Trampoline Injuries, Raising Fit Kids, and Toddler Violence – PediaCast 043

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Topics

  • Trampoline Injuries
  • School Bus Crashes
  • Pre-Kindergarten TB Testing
  • Raising Fit Kids
  • Gerber Baby Food Recall
  • Feedback from a Dermatologist
  • Infant Sleep: How Much?
  • Toddler Violence
  • Allergies to Cat Dander
  • Folic Acid and Prenatal Vitamins
  • Evaluating Vitamin Content
  • Swimmer's Ear
  • Treatment Options and Deliberation
  • Deaths Caused by Computerized Order Entry?
  • Daily Antibiotics to Prevent UTI: Still a Good Idea?

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Transcription

[Music]

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast, the pediatric podcast for parents and others. This is Episode 43, one year later. This is Dr. Mike coming to you from Birdhouse Studio and I'd like to welcome everyone to the program this week. Before we get started, I just want to say thank you to our sponsor this week. It is Mariner Software, you can find them at marinersoftware.com. And as we usually do, we'll talk a little bit their programs that they offer right at the beginning at our listener segment so that will be coming up later on in the show.

Even though it's our one year anniversary episode, we did not go the easy way and come up with the collection of bits from the past year. We have a jam-packed show for you like we do week after week.

0:01:05

This week in the news segment, we're going to talk about trampoline injuries and school bus crashes. Just tell us some nice things, right. Pre-kindergarten tuberculosis testing, is it important? Raising fit kids and a Gerber Baby Food recall, we'll tell you which ones you want to avoid or throw out or seek a refund for if you have it in the house.

And then we'll move on to our listener segment. We have a dermatologist right in, to set a couple of things straight. I'm glad she did. Infant sleep, how much is too much? How much is not enough? Is your baby sleeping the right amount? We'll talk about that.

Toddler violence. What do you when your toddler is threatening you? Allergies to cat dander, folic acid and pregnancy, evaluating vitamin content, swimmers' year, my goodness. Maybe I packed a little too much into this one.

0:02:05

You know though people say why don't you just divide it into two or three shows a week because then you can double or triple your downloads. But no. Alright, commitment to you is to come at you week after week with lots of information.

Also we have a research segment in which we'll round out the show. We're going to talk about treatment options and deliberation in the examination room, also deaths caused by computerized order entry, daily antibiotics to prevent urinary tract infections, is that still a good idea? So that's all coming up in this week's show.

And don't forget, if there's a topic that you would like us to discuss, all you have to do is go to the website at pediacast.org and click on the Contact link. You can also go to pediacast@gmail.com and write to us that way. Attach an audio file if you like, or call the voice line at (347) 404-KIDS, (347) 404-K-I-D-S.

0:03:07

Now let me tell, I just want to give you a little bit of advice here real quick. If you are at home and particularly if you have issues, let's say with something like poison ivy and your brother in law decides to come down to help prune some trees and he's up on a ladder sawing branches, doing his thing and your wife is throwing these branches that had fallen into a patch of poison ivy, unbeknownst to you, of course.

And she throws them over the fence and then you dragged said branches to a burn pile and burn them, we're in shorts and you know, really low-cut socks and bare arms. If you find yourself in that predicament, good luck. [laughter]

0:04:01

This happened to me two weeks ago and ahh, I am still just an itchy mess. My legs are just terrible. I've had to take steroids and Benadryl and antibiotic, it's just really been tough. You think I would learn because I did have a really bad poison ivy, it was in the year 2000. I remember, it was the summer of 2000 and our cat had gone into our back fence line and some poison ivy and I picked up our outdoor cat whose furs still had the poison ivy oil on it. And I had terrible poison ivy that summer, so I've avoided it for the last seven years, but my luck ran out.

Alright, yes, it is our one year anniversary. And if you would like to give us a gift, you know, a little birthday gift to celebrate when you're at PediaCast, the only gift that I would ask for is a review in iTunes. iTunes reviews are really important and if you have not made the time to go into iTunes and review our podcast, yeah, it's what it's called, please consider doing so.

0:05:08

Right now, we're standing at 80 reviews and in this next week, if we could push it over a hundred reviews as a birthday gift to PediaCast, I would just really be tickled. So if you haven't taken the time out of your very busy schedule to give us some nice reviews on iTunes, please do so because those are just so important.

Also, the 3rd Annual Podcast Awards are going to be entering the voting phase here soon and if you follow the link in the side bar of the website at pediacast.org, that will take you to the podcast award site so that you can look for us and vote for us. And again, there will be a link in the side bar to that. They're not open for voting yet, but they should be probably in about a week or so. So just a heads up on that.

Okay, we'd better be moving into the program because as you heard in the introduction there, we have lots to talk about. I do want to remind you here real quickly that the information presented in PediaCast is, as always, 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, call your doctor and arrange a face-to-face interview and hands-on physical examination.

0:06:25

Also, your use of this audio program is subject to the PediaCast Terms of Use agreement, which you can find at pediacast.org. And with that in mind, we'll be back with News Parents Can Use right after this short break.

[Music]

0:07:20

Dan: Hey, Dr. Mike, this is Dan and Carrie from the Babytime podcast.

Carrie: Congratulations on PediaCast one year anniversary. I can't believe it's been that long. I remember when I first Googled poop and came across the PediaCast. I've listened many times since then and I so appreciate what you do and so many of our listeners do too.

Dan: Absolutely. And one year is an important milestone. It means that you're no longer a podcasting baby.

Carrie: Right. Now you're a podcasting toddler.

Dan: Uh-hmm. Here come the tantrums.

Carrie: Congratulations.

Dr. Mike Patrick: Our News Parents Can Use, thanks to tantrums. [laughter] That's probably going to be true. Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website and you can visit them online at medicalnewstoday.com.

0:08:11

Increase in trampoline-related injuries mainly at home, according to the latest study on trampoline injuries by Rhode Island Hospital Researchers. They have more than doubled in the past decade. And earlier, Rhode Island Hospital Study, looking at data from 2001 and 2002, indicated an average of 75,000 children per year who were seen in emergency departments across the country for trampoline injuries.

The new more comprehensive study which examined emergency department visits from 2000 to 2005 shows even higher rates, over 500,000 trampoline-related injuries over the study period an average of 88,000 each year and 95% of the those injuries occurred on home trampolines.

