrible mother because your children will not sub still and eat the roast beef or the turkey that's being served. And about thumb sucking, well my son doesn't suck on his thumb, he's still on his pacifier and I was just thinking of what to do this weekend about getting rid of it. So as usual, thank you for a very informative, very helpful show. And you're absolutely right, no pediatrician would spend the time that you do answering these questions. So thanks, from all us moms, we appreciate it! Have a great week!

0:05:38

Alright, Erin thank you very much for the feedback and the phone call. I might, I did want to mention here real quick, you may want to do a little bit of a research on this. And this really is not aimed in Erin specifically but just everyone else out there. There's sort of a misconception that kids who have an egg allergy cannot get vaccines that have egg in them. And there's not a 100% agreement among doctors, pediatric allergy doctors, and pediatric confections disease physicians, there's not one way to look at this.

0:06:18

For flu shots, I think everyone is pretty much an agreement that those are a good idea if you have an egg allergy because the flu shot, because right from a young age you are injecting the flu into a kid and that immunity is not going to last for as long as natural immunity would last. You're sort of committing yourself to getting flu shots every year which is not necessarily bad thing. I think that the scientist do a good job about determining which flu strains is going to be in a given area in a particular year.

0:06:51

So I'm not anti flu shot but certainly if you get the flu you're going to have better immunity against it. So if you are committing yourself to getting the flu shot year after year, after a year, and you have an egg allergy, you're going to get exposed to the egg antigens year after year, after year. And you can eventually have worsening and worsening reactions to the point where you know you're just covered in high, and have troubled in breathing and certainly you don't want to be on that kind of situation.

0:07:20

But when you're talking about the MMR shot, which you're only going to get to of, or the chicken pox shot, which used to be just one shot in young children but now it looks like it's going to be 2 shots. So instead of a year, after year, after year, you're only talking about exposure to the egg product in 4 vaccines and you know that maybe okay. So if you have a kid, who, when they had eggs, had troubled breathing, or had wising you know that may not be a good idea to do that. But if it was just a mild rash that is still may want to think about doing a MMR or chicken pox vaccine. But you want to talk to your doctor about that and just get their opinion.

0:08:03

I know that in the, most of the infectious disease people that I have talked to about this, and the pediatric allergy people I have talked to, they recommend going ahead in doing the MMR and chicken pox vaccine even in someone who has an egg allergy. However you certainly would want to stay there a little bit longer to make sure you're not going to have a reaction at the doctor's office after you get the shot. You wanted to make sure that you know if you're the doctor that you have epinephrine available, or maybe able to do an albuterol breathing treatment if you had to. I mean you want to be prepared in case there is a severe reaction.

0:08:42

So my only point with this is not that if your doctor has said no MMR or no chicken pox vaccine because you have an egg allergy. I'm not disputing that, I'm just saying there's different opinions out there and you might want to talk to your doctor about it or you know, do a little bit a research on it yourself because it is important to be protected against measles, mumps, rubella, and the chicken pox shot also.

0:09:07

Okay, so we have to be little tangent there but that's okay. Before we move on to our first listener question of this episode, I want to remind you that 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 PediaCast terms of use agreement which you can find at pediacast.org.

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0:09:57

Alright our first listener question this week comes from Shana in Georgia. She says, I have a 4-month old son, he's formula fed and drinks about 6 ounces every 3 hours and sleeps all night long. Generally he's getting 24-30 ounces a day and he's doctor said that he could have some cereal 2 or 3 times a day as well. He also seems hungry and the cereal doesn't seem to be making any difference. My question is how much is too much formula?

0:10:24

Well in terms of how much formula to give to a baby I get asked this question really a lot in the office practice. Now there's not necessary a right and wrong answer to this question. You really have to look at the whole picture. You can't just say, oh your child is newborn, this is how much they should be drinking 2 months, 4 months, 6 months for each of those ages and this is how much your baby has to take. I mean you have to look at how well your child is growing, you know look at the growth chart so to look at the family pattern of growth that's typical for your family so that you can compare your child and so yeah, he is small but he's following the family pattern so we know he's getting enough calories in.

0:11:01

Also as your baby is spitting up, spitting up frequently can be caused by overfeeding. So you know that it's little bit too much or if you have a child who has some reflux problems even if others would consider a normal amount of food. They may spit up with that and it's helped to spit up is helped if you decrease the volume of the feeding but then often you have to feed them more frequently to make up for that so they could still get enough calories in.