0:09:00

The study compares statistics from 2000 to 2005 to a study from 1990 through 1995 when there was a total of 41,000 trampoline-related emergency room visits annually. The study presented at the recent American Academy of Pediatrics Annual Meeting shows a progressive increase each year and injuries causing even greater concern among researchers.

Our first study on this subject gave us reason for concern and the need to send a warning to parents. Clearly, this new study indicates even higher rates of injury than first thought, said Dr. James Linakis, a emergency physician at Hasbro Children Hospital. There were 1.2 million new trampoline sales in 2004 indicating that parents continue to purchase this as a form of fun and exercise for kids.

We urged parents not to purchase this equipment for their children based upon the dangers they posed and the injuries that had been documented. The most common injuries were those of soft tissues such as brains, cuts and scrapes with 250,000, that's a quarter of a million total cases or fractures and dislocations were next with over 168,000 of these.

0:10:13

The age group with the most injuries was the 5 to 12-year old range. The vast majority of accidents involves the extremities which represented 71% of all injuries. Dr. Michael Melo, an emergency medicine physician and director of the Injury Prevention Center at Rhode Island Hospital who worked with Dr. Linakis on the study, said, "Physicians strongly encourage physical activity in children. And while trampolines appear to be a fun activity that satisfies the need for physical activity, this study indicates they post too greater risk to be used in an unsupervised environment like a backyard.

Okay, over 10,000 kids were involved in school bus crashes each year in Ohio. Annually, in the USA, 25 million children travel an estimated 4.3 billion miles on school buses. New research findings by investigators in the Center for Injury, Research and Policy at Columbus Children Hospital emphasized the large number of children involved in school bus crashes each year.

0:11:16

According to the new study, there were approximately 20,800 children younger than age 18 years who are occupants in a school bus involved in a crush in Ohio during the two-year period 2003 to 2004. This high frequency of children involved in school bus crashes, more than 10,000 per year in Ohio alone, reinforces the need to provide the best occupant crash protection possible to children on school buses which is a lap shoulder belt for most school-aged children, said Dr. Gary Smith, Director of Injury, Research and Policy at Columbus Children Hospital and a faculty member Ohio State University College of Medicine.

In November 2006, this research group was also the first to use a national sample to describe non-fatal school bus injuries to children and teenagers treated in a hospital emergency departments across the country.

0:12:09

Following the release of that study and a number of tragic bus-related crashes earlier this year, the National Highway Traffic Safety Administration held a public meeting on July 11, 2007 to discuss the issue of seat belts on large school buses.

The previous study from Columbus Children's Hospital published in the November 2006 issue of Pediatrics found that from 2001 through 2003, there were an estimated 51,100 school bus related injuries nationally that was ordered in treatment in U.S. emergency departments. That equals approximately 17,000 injuries annually.

In addition, that study showed that traffic-related crashes are the leading mechanism of non-fatal school-bus-related injury to children in the U.S. accounting for 42% of injuries. It makes you wonder how those 60% that's left over are injured.

0:13:01

Current Federal regulations use as strategy known as compartmentalization is the main method for protecting children in crashes on large school buses. Compartmentalization uses tall, padded seat backs on closely spaced seats to provide protection in a crash. However, in the new study examining school bus crashes in Ohio, 23% of the children were involved in a side impact or rollover crash when compartmentalization offers no protection to child passengers.

Compartmentalization also fails to prevent injuries from sudden swerves and when children are out of their normal seated position. Lap shoulder belts kept children in their seats and not for protection during swerves and crashes of all types.

In addition, lap shoulder belts can improve student behavior by keeping children in their seats which results in less driver distraction and thereby lessens the chance of a crash. Compartmentalization may have been the best that could be offered 30 years ago, but this concept is no longer state of the art, said Dr. Smith.

0:14:02

School bus crash tests show that lap shoulder belts offer better protection to occupants. Congress stated in 1974 in the School Bus Safety amendment that school transportation should be held to the highest level of safety because it involves protection of children. If the National Highway Traffic Safety Administration holds to that important mandate as it deliberates the topic in Washington, then a decision is clear. Lap shoulder seat belts should be required in all newly manufactured school buses.

Findings of the new study were based on data from the Ohio crash outcome data evaluation system program which links large statewide databases including crash and hospital data files for Ohio.

The analysis included all children younger than 18 years who are occupants on a school bus involved in a crash in Ohio during 2003 and 2004. 39% of children were 5 to 11 years old or elementary-school age, 27% were 12 to 13 years old or middle-school age, and 33% were 14 to 17-year-olds or high-school age.

0:15:04

Most children had minor or no injuries, however, injuries did include two skull fractures, one bleed inside the head, one broken back bone, one serious injury to the spleen and 28 other head injuries including concussions. Average hospital charges for those who sought medical care were $730 with the maximum of $68,100 for one of the children.

So I asked again, as I usually do, does your child's school bus have seat belts on their buses? Probably not, but they probably should. And someone, of course, has to initiate the process, right? Maybe that someone should be you.

Prekindergarten tuberculosis testing is not cost-effective. The Healthcare System in California could save nearly $1.3 million a year with few adverse public health effects if it discontinued universal tuberculosis skin testing of children entering kindergarten, according to a new study by researchers at the University of California, San Francisco.

0:16:03

Over 20-year period, the study projects that only two additional cases of tuberculosis would be detected from screening the prekindergarten group. Dr. Valerie Flaherman, research fellow at the University of California San Francisco Department of Pediatrics is principal author of the report which appears in the July issue of Pediatrics, the journal of the American Academy of Pediatrics.

"Prekindergarten screening is not a cost-effective way to spend our health care dollars,… Flaherman said. You need about 7% of the children who are being screened to test positive in order for prekindergarten screening to be cost-effective. That may have been the case in the past, but now, often less than 1% test positive.

Tuberculosis remains a persistent health threat in California with over 2,800 cases reported in the state in 2006. California has more cases of tuberculosis in young children than any other state. The savings from an illuminating universal tuberculosis skin testing of youngsters could be redirected toward more cost-effective methods of stopping the spread of the disease, according to Flaherman. Instead, finding and treating adults with tuberculosis would be a better approach to stopping the spread of the disease to children, she said.

0:17:17

The tuberculosis skin test, also known as the tuberculin or PPD test, is use to determine whether someone has been infected by breathing in the germ from a person with active TB. People with latent TB infection had no symptoms and usually had a positive tuberculin skin test. They cannot spread TB to others, but need treatment to prevent them from developing active TB in the future.

By contrast, people with active TB are usually sick with symptoms that can include a cough of more than three weeks duration, coughing out blood, fever, chills, night sweats, weight loss and fatigue. They need treatment to stop them from spreading TB to others.

The study titled Cost-effectiveness of Alternative Strategies for Tuberculosis Screening Before Kindergarten… that's a mouthful, was conducted using a computer-based decision analysis model that calculated cost and benefits of routine or universal TB screening, targeted screening according to risk factors and no screening at all.

0:18:16

Faherman's research team found that the use of targeted testing instead of routine testing would save California $1.27 million per year. The study provides tools that help health officials… I'm sorry, the study provides tools that health officials can use to tailor TB screening decisions to the particular circumstances of their communities, said Flaherman.

And then preventing obesity and raising fit children is a family affair. The numbers of overweight children are increasing and many parents are rightly concerned about their children's weight and how it affects them. The good news is that parents can help their children live healthy, active lives. Sometimes it's best to change your vocabulary. That what Peggy Supple, a pediatrician from Advocate Good Samaritan Hospital in Downers Grove, Illinois, often has to remind the parents of children struggling with obesity.

0:19:09

"I find that overweight children respond better to the word activity than to the term exercise,… Supple explains. "I think it's because some children associate exercise with sweat and work, things they may feel are negative. To really make an impact with overweight children, you must help them increase their level of activity throughout the day….

Some parents underestimate the health risk of excess weight to their children. Overweight children tend to become overweight adults, Supple explains. Childhood obesity can result in increased risk of diabetes, heart disease, stress and high blood pressure, diseases we traditionally associate with adults.

Here's some strategies to create a family that's active and fun. Make time for the entire family with to participate in regular physical activities that everyone enjoys. Try walking, bicycling or rollerblading. Plan special active family outing, such as hiking or ski trips, assigned active chores to every family members such as vacuuming, washing the car or mowing the loan. Limit the amount of TV watching and other activities that require sitting for long periods of time.

0:20:14

To get your family eating healthy, implement the same healthful diet, rich in fruits, vegetables and whole grains for the entire family, not just for select individuals. Plan times when you prepare food together children enjoy participating and can learn about healthful cooking and food preparation.

Limit the frequency of fast food eating to no more than once per week. Avoid using food as a reward or the lack of food as punishment. If their child is overweight, parents also may not realize how difficult it can be to maintain behavioral changes associated with obesity treatment and prevention, said Supple.

Change takes both time and attention, she says. Parents can establish a lifetime of healthful habits for themselves and their children through a focus on increasing daily activity and improving food choices. This is a more active healthful lifestyle and it would benefit the entire family, Supple says.

0:21:07

To learn strategies for the prevention and treatment of obesity among children, visit the American Obesity Association website at obesity.org and click on the Childhood Overweight Fact Sheet. Of course, we'll have a link to that in the Show Notes.

And then finally in our news segment, choking hazard of some Gerber baby food precipitates a product recall. Gerber organic rice and oatmeal cereals have been recalled because they may clump together and be a potential choking risk, said the Gerber Products Company.

According to the company, reports have come in of baby's choking, but no injuries. The problem, says the company, is that small quantities of rice or oatmeal might not dissolved in water or milk and remain as lumps. The products in question are marketed in the USA, Puerto Rico and some parts of the Carribean.

Products presented in eight-ounce boxes with the following UPC codes are being recalled: For organic rice cereal, it's 15000 and 12504. For organic oatmeal cereal, it's 15000 and 12502. And since you have a rewind button on your digital audio player or on the website, you can rewind and hear those numbers again.

0:22:23

Purchasers may call the following telephone numbers to return their products and get a full refund, it's (800) 443-7237 or (231) 928-3000. And you can find those numbers also on the bottom right side of box in question.

The FDA is aware of this problem and no other Gerber products are involved in the recall. And of course, we'll have a link in the Show Notes to… that has all that information in that as well, in case you can't find that rewind button. You know what I'm trying to say.

Okay, we will be back with our listener segment right after this.

0:23:00

[Music]

Whitney Hoffman: Hey, Dr. Mike. It's Whitney Hoffman from the LD Podcast. I wanted to congratulate you on your one-year anniversary. The LD Podcast also just celebrated it's first year anniversary and I couldn't have done it without the great support that you've given me. It's really been a wonderful year. So grateful that you were an early guest on my show. And again, it's been a pleasure getting to know you. You have a fabulous podcast and again, I'm so glad that we are internet and podcasting buds. Congratulations again on your anniversary, Mike. Couldn't happen to a better person and please give my love to Karen and the kids. Take care, bye bye.

0:24:14

Dr. Mike Patrick: Well, thank you, Whitney. Those comments are definitely appreciated. I would like to thank this week's sponsor, Mariner Software. You know from Play-Doh to the present day, people have recorded their lives in personal journals. Mariner Software makes this process easier than ever with the release of WinJournal, integrated journaling, blogging and podcasting software for Windows.

WinJournal offers a new twist to traditional paper by using technology to incorporate digital photos and live website links to journal pages. Easily post online blog sites such as Blocker, Live Journal and Windows Live. For those who prefer their privacy, WinJournal includes password protection and powerful AES 256 encryption.

WinJournal also redefines full audio recording and podcasting. One can record thoughts as a journal entry or publishes a podcast. WinJournal, along with a collection of other fabulous programs, is available from the Mariner Website, at marinersoftware.com. And of course, if you look in the side bar at pediacast.org, you'll find a link to their site.

0:25:19

Okay. Up first in our listener segment is Suzanne from Virginia. Suzanne says, "Dear Dr. Mike, as a practicing dermatologist and mother of a 13-month old, I have thoroughly enjoyed your podcast. For me, sometimes it's like attending pediatric journal club, but not having to read the articles beforehand. Please continue with the wonderful contribution you're making in sharing current medical information that is also evidence-based.

I have a couple of comments based on your recent podcast. Number one, your comments of how to treat scrapes and abrasions was pretty much on the mark except for one thing. In the wound-healing community, it is known that keeping things open to air actually impedes wound healing.

0:26:01

Wounds heal up to 40% faster when kept occluded with a moist environment or dressing, such as antibacterial ointment or petroleum jelly and a bandage. One of the original studies that presented this data was in the Journal of the American Academy of Dermatology in 1985.

So when most of us dermatologists perform surgery or giving patients recommendations for their accidental scrapes, we tell them that leaving it open to air is a myth. It is thought that the occluded, moist environment enhances skin cell migration and protects from infection. The patient is instructed to continue wound care until it has fully healed.