0:11:27

So I know I'm dodging. I'm dodging the answer but you really do have to look at the whole picture because different babies are going to have different needs really depending on how big or how small they're sort of programmed to be from a genetic standpoint. And also their metabolic rate and things like that. Now what I can do is tell you in general what are the normal range is but again if your child falls outside of this range, it's either on the less side or the more side, you know that doesn't mean that there's a problem as long as they're growing well, they're healthy, they're not spitting up too much, you know that sort of thing.

0:12:05

So in general, for newborns the number of ounces and the hours in between the ounces is usually going to be about the same. So they're usually, they're taking an ounce every hour, couple of ounces every 2 hours or 3 ounces every 3 hours, right around on that range for newborns. And then as they advance up to 2 months, they're going to increase their intake a little bit so now we're talking 3 or 4 ounces every 4 hours or so. But at the time that they're 4 months old, 4 to 5 ounces every 4 hours you know somewhere between 4 to 6 months you start some cereal. Usually at that point though, they're still taking a bottle, you know 4 or 5 ounces every 4 hours with the formula.

0:12:45

And then when they get about 6 months of age, this is when the food intake is going to increase to the point where you can start to backing off of the frequency of the formula. So now we're talking you know anywhere from 4 to 6 ounces, 4 or 5 times a day, somewhere around there. You know if you're more toward the 4 ounces, you probably do it 6 times a day. If you're to 6 ounces more like 4 times a day.

0:13:07

And then when you get up to 9 to 12 months of age, now they're up to 6 to 8 ounces about 4 times a day or so. So on average I think for the older infants, 6 months and over, you know your target is somewhere going to be between 20 to 30 ounces a day that is in a good range. You want to avoid more than about 30 ounces a day. For one, you know because there are too many calories, they're going to be more likely to become obese. And then there's also the risk of anemia if you drink too much milk, the milk protein causes some microscopic blood loss in the intestine and over a long period of time. You have enough blood loss that it can result in, and sometimes severe anemia.

0:13:49

So anemia can result from too much milk intake. And usually we're talking you know over 30 ounces in a 24-hour period. The bottom line with this is don't focus too much on the number, you know you got to look how they're growing well and are they spitting up. So I would say Shana, who has a 4-month old you know if they're taking 6 ounces, oh you said that they're getting 24 to 30 ounces a day. For a 4-month old, you know if you were 6 to 9 months or a little older, you know you we're talking somewhere between you know the 20-30 ounces a day. For a 4-month old that maybe a little on the high side compared to what the average would be.

0:14:27

But again, just because your child falls a little bit above what is average for everybody, doesn't mean it's necessarily a problem as long as they're growing well, they're not overweight or not spitting up you know. So for your specific child you want to talk to your doctor about how much is the right amount because it's going to take looking at their growth chart and other questions such as are they spitting up or having any stool difficulty or any other problems. So that's something Shana that you want to ask your doctor next time you go in but again those just sorts of some of the guidelines in terms of how much formula to give your baby.

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0:15:31

Alright on to question number 2 of PediaCast number 24, this is from Isabel in California, she says Hello Dr. Mike, I've been hearing your show for a couple of months now. I congratulate you about it, I just love it. I regularly download it to my iPod and hear it in the office. I have a 7-month old baby, Gabe has been very healthy and a strong baby so far, he's breast fed, he's over the 95th percentile on height and 75th percentile on weight. He is very smart and happy and already crawling, bubbling, he likes to stand on his feet with our help, and he's starting to say mama-mama-mama and dada with the meaning or at least we like to think it's with meaning.

0:16:12

I'd like to hear you talking about a topic that has come to my attention, the topic, and urinary tract infections in babies. Could you please talk about UTI, their causes, treatments and other conditions related? The reason I'm suddenly interested in it is last week, in the middle of the night, on Thanksgiving weekend okay, sorry for some little behind on the questions, the baby got sick, suddenly he was feeling sick. He was crying and screaming. We immediately rush to the emergency room and while we were getting into the car he started vomiting.

0:16:45

We changed his clothes and kept going and after vomiting 4 more times, he immediately started feeling better and he had been looking even playful, and happy, and healthy as usual. The whole sickness took about an hour and a half and it ended while we were waiting for help in the emergency room. Well they still check him out and did some tests and found out he had a urinary tract infection. We went over the weekend to have another test and asked the opinion of a pediatrician because there were no pediatricians in the ER that evening, and he confirmed the diagnosis.