Two, you also mentioned that a stork bite is a hemangioma, which is not correct. Technically, it is a vascular malformation and not a tumor, which is what hemangioma is. Although the regular non-medical listener won't know the difference or care, the healthcare professionals who do listen to your show may be interested in knowing the benign tumors of blood vessel cells hemangiomas and capillary area malformations are very distinct entities.

0:27:06

Thank you so much and keep up the wonderful service you provide…. And thank you, Suzanne, for listening and for setting records straight on these two points.

Next up is Laura from California. Laura says, "I have a three-month old boy. He sleeps so much! I am concerned about narcolepsy. His doctor has said he will awake more as he gets older. Well, he still sleeps as much as he did when he was one-week old.

When he is awake, we play with him so much, we even have woke him up to play. We do this in case his oversleeping is due to under stimulation. My question is can a three-month old be narcoleptic?…

Well, of course, if you're worried about your baby's sleep pattern, don't be afraid to bring it up with your doctor, like you did, Laura. That was the right thing to do. It is okay to worry about the little things and that's why we're here, you know.

So Laura did bring it up with her pediatrician, good for her. I assumed her doctor asked some questions, took a good look at the baby and said all is well. And of course, I would trust that unless something changes that concerns you and if that happens, of course, call your doctor back. That's always the prudent thing to do.

0:28:13

But let's talk about baby sleep here in the general sense. No, I've never heard of baby with narcolepsy. Baby sleep patterns vary widely from infant to infant. Some babies are going to sleep for multiple short stretches and some are going to sleep fewer times during the day but longer stretches each time. Still some of them are going to sleep through the night, some of them are going to sleep more during the day.

I mean, there's really just a huge wide range of what's normal. Now, if we look at average, the average infant from birth until about three months old is going to sleep a total of 14 to 18 hours a day and in between three and six months, typically drops back to the sort of 12 to 16-hour range. But not all infants are average. I mean some are going to sleep a lot more and some are going to sleep a lot less.

0:29:05

So even up to three months of age, sleeping 18 hours a day and if you say, well, that's average, so my baby's going to sleep a little more, you may have a baby that sleeps 20 hours a day. And that's still would be okay. So now we're talking only being awake four hours during the day.

Now there are some parents that just are saying what? My baby only sleeps 10 hours. So really, there is a huge range of what is considered normal. The key is to let your doctor know when you're concerned and trust his or her opinion when he or she gives it.

So certainly, if they're sleeping 20 hours a day, it's a good idea to bring the baby in for an examination. Make sure that they're gaining weight okay and that everything looks alright. But then, when your doctor says, nah, it looks good. I would trust that. Your doctor sees many more babies than your family members who are giving you advice at home. They see the entire range of normal everyday which gives them a big advantage over your Aunt Gertrude's observations.

0:30:05

Aunt Gertrude. Boy, that's a name I haven't heard of or thought of in a long time. Anybody remember who she was? If so, drop me an email. We'll see how good the audience is at literary trivia. And that's the only hint that you get, Aunt Gertrude.

There is a great infant sleeping resource that I came across. It comes from Ask Dr. Sears. And yeah, Dr. Sears, I guess you'd consider him sort of a competitor in the child health information market. But here PediaCast were all about pointing you in the right direction and he has an information sheet at his website that's called Eight Infant Sleep Facts That Every Parent Should Know. That's a good one. We'll put a link up to that in the Show Notes which you can find, of course, at pediacast.org.

Okay, listener question number three. This one comes from Sandy in New Hampshire. "Hi, Dr. Mike, I stumbled across your podcast and really enjoy your program. I have a question regarding my three-and-a half-year-old son. He is constantly turning every toy into a pretend gun, knife, sword and talking about killing and hurting the cat, my husband and I and especially his 11-month old brother.

0:31:17

He has also been hitting, kicking, pinching our 11-month old whenever he thinks we're not watching. I'm concerned about his aggressive nature and wonder if there is more to it than just a phase as my pediatrician suggested.

So here we have a three-and-a-half-year-old who is being violent with specific weapons and saying specific threats about specific people. And that is serious, serious issue. And I would say that your child probably needs more help than just what your pediatrician's going to be able to provide in the form of counseling or child psychiatry referral will be my guess.

Again, the important thing is that you talk to your doctor about this. And if your doctor says, nah, it's just a phase, let him know how worried you are. Give him specific examples of what happened and just make sure that he understands exactly what it is that's going on and that he hears or she hears exactly what you're saying.

0:32:18

Kids at this age are copycats. So you want to make sure that you or someone else, such as a baby sitter, is not exposing them to violence. I mean it's really important to be careful about what television shows they're watching, what cartoons they're watching, what movies, what video games they're watching or playing because there's a lot of potential sources for coming across violence.

Now, is that to say that all cartoons that portray any type of violence are bad? Not necessarily. You're going to have a lot of kids who watch it. They understand it's part of the cartoon. And they're not going to necessarily imitate it in any meaningful way.

But if you have a child who's starting to do the kind of things that this listener asked about, then definitely, you want to make sure that they're not expose to any forms or sources of violence of any kind.

0:33:07

If your child pretends that a toy is a weapon, take it away from him for the rest of the day. Tell them, you've got another chance tomorrow. You're not allowed to play with guns or knives, even pretend ones, and take it away. And really, there's got to be no allowance for exceptions to this. If they do it, you take it away. There's no warnings. It's just that's what happens so the next time that the little thought goes in their brain… well, maybe not the next time, but maybe the tenth time that the thought, oh, this is a knife goes to their brain, they're going to think, oh, if I do that, then it's going to get immediately taken away.

Again, it's going to take some time for that to sink in. So you have to be consistent with that. If you take it out, of course, any of these should be obvious, but I still need to say it. Any real weapons should be locked up and put out of reach always.

If they have a tantrum because you took their toy away, ignore it. Pay no attention to the tantrum. You do want to make sure they're in a safe place where they can't hurt themselves, but other than that, let them do their thing. And when they're done having their tantrum and they're calm, then you can talk to them about why you took it away and how they can avoid having it taken away again.

0:34:16

If they hurt someone, you want to give him an immediate timeout, back against the wall and in the kitchen and up against the cabinets sitting on the floor, set the kitchen timer for three minutes if they're three years old. One minute for every age. If they get up, you start over. If they keep getting up, you hold them down if you need to, not hurting them, but you know, firm enough. You're bigger than they are that they can't get up. You don't want to suffocate them or make them have trouble breathing, but you can hold them down without bruising them.