0:17:14

This week you have more tests done with his regular doctor and he'll have at least a sonogram as far as I know and in the mean time, his doctor keeps, oh no he's keep taking his antibiotics. By the way I am not sure if it helps to the baby but Gabriel is not circumcised. Okay, so let's talk about urinary tract infections in babies. Another baby topic and I need more questions from parents of older kids so please, if you're listening and if you have an older kid feel free to write in and you may get your question bumped into the front of the line cause we're talking a lot of baby issues here.

0:17:47

But it is important to me to get your questions answered rather than making up topics of my own. So for now we'll go with it. So infant urinary tract infection, you have to take urinary infections in babies seriously. And let's take a look at the most common way that a baby gets urinary tract infection to understand exactly why this is.

0:18:07

Now our skin, you know yours, and mines', and babies is loaded with bacteria on the surface of our skin and the bacteria is able to go up through urethra, which is the tube that connects the outside of the body up to the bladder. And they're going to be able to make it up into the bladder a lot more often than girls and that's for the simple fact that the urethra is much shorter in girls. It's a shorter trip is just easier for the bacteria to get up there into the bladder.

0:18:34

But most, at most babies, women, girls and then of course boys too, don't get urinary tract infections because the act of urinating sort to help to wash the bacteria back out to the bladder. So when we get urinalysis is just on a routine basis especially in girls. Almost always there's some bacteria in the urine and even if it's a really good clean catch here and that's because some of the skin bacteria is able to get up the urethra and go in to the bladder. But as long as you're rinsing them out and peeing frequently you know it's unlikely that you're going to get urinary tract infection.

0:19:08

However, if you're a baby that has, what we call kidney reflux, her bladder reflux would be a better name for it. What this is, is when the bladder squeezes, some of the urine goes back up toward the kidneys. Now the reason this happens is if you go up river a little bit, you got your kidneys and your ureter is the tube that connects the kidney to the bladder. And where the ureter attaches to the bladder at that junction, there's a valve and that valve is there and so that the urine flow coming from the kidney can only go in one direction.

0:19:45

So it goes down, enters the bladder but it can't get back cause there's a flap there and that's the function of that valve. Now in kidney reflux, these kids those valves are kind of loose and a little bit leaky, so when the bladder squeezes you know most of the urine's are going to go to the urethra at the bottom and out of the body but a little bit of this going to reflux back up the ureter toward the kidney because there's a leaky valve there where the ureter connects to the kidney and there's two of those one of each side, one for each kidney.

0:20:15

So now the problem is because if you got urine in the bladder and some of that urine gets reflux back up toward the kidney, well now the bacteria's up there in the ureter you have a bit of a different situation because whereas from the bladder through the urethra to the outside of the body, it's a pretty good flow of the urine so it can help rinse the bacteria out. It's really more of a trickle of urine coming from the kidney down the ureter just gradually filling up the bladder you know as the hours go by.

0:20:46

And that kind of flow is a lot less likely to rinse the bacteria from the ureter into the bladder. So between the bladder and the kidney in that tube, if the bacteria get up there it's more likely that they're be able to cling and reproduce and the new basically end up with a urinary tract infection. Now the next part of this is oftentimes these kind of urinary tract infections are not severe. You know they may have a little bit of a fussiness with it and maybe some fever but you know especially in the winter time, how many babies do we see in the office who are fussy, they have a fever, they've got a runny nose, you look on their ear and they got ear infection.

0:21:23

Well what if they had reflux of the bladder and the urinary track and that was happening at the same time they had their cold virus? So maybe they had just their cold virus, maybe they had a viral ear infection and when we saw them we called it an ear infection. This probably happens so fairly frequently. And we put him on antibiotic but what we really treated was not their ear infection, cause that was probably caused by a virus and the antibiotic didn't work anyway, but what we treated was their urinary tract infection that we didn't know about.

0:21:56

So if you have a baby with a more severe urinary tract infection and you diagnosed it because maybe their ears look fine, they are still having a high fever, they're vomiting, and you think to check the urine and they have a urinary tract infection and they're an infant, you have to step back and ask now, how many other times when they're diagnosed with ear infection or some other thing was the cause of the fever really urinary tract infection.

0:22:19

So if you find even one and that's why you sort of go after and look because if they have the reflux problem it could be that they have some other urinary tract infections that you missed in the past because you're blaming the fever on something that seemed more obvious at the time. So once they have the urinary tract infection, how do you check to see if they have this reflux thing? Well one thing you do is the sonogram that Isabel was talking about. And this is a renal ultrasound and you're just looking with sound waves to make sure that the kidneys look okay. You make sure that they are of equal size, that they're normal size for the age of the child, and if there's a collection of fluid or urine, or around the kidney, this would be called hydronephrosis, is the name for that.

0:23:04

And that's just from reflux urine moving from the bladder up the ureter and then surrounding the kidney and then that would be the evidence that they have some reflux going on. Now that would be the severe cases for reflux. The vast majority of kids, the renal ultrasound is going to be normal even if they have reflux. The other thing too is where current urinary tract infections especially ones that are sold of mild but they're there, and they're frequent but you know not treating the problem that can cause some inflammation in the kidney over and over and over again which can lead to scarring of the kidney.

0:23:42

And there are plenty of young adults who are on dialysis and they have renal failure because they had their current urinary tract infections as kids and weren't treated for the urinary tract infection. There was always blamed on something else also they didn't go to the doctor. So this process was not discovered and it led to renal failure from scarring. So the renal ultrasound also helps you to see you know, is there potentially areas of the kidney that looked different that might represent scar tissue.

0:24:09

Now you can't see the scar tissue really well on an ultrasound. You have to do a nuclear skin and you know more sophisticated test really look for that. But if the urine looks pretty you know one echo pattern throughout the whole kidney, you can say well you know the whole kidney looks pretty good, its normal size and there's not fluid around it so it's a good test to start with.

0:24:31

The other study that we do is what's called a VCUG, which is a voiding cystourethrogram. Basically what you do with this is you put a catheter into the urethra, put some contrast into the bladder, fill the bladder pretty full so that the child has to urinate and then take extra as well while they're urinating to see if some of that contrast goes reflux is back up towards the kidney. So you can actually look at it and see how much bad, how severe. And t then once if they do have that the reflux is grade it on a scale of 1-4, where level 1 and 2 are going to be the mild reflux and those were the most common. And then the 3's and 4's are going to be a lot less common but those are the more severe reflux, so that you really see the urine being refluxed back up toward the kidney on either one side or both sides.

0:25:22

Now the level 3's and 4's may require a surgical intervention. The 1's and the 2's often will correct themselves over time so generally what we do for those is put kids on a daily antibiotic and this is used to prevent these recurrent infections. So if any of those skin bacteria's getting up into the bladder and then being refluxed back up the ureter toward the kidney, you have some antibiotics in the urine that's trickling past to kill the bacteria so that you don't get these infections.

0:25:52

Now yes I really did say we used a daily antibiotic, we usually do it for 6-12 months and then re-evaluate with another VCUG and then once it looks like the reflux is gone then we can go ahead and stop the antibiotic. So now, one of the things that I often come across is you see as tell these parents your child is going to need an antibiotic everyday for the next 6-12 months and possibly longer. They look at you like are you from 10 years ago? Are you from 20 years ago? Hey doc don't you know that there's resistance to antibiotics and you're just creating this super bacteria?

0:26:27

Well it's true you do make it more likely that you will create some resistant bacteria but what's the alternative? The alternative is surgery to correct something that's probably going to go away on its own and how many kids are going to have complications in that surgery or cause as more damage to their urinary track because of it. So certainly that's not going to be the great option for something that goes away pretty easily.

0:26:50

The other option is to let them get the infections and then treat them before that as they get them. But then you're still taking the chance that they're going to get kidney scarring and end up of renal failures. So when you look at the alternatives the best one is to put them into daily antibiotic and monitor him for signs of recurrent infections. So you know you have to look at the whole advantage versus disadvantage package in deciding what you're going to do. Certainly we don't want to use as many antibiotics as we used to. We shouldn't be treating cold virus with antibiotics but in the case of infants with a level 1 and 2, reflux still the standard of care is going to be to do a daily antibiotic in most places.