Don't look at him, don't talk to him. And then after three minutes, give him a big hug and explained why that happened. If they turn around, they do it again, repeat the timeout immediately. Do it 20 times in a row if you must. Twenty times on the first day will end up leading that to only 10 times by day five and five times by day seven and maybe one or two times a day by day 10. But you have to be consistent with it. It doesn't work overnight, but it usually does work.

0:35:09

And this is the sort of thing if you've ever watch the show Super Nanny or Nanny 911 or any of those kind of things or read their books. This is the sort of timeout discipline method that they described. And it usually does work. If it doesn't, tell your doctor, again, your child might need a counseling referral or a psychiatry referral. Although I think most child psychiatrist and counselors should probably in the three-and-a-half-year-old who's having behavioral difficulties, probably start by handling things as I described. And if there are any child psychiatrist in the audience and I'm wrong about that, please email me and sent me straight, just like dermatologist Suzie did.

By the way, I am lining up my interviews and looking for any child care professionals so if you'd like to be a PediaCast guest in the future, drop me a line. If you are in the healthcare profession.

0:36:04

Okay, listener number four, this is Ashlyn in Saskatchewan, Canada. She says, "Dr. Mike, I am surely due to give birth to my first child as a young single mother. I have begun listening to your show religiously and I absolutely love it. It's very reassuring, informative and interesting. I enjoy listening to your opinions as a pediatrician and parent. You seem quite rational and well-informed in all topics which you discussed on your show…. And when I'm ill-informed, I'm not afraid to say so and set the records straight.

"I do have a question regarding allergies in infants. Some episode ago, you touched on nut allergies. My question concerns cat dander. I have a strong family history of allergies to cat dander, though luckily, nothing life-threatening. The father of the baby wants to be quite involve in the baby's life, but his family owns medium and long-haired cats.

I have done some research to cat dander allergies and have learned that it is active for up to a year. You mentioned that it's possible for a mother to transfer an allergy to a child through breast milk.

0:37:07

I wonder how concerned I should be about this possible allergy in the baby and if it's serious enough to disallow the father to take the child to his home due to the possible allergy. How soon should one have their infant tested for allergies and what would you recommend be done if it's found that the child is indeed allergic to cat dander. Thanks so much for the time and effort that you put into this show. Keep up the good work….

So let's talk about cat allergies or allergies to cat dander and along the way, I think we'll answer most of Ashlyn's questions. Cat allergy, is by far, the commonest allergy to pet animals. It's much more likely to cause problems than dog allergies.

So what's the culprit? Well, a tiny protein particle, the Fel d1 allergen is found mainly in the cat's skin flakes and saliva or their spit. The protein is actually produced in the cat's salivary glands, so the glands that make the spit and the sebaceous or oil sweat glands of the skin.

0:38:10

Now cats, as you know, are fastidious groomers so they deposit the Fel d1 protein on their fur by licking themselves, which cats do all the time. In fact, Karen, on the PediaSribe blog posted a picture not too long ago of our cat licking himself.

And allergen, of course, is a material… in this case, it's a protein which is capable of provoking an allergic reaction such as pollen, grain, dust mites or animal dander. Cat allergen, the allergy-causing material from cats, is not cat hair. Rather, it's the protein present in the dander or skin flakes, microscopic skin flakes and saliva of cats. The allergens become airborne as microscopic particles which when inhaled into the nose or lungs can produce allergic symptoms.

0:39:01

Although individual cats may produce more or less allergen, there's no relationship between the pet's hair length in allergen production and no such thing as a non-allergic breed because all cats have this protein Fel d1 in their saliva and in their skin cells as they lick.

Male cats do tend to be more allergic than female cats because testosterone increases Fel d1 production by the sebaceous glands. Of course, if you're male cat is neutered, then you don't have lots of testosterone floating around which means they're more like girl cats with regard to allergen production.

So where is the cat allergen found? Well, cat allergen is present in the largest amounts, of course, in homes with cats. But it's also been found in homes where cats have never been present and in office and public spaces where animals are not allowed. Cat allergen is particularly sticky and is carried on clothing from the places with cats to other locations. It's almost impossible to not be exposed to some level of cat allergen. Of course, level of exposure will be much higher where cats are present and these levels are likely to cause allergic symptoms.

0:40:11

Because cat allergen particles are particularly small, in fact, they're one-tenth the size of a dust mite allergen. I mean these things are tiny. They remain airborne for prolong periods of time. Cat-allergic individuals are more likely to have a rapid onset of interest when entering a room with cats because there is always allergen which is airborne and can be easily inhaled.

Opening windows, using exhaust fans and using high-efficiency air cleaners can decrease the amount of airborne allergens. Soft furnishings such as carpets, sofas and mattresses will hold cat-allergens even after a cat has been removed from the home or banished from the bedroom. It has been shown that it can take as long 20 weeks for levels of allergen in carpets to decrease the levels found in the home without a cat and up to five years for cat allergen levels in mattresses to decrease to such levels.

0:41:07

Removal or treatment of the carpet, sofa and encasing of the mattress will reduce the continued exposure to this reservoirs of allergens. So you can start to see why allergist are not particularly fond of cats.

Cat allergen is also found on vertical surfaces such as walls and attempts to decrease cat allergen exposure in the home should include wall cleaning. If the cat is removed to a restricted area of the home, it is important to realize that air flow through the duct system in a hot-air-heated home could spread the allergen. Efficient vent and furnace filters could help trap the allergens and reduce the spread.

So what happens? What are the symptoms of cat allergy? Well, there's an immediate rhinoconjunctivitis… oh boy, what that does mean? Rhino's nose, so you get a stuff nose. Conjunctivitis is inflammation of the eyes so you get a mild pink-eye looking thing with watery, itchy eyes. Wheezing is also common on entering the room with the cat. This is the most easily recognized feature of cat allergy. That combination that I just mentioned.

0:42:11

You also get a delayed type reaction present after cat exposure or even persisting for weeks after. It's important to know that with all allergic reactions, there's an immediate, occurring within an hour, and a delayed, occurring several hours later. In cat allergy, the immediate reaction might be sub-clinical, meaning you don't really see much in the way of symptoms and only the delayed reaction is clinical. So an asthmatic might notice worsening of their asthma the day following a visit to their relation who has a cat.