0:27:34

Now there is some other research out there that looks into more of the level 1's and are we over doing them a little bit and so there is, there's not a 100% this is what you have to do. The level 2's and 3's that you're not going to operate on; I think most people would still agree with daily antibiotics for them. But you know the people are starting to question it a little bit especially for the level 1's you know are we doing too much. So that's, you're going to get a room of a 100 pediatric infectious disease specialist or pediatric urologists or renal doctors you know and you get a little bit of a difference of opinion. But that's normal you know in medicine and any specialty as people experience as their experiences dictate sort of how they practice or, no question about that.

0:28:25

Okay so that's enough about urinary tract infections. Let's move on.

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0:29:01

Question number 3 this week comes from Katherine from Texas. She says Dr. Mike; I really enjoyed your show. Thank you for all the good information. I have a question for you about babies and thermometers. We have a 6-month old baby girl and have a lot of trouble figuring out what type of thermometer is best to use with her. What kind of thermometer is most accurate with babies? And related question, can a baby's temperature ever be too low? What are some of other reasons that a baby might have a lower than normal temperature? Again thanks for your show, I tell my families and friends about it all the time but most of them don't understand podcasting yet. Yeah you got to explain it to him. But I am spreading the word about your show anyway because I think it is so helpful to moms and dads especially overwhelmed new moms and dads like us.

0:29:44

Alright well thanks for your question Katherine. The gold standard for taking a temperature really at any age and making a decision regarding that temperature is going to be rectal, so rectal temperature is the gold standard. So when we say rectal temperature is a certain amount or certain temperatures too low or too high, we're always talking about their core body temperature. And probably the best way to measure that is rectally.

0:30:10

Now the elevation of the core body temperature in determining a fever is going to be most important in little babies. Because depending on what that level is you're going to make some pretty serious decisions on whether they need a whole kept of work up with blood work, and a urinary catheter, and spinal tap, and in the hospital with IV antibiotics. So you want him to have some sort of standard on when you do that and when you don't have to do that.

0:30:36

And so, the rectal temperature is really the gold standard especially for little infants. Now keep in mind that the elevations of the core body temperature so the inside body temperature, that's what makes up a fever and not the skin temperature. The skin temperature does not always reflect the core body temperature and example is if you have a kid who's out there on a hot summer day and they're running, they're playing, you know they're sweating; their skin's going to feel warm to the touch and their core body temperature maybe elevated to some degree.

0:31:07

But you have to keep in mind that the skin is acting as a radiator in this case so that the blood vessels are dilating to let off heat. And so the skin feels warm but if you take their temperature you know maybe there'll be you know 99 instead of 98.6. But they can still feel when you touch their skin like their hot. And certainly with my own kids, you know they're sick, you feel their skin, they feel hot, you take their temperature you know it's 99.

0:31:34

You know no big deal. So you're really feeling their skin temperature is not a very good way to determine if they have a fever or not. You have to actually take their core body temperature. So right there, just based on that forget about the skin's strips. You know these little strips that you put on the forehead and it's gives you the temperature, those are not going to be that helpful.

0:31:55

I would also avoid the pacifier thermometers that I've seen out there. Remember those aren't very deep in the mouth, and not under the tongue which you want to measure the core temperature so those aren't really going to be that helpful though, those pacifier thermometers. So what do we have left? Well we have the rectal one, which we talked about but as kids get older that's most face is not that pleasant. So the ones we have left are going to be oral auxiliary which is under the armpit, also the ear thermometers and then there's these new scanners that are temporal artery scanners, we'll talk about a little bit about those.

0:32:27

The worst of these that are left over I think is the ear thermometer, this is my personal opinion and I find they tend to read higher than the rectal temperature but they're not accurate enough to say okay, we'll always just subtract a degree from it. You know from what you get, it's just their pretty inaccurate that typically read higher than you know if I have a parent that says oh my kids got a fever of 106 you say how did you take it and it's usually the ear.

0:32:51

So those can be not nearly as accurate as other forms. Now an auxiliary temperature in infants and oral temperature taking in older and older kids, it's easy, it's reliable, there's plenty of thermometers out there that can do it. When you do an oral one under the tongue, you know you want to wait until if its digital device until it beeps or if it's a more glass thermometer one then you want to make sure that it hasn't stop rising anymore so you want to give it a few minutes and then the auxiliary the same way.

0:33:26

Now do you add a degree? No, what you do is you just to tell your doctor what temperature you got and how you got it. So you know let us do the interpreting, certainly if you took an auxiliary oral temperature and then immediately that a rectal temperature, not the other way around. You know would they be exactly 1 degree off from one another, not likely. So your best bet is just take the temperature, see what it is. If it's a high, call your doctor and let them know what number you got and how you took it. Don't add the degree on your own.

0:34:01

Okay, in young infants again rectal is best. And again I'm going to say this because we based our decisions on hospitalization, blood work, urinary catheters, spinal tap, all that on their temperature. Most folks would use 100.5 degrees Fahrenheit as the cut off for that which is 38 degrees Celsius so you want to be accurate, you wanted to go to the gold standard in little infants and that's going to be the rectal one.

0:34:26

Okay newer device, the temporal artery scanner, this basically are a cool little machine that it swipes from the middle of the forehead to the ear and gives you an instant reading and it's what it's measuring is the temperature in the temporal artery under the skin. And studies have shown this to be an act just as accurate of an indicator when used properly as a rectal temperature in trying to determine what the core body temperature in a person is.

0:34:52

They're becoming more routinely available but they are expensive. And you also have to follow the directions exactly to the letter to get an accurate result. So in my opinion, the best bet for you to have at home would be a glass thermometer for rectal temperatures in young babies and then either a digital thermometer or glass thermometer that can be used auxiliary for older infants and then for children that you could use under the tongue. That's probably your best cheapest most practical way to take a temperature.

0:35:23

I do want to mention mercury. The new thermometer is the glass ones are not or the plastic ones too. You're not going to have mercury in them anymore. But if you have older thermometer that you suspect might have mercury in it then you want a dispose of it properly. And if you don't know how to do that, probably the best bet is to call your local health department just let them know you have an old thermometer that it's intact, don't tell him it's broken. You know if you break your thermometer and has mercury in it and it spills in your house so it'll be like in Monsters, Inc. You know when they, the control comes in and cleans the monster because he touched the kid, it be like that trust me.

0:36:00

So just let them know you have an old one, it's intact, and you just want to dispose of it, what's the best way to do it in your area. Some place does have a waste disposal day you know when you can take those kinds of things in but you definitely want it just out of your house.

0:36:15

Okay and what is a low temperature? What is too low? Well, you know the normal body temperature we talked about 98.6 Fahrenheit which is 37 degrees Celsius. But the normal range you know can be 1 to 2 degrees above or below that. So we talked again about a fever be in about 100.5 or higher which is 38 degrees Celsius. And too low would be you know 97 or below and that's going to be 36 degrees Celsius.

0:36:42

Also if it's a young infant, and they were even in that 97 ranges somewhere, try to call your doctor and just let him know. In terms of what can cause a real low body temperature especially in infants, which is one of the questions that Katherine had. You know most likely, it's just going to be that they're a little chilly. You know they need some warmer clothes but overwhelming infection and overwhelming sepsis, instead of causing a fever can cause a very low body temperature instead.

0:37:11

So if I had a mom that said you know, my 1-month old infant is 96.4 you know I would tell him they need to get that emergency room, just to have the baby to be looked at right away. Because too low of a temperature in an infant especially down below 97 but even between 97 and up to 98, you still worry a little bit. You know you want that baby looked at to make sure that they don't have any other signs of infection going on.

0:37:35

Alright Katherine, so I hoped that answers your question about body temperature and thermometers and we'll move on.

[Music]

0:38:53

Okay, our last question for PediaCast number 24 comes from Rita in North Carolina. She says, Dear Dr. Mike, I found your podcast on a recent search for constipation as to lots of people read it. My daughter just turned 4 and she's had a terrible 8 months dealing with constipation treatment. She's had glycol ax, she's had encopresis every 10 to 14 days, stomach pain, embarrassment etc. And I wanted to let you know that your podcast number 17 was a tremendous help. She loved listening to you and we're on week 3 of our sticker chart and it is actually working. At the same time we have discontinued on milk dairy products and there has been a huge difference.

0:39:37

We had been through several doctors and none consider her diet which by the way she eats really, really well. I finally wrote a study of 65 kids with the same problem and half were fix simply by removing dairy. I would love to hear your views on lactose intolerance and constipation. Thanks and great job!

0:39:55

Well I tell you Rita this is a really great observation and question that you have, an observation that you have made, you really did your homework. The study that Rita is talking about comes from University of Palermo, sorry anyone from Italy out there I'll work on my Italian cities, but it comes from the University of Palermo and it was published in New England general medicine in 1998. Now the study looked at 65 kids with chronic constipation and all of these were kids with severe chronic constipation that had failed treatment with diet, increasing fiber in their diet that sort of thing, and had also failed treatment with any kind of stool softeners and laxatives and all of them were big milk drinkers too.