So they enter a room, the initial reaction is not very strong so you don't think about it being a cat allergy, but then they have a runny nose and watery, itchy eyes a few hours later or even wheezing the next day and it still can be from that cat exposure.

Another manifestation of cat allergy is chronic, severe, unstable asthma. Many patients do not get acute flare up of their asthma with cat exposure and they assume that they are not allergic to their cat, but in this situation, there is ongoing chronic inflammation in the lung due to the ongoing cat exposure.

0:43:20

So if your child has asthma, even if it's just this stable asthma with episodes of instability, that can still be due to your cat. Contact urticaria or hives, hives at the site where the individual comes in contact with cat fur or saliva, it can worsen atopic eczema, atopic dermatitis.

Cat allergen is also a common trigger for rhinitis in general where you just have you know, your doctor may think it's an environmental allergy that we call the perennial rhinitis. You talk about hay fever and really, it could be your cat that is contributing to that. And there are a lot of kids who the parents have this idea that they just have this permanent cold or they're getting one virus after another and that could be from a cat as well.

0:44:11

So what can be done to help with cat allergies? Well, of course, first, you want to address the cat. Daily grooming will help remove loose hair and dander. You can bathe the cat weekly with plain water, which is reported to be better than soap and water as this has been shown to remove much of their surface allergen and significantly reduce the amount of future cat allergen produced. So weekly bath with plain water.

It's not necessary to submerge the cat or to use detergents. Simply place the cat in the sink and pour a pitcher of comfortable room temperature water over its body. Washing should be done weekly for three weeks and then a two to three-week intervals after that. Kittens usually do not mind getting washed, but your cat should be gradually conditioned to being washed.

Avoid anything such as fleas and mites that will cause your cat to lick and scratch themselves since this transfers the allergens and spreads that microscopic dander into the air.

0:45:11

Then you want to address the home. Cats should be restricted to as few rooms in the home as possible. Most allergist would tell you the best thing as just get rid of the cat. Cat dander settles into carpets and soft furnishings which acts as a reservoirs for the allergen, releasing it back to the air when touched so you're going to want to remove carpeting if possible.

Install a HEPA or high-efficiency particulate air filter in as many room as possible starting with the bedroom. Air cleaners of this type can reduce the level of airborne cat allergen by about 50%. It's important to place the unit away from furnishings and not directly on the carpet so as not to disturbed settled allergen.

Vinyl or hardwood floors instead of carpets and minimize upholstered furniture and fleasy surfaces and HEPA vacuum all fleasy surfaces including carpets. Mattresses and pillows are also a reservoirs of cat allergen and should be encased in allergen-impermeable covers.

0:46:09

If possible, keep the cat out of doors all or some of the time or limit it to a single area of the house. Ventilate the home, very insulated energy-efficient homes actually trap in the animal dander in site. Opening windows and using exhaust fan help increase air exchange and decrease airborne allergens.

Keep the bedroom cat-free at all times. No exceptions. Vacuum carpets with HEPA-equipped vacuum cleaners. This will reduce the allergens by up to 90% over standard vacuum cleaners. Wear dusk mask while vacuuming. The exhaust from a standard vacuum cleaner will stir up the allergens. Ideally, vacuum while the allergic person is away from the home. Consider using a damp mop to clean the walls and furniture and air the house as often as possible.

Okay, so we've addressed the cat. We've addressed the house. Now we've got to address the allergic person. Wash hands and change clothing after each contact with the cat. Use a face mask when brushing, cleaning or changing the kitty litter. Non-sedating antihistamine such as over-the-counter Claritin taken one hour before visiting homes with cats can be helpful.

0:47:19

Also, immunotherapy can reduce sensitivity to cats. For cat-allergic people who work with animals, like veterinarians or severely cat-allergic children whose symptoms always correlate with cat exposure, immunotherapy or allergy shots can be an effective non-drug therapy.

There are several studies showing long-term benefit from allergy shots aimed at cat dander. Of course, the weekly shot, it's a big deal to put your kid through. I think, if all else fails, probably your best be is to find a nice home for the cat where people aren't allergic to the dander.

Okay. Let's think about Ashlyn's questions in light of our new knowledge. Can cat dander cause babies to have chronic runny noses, watery eyes and skin rashes and the answer to that is yes. Does it mean it will definitely do that? Hard to say, you just have to wait and see.

0:48:10

Should dad be allowed or should the child be allowed to go to dad's house? Well, that's a legal question. You've got to talk to the court system about that. But barring any unseen issues, I personally think it's important for little boys and girls to have an active father in their lives. And their dads certainly can take the precautions that we have mentioned in addressing the cat, addressing his house and then addressing the allergic person whom that person is visiting.

If he's unwilling and the child's symptoms persist, then you're going to have to think about other options and of course again, that boils down to see attorneys and the court system unfortunately.

Will cat dander transfer through breast milk? No. Should the child be tested for cat allergies with a skin test? Usually not, I mean most of the time, your doctor can figure out what's going on based on the history and physical examination. If there's question about, skin testing is possible. But keep in mind, we've talk about this before in previous episodes. Skin testing for allergies is not always the most accurate thing in babies, in young children as well.

0:49:14

So what to do? I mean if your child has a problem with cat dander, well again, rewind, listen to all the things we went through because we did cover them all. But I think the best thing is if nothing's working and your child's miserable and you really think it's from cat dander, whether it's constant runny nose or whether it's wheezing, you really should think about getting rid of the cat.

I know I'm going to get email from cat lovers, but you know, I like cats. We have a couple of cats and I'm not a… it's not that I dislike cats. But sometimes you've got to do what's best for your kids and not the cats.

Information… all this information we went through is summed up online very nicely from an allergy doctor in New Zealand, so wonderful resource and look for link to that in the Show Notes.

0:50:03

Okay, this comes from Sandra in France. Sandra says, "Bonjour, Dr. Mike. I absolutely love your show. I'm an American mom living in France for the past two years. We have a four-year-old boy who was born in New York City and a nine-month-old baby girl who was born here. It has been an interesting experience being pregnant and having my daughter here in France.

For example, when I found out I was pregnant, I asked my doctor for a prescription for prenatal vitamins. You need a prescription for those here. And the doctor said I didn't need them even though she knew I was six weeks pregnant. She laughed at me when I asked her for folic acid supplements and said it was too late.