0:40:42

Now what the researchers did is divide them in 2 groups. And one group would stay with milk while the other one switched to soy for 2 weeks and the parents did not know if their children were kept on milk or were switched to soy. Although they didn't talked about how old these kids were and you know they don't taste the same so I'm sure the kids knew which group they were in and they probably told their parents. So you know that's not really a blind study.

0:41:08

The researchers who were giving the kids and taking, asking the parents questions also did not know which kids were stuck or which still on milk and which one's has been switched to soy of course the person analyzing the data of course would know. And then after 2 weeks they basically switched sides so the kids who had been kept on milk were now put on soy and the kids who were switched to soy were switched back to milk.

0:41:30

And what they found while on soy milk, 68% of these kids had a significant resolution of their constipation symptoms. So the ones who were switched markedly improved and when they went back to milk their constipation came back and the ones who were left on milk you know still have constipation problems but then when they're finally switched to soy during the second half of the study, they had a lot improvements.

0:41:58

So that's you know, it's a very compelling study and I think that, I think we really have to take this pretty seriously. The thought is with this is not lactose intolerant, it's not lactose intolerance, it's actually a milk protein that's causing the issue. What they think, the researchers who did the study, their hypothesis was that the milk protein was causing intestinal swelling in these kids because they had a milk protein allergy. And that the swelling decreased about a function including the bowel's ability to move things along. And this decreased motility or decreased ability to move things because of the chronic inflammation decreased to their stool movement which then led to constipations.

0:42:43

So this is a milk allergy issue, not a lactose issue. Remember lactose intolerance is caused by a lack of the enzyme lactase, so lactose the sugar doesn't get broken down and lactose is not absorbed very well so the sugar is undigested sugar passes into the large intestine. You got all these extra sugar part that draws water into the gut by osmosis, and usually that causes loose stool and diarrhea so lactose intolerance would be caused, would be associated more with diarrhea where the milk protein allergy in some kids is going to cause constipation because a decreased ability of the gut to move things through because of the chronic inflammation that's there.

0:43:25

So the take home message here is if your child has constipation and the dietary measures so increase fiber and stool softeners are not helping then you might want to try to switch to soy milk. But remember it'll take a while for the inflammation to improve so you need to be patient and give it a couple of weeks. Also be sure you talk to your doctor about this because you want to make sure your doctor is on a soy product and not whole Vitamin D milk because soy milk, unfortified soy milk has less calories about half the calories of whole milk. And then also it doesn't have vitamins and calcium in like Vitamin D whole milk has.

0:44:05

So for toddlers, you might want to consider a fortified soy product such as ice milk too or next step soy. They're more expensive than soy milk but they're going to have more calories in them and they are also fortified with the proper amounts of calcium and Vitamin D. If you're interested in the poop topics which I know a lot of people who find their way to PediaCast are, PediaCast number 16, that would be baby bowels, number 17 that would be constipation and number 18 that with toddler diarrhea.

0:44:34

And way back, it's not even in the feed anymore, in PediaCast 7 we had an extensive discussion about milk. So even though it's not in the feed, if you got to PediaCast.org you can still take a listen at the website to the PediaCast number 7. All of the old episodes are at the website. And in the show notes for this week I'll have links to number 7, number 16, 17 and 18. So if you're a first time listener and you want to know more about constipation and baby poop and diarrhea or milk, you can refer back to those programs.

0:45:07

So once again thanks Rita for your question and we'll wrap things up right after this.

[Music]

0:45:29

Well that wraps our program, its episode 24 of PediaCast. I'd like to thank all the listeners out there. Also I thank my family as usual and thanks vlad over vladstudio.com for providing the artwork for the website. Don't forget you can submit a question or comment, view the show notes, take our listeners survey, sign up for our news letter and read our blog at PediaCast.org. And if you like PediaCast please spread the word by telling your friends, relatives and neighbors about the program. You can download free promotional materials on the poster page of our website.

0:46:00

Also reviews in iTunes are most helpful as our digs in the new podcast directory at digg.com, that's dig with 2 g's. Also be sure to vote for us at podcast pickle and at podcast alley as well. So until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.  So on everybody.

[Music]

The tripod network. What's on?

[Child laughing]

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