She told me that if I eat a healthy diet, that should be fine. I was really surprised because I was pregnant with my son or when I was pregnant with my son, I felt lots of pressure to take prenatal vitamins and lots of folic acid and I am curious what your take this is.

I also thought you'd be interested to know that amnios are done at 14 weeks here and I had to have my blood tested every month for diseases. It was mandatory. I was required to stay in the hospital for five days after the birth. There's absolutely no pressure at all to breastfeed and I think the statistics is quite low compared to the USA of moms who do breastfeed.

0:51:17

But there are special nurses in the hospitals to help you and you can stay in the hospital until you feel confident that breastfeeding is going well. In addition, you can visit these nurses at the hospital any time, day or night. If you need assistance after you are home even.

I can go on and on, but the point of my email is mostly to ask you about prenatal vitamins and folic acid issues. Thank you for your podcast. It's a great resource for us expatriate moms.

Okay, so let's just talk about folic acid here a bit. Folic acid, sometimes called folate, is a B vitamin, in fact, it's a B9 and is found mostly in leafy green vegetables like kale and spinach, orange juice and in rich creams.

0:52:02

Repeated studies have shown that women who get 400 micrograms, which is 0.4 milligrams daily, prior to conception and during early pregnancy reduce the risk of their baby being born with a serious neural tube defect, which is a birth defect involving incomplete development of the brain and spinal cord and it can decrease the risk of that by up to 70%.

Now the most common neural tube defects are spina bifida which is an incomplete closure of the spinal cord and the spinal column. Also anencephaly which is severe underdevelopment of the brain and encephalocele which is when brain tissue protrudes out to the skin from an abnormal opening in the skull.

Now all of these defects occurred during the first 28 days of pregnancy usually before a woman even knows she's pregnant. And that's why it's so important for all women of child-bearing age to get enough folic acid, not just those who are planning to become pregnant because only 50% of pregnancies are planned. So any woman who could become pregnant should make sure she's getting enough folic acid.

0:53:15

Doctors and scientists are still really unsure why folic acid has such as a profound effect on the prevention of neural tube defects. But they do know that this vitamin is crucial in the development of DNA. So as a result, folic acid plays a large role in cell growth and development, as well as tissue formation and obviously, it's particularly important in nervous system tissue formation.

So how do you get enough folic acid? Well, the U.S. Centers for Disease Control and Prevention recommend that all women of child-bearing age and especially those who are planning a pregnancy, consume again about 400 micrograms or 0.4 milligrams of folic acid everyday. Adequate folic acid intake is very important one month before conception and at least three months afterward to potentially reduce the risk of having a fetus with a neural tube defect.

0:54:10

So how can you make sure you're getting enough of it? Well, in 1998, the Food and Drug Administration mandated that folic acid be added to enriched grain products. So you can boost your intake by looking for breakfast cereals, breads, pastas and rice containing 100% of the recommended daily folic acid allowance. It should be there on the label. But for most women eating fortified foods isn't going to be enough. To reach the recommended daily level, probably need a vitamin supplement.

During pregnancy, you require more of all of the essential nutrients compared to before you became pregnant. Although prenatal vitamins shouldn't replace a well-balanced diet, taking them can give your body and therefore, your baby an added boost to vitamins and minerals.

Some healthcare providers even recommend taking a folic acid supplement in addition to their regular prenatal vitamin. Talk to your doctor about your daily folic acid intake and ask whether he or she recommends a prescription supplement and over-the-counter brand or both.

0:55:09

Also talk to your doctor if you've already had a pregnancy that was affected by a neural tube defect. He or she may recommend that you increase your daily intake of folic acid even before getting pregnant to lower your risk of having another occurrence.

So the bottom line is this. Well-designed research study show it is important to maximize folic acid intake before endearing the first trimester of pregnancy. So I would recommend it. But as always, ask your doctor and if your doctor happens to be French, then it sounds like you might have a little fight on your hands. But in the end, I think it's one worth having.

As always, have a nice resource for you that describes the role of folic acid during pregnancy and it comes from kidshealth.org and of course, you can find a link to that in the Show Notes at pediacast.org.

Speaking of vitamins, this comes from Tiffany of New York. Just a quick message about the show two weeks ago. Someone called in about vitamins and finding out infant for children. Okay, I have to say that was two weeks ago when she wrote this. It may have been a little longer than that.

0:56:11

One resource she might want to mention is consumerlabs.com. They evaluate brands to see if the strengths and content are as advertised on the packaging. There's a $20 per year fee but with all the crazy stuff that is found in food products lately, it's a small price to pay for peace of mind especially when a child is involved.

Well, thanks for the heads up Tiffany. So check out consumerlabs.com. I took a look at it and it did look like a nice site. They look very unbiased to me. So I think they're just an independent lab. They test the products to see what's in the product is really what it says on the packaging. And we'll put a link to that site in the Show Notes as well.

And then finally in our listener segment this week. This comes from Regine in Atlanta. Regine says, "I enjoy your show. Have finally caught up with all the episodes. Will try to leave a review on iTunes if it's not too technically challenging…. No, it's not too technically challenging at all! Please do. Leave a review on iTunes. Remember, it's my birthday present. Not my birthday, the show's birthday.

0:57:15

She says that she was trying to get to the Show Notes from episode number 2. In particular, the recommendations regarding swimmers' year, but they don't seem to be there. If I'm missing the links or you can repost somehow now that summer is upon us again, that would be fantastic. Thanks for all you do. I'm a working mom of three: eight, five and two-year-olds. So rarely have time or the memory when I visit our pediatrician to ask about the many issues that you cover.

So thanks for writing in, Regine. You're right, we did cover swimmers' year once before clear back in the episode number 2. The information is not in the Show Notes. You actually have to listen to the episode to hear the information on swimmers' year. But that episode is still in the feed. Or you can listen to it on the website simply by going to pediacast.org and look in today's Show Notes and there's a link there to… perma link to Episode Number 2 and you can stream the audio right there at your computer.

0:58:13

I did not go back and find out exactly what the time of when swimmers year was mentioned, but if someone does that and can give us the time that swimmers year starts, that discussion in Episode 2, I would be happy to add that to the Show Notes so that others can find it easily without having to listen to that entire episode.

Alright, well that wraps up our… what was that? Our listener segments. We will come back and do a research round up right after this.

[Music]

0:59:17

Kristin: Hey, Dr. Mike. This is Kristin from the Manic Mommies. Anne is on vacation this week, but I know she joins me as I say congratulations on one year of PediaCast. I know that as a mom, I really appreciate all the great information that I have found to your show and I hope you keep up the good work for many years to come. Talk to you later.

Dr. Mike Patrick: Well, thanks to everyone who wished us well on our anniversary. I did have another message from a listener, but unfortunately, the audio system failed us miserably. The message is accompanied by a high-pitched squeal that is something like fingers on a chalk board and it's resistant to all forms of sounds scrubbing attempts. So I couldn't put it on because if you're driving a car and listening to this, it would have not been good.

I couldn't make out the name of the caller because of the noise, but I did hear the well wishes on making it to one year of shows. Even though I have to grit my teeth as I listen. But whoever it was that called in, you know who you are and I do appreciate the call.

1:00:19

Alright, moving right along to our research round up brought to you in conjunction with research partner, Devon Technologies, creator of robust information retrieval software for the Macintosh platform and you can visit them online at devon/technologies.com.

Evaluating deliberation in pediatric primary care. What is this all about. Well, this comes from the University of Wisconsin in Madison and the author start with the assumption that patient and parent decision-making can improve healthcare outcomes and satisfaction.

That said, the authors wanted to quantify the characteristics of clinical decision-making in the examination room. So what they did is they studied 15 doctors. Altogether, they looked at 101 office visits that were captured on video.

1:01:08

And then the went back through, looked at all these videos and measured the following components of each visit. They measured the number of different treatment plans that were proposed; how long the doctor talk about the different treatment options; number three, parent and/or child involvement in the deliberation and then was that involvement active meaning that the parent or child proposed the plan of their own or disagreed with the doctor's plan or was that involvement passive because the physician alone proposed the plans and the parent or child just goes along with it.

Now when you look at all the numbers, the mean number of plans proposed was 4.1. So that means that… so the mean number, there were few that were more, there were few that were less but the mean right in the middle number was 4, close to 4 different plans that were presented.

1:02:05

Now that surprises me a little bit. That seems like a lot. Usually or maybe it's just because of the way that I practice, but you know, the doctor is saying okay, we could do this or we could do this or we could do this or we could do this. That seems like a lot of plans.

But you could argue to these doctors. They all knew they were being video-taped and they knew what the study is about so maybe they were offering more plans than they would if the camera hadn't been there. But it's difficult to do a blind study for this sort of thing because if you're taping someone, you have to have permission to tape them. You can't hide a video camera. I mean it can be behind one-way glass, but still, there are ethical issues to consider.

The deliberation in time averaged 2.9 minutes. So now, we've got these four options. We could do this, this, this or this and here they all are in three minutes. [laughter] That seems a little crazy to me.

1:03:05

Passive involvement occurred 65% of the time, they said you tell me what to do doctor and I'll do it. 35% of the time, the patient or child came out with their own plan or disagreed with the doctor. More plans were presented in visits with girls. If boys were there, less plans were presented. And as parent education level increase, deliberation time decreased. So the more educated the parent, the less time the doctor spent going through the different plans.

A longer visits were associated with more plans proposed, longer deliberation and increased chance for active parental involvement. So the conclusion of the authors of this study were that physicians often present multiple plans to patient, but the majority of parents and patients remain passive during these deliberations. And they conclude that doctors should take more time, more plans, longer deliberations and increase the chance for active parental involvement.

1:04:09

Now my take on this is first, if I had been doing this study, I would like to have added two more components to it. What about outcome? Did the right plan get picked? Did the plan work? Because if you have a parent arguing for a certain plan and it doesn't work, then that should counterstrike against the experience, I would think.

Number two, what about satisfaction? Did the parents go away feeling satisfied that their questions were answered and that they're doing the right thing? So these authors started with the assumption that increased options and deliberations increases outcome and satisfaction results, but it would have been nice to see if these observations really held true for the study. I mean if you increased all these things, were there better outcome and was there better satisfaction, we still don't really know that.

1:05:00

Often in medicine, of course, there is more than one way to get from point A to point B. I mean doctors are always deliberating in their mind and some parents want choice and that's great. But some parents look at this behavior as being wishy-washy and they're going to switch doctors if you do it too much. And some parents just don't care. Just tell me what to do and get me out the door.

So there's different styles and I think, this is my personal opinion, I don't have research to back this up, a person who wants choice in explanation will gravitate toward a doctor who provides that and the person who wants a physician control, they just want the doctor to say this is what's wrong, this is what we need to do. They're going to gravitate to a doctor who provides that kind of experience.

So this study did not really take physician style into account nor it did it take parent or patient preference for physician style into account. So an important take-home message here as time passes in the physician-patient relationship, you get a feel for who wants control and who wants choice. And in my opinion, the best outcome in satisfaction is going to occur when styles match up. So no, I don't have a study to back that up, but I think it'd be an interesting sort of one to do.

1:06:11

Okay, moving on to a research study number two. This comes from the Children's Hospital of Pittsburgh and was studied in The Journal Pediatrics July 2005. Unexpected increase in mortality or death associated with implementation of a computerized order entry system.

So do computerized physician order entry system present a barrier to quality healthcare? So what is this? What are we talking about here? Well, sort of the old way of doing things as there was a chart, when the doctor wanted something done, they would write in order by hand in the order section of the chart. The nurses would take the order, get the medicine, do whatever needed to be done.

Well, the newer way to do this is with computerized physician order entry where instead of going to a chart, the doctor goes to a computer, clicks on some things and basically does the ordering through the computer system.

1:07:08

Now, advantages to this are that with the computer, what you want done is legible, so you can look at the screen and see exactly what the doctor put there as long as they clicked the right buttons, whereas in the chart, the writing might be illegible and that could cause medication errors if the order was misinterpreted. So with this computerized physician entry system, there's supposed to be a decreased risk of medication errors.

So what they did with the study was an 18-month study period between October 2001 and March 2003. And the study period included 13 months of data prior to a hospital-wide computerized physician order entry system and then for five months after the implementation.

Now right here, I have to stop. It seems kind of silly. You know why not do 12 months before and 12 months after to avoid seasonal bias? Because I mean with the same… I mean different seasons especially in pediatrics when you have RSV and rotavirus seasons so I mean some kids are sicker at certain points of the year.

1:08:14

So you think you would want all of the seasons before the implementation and all of them after. So to do 13 months before and 5 months after, sounds like someone was pressured to get this out. Maybe it was a resident who is doing the study and they are going to be graduating or something like that, but I don't know that for sure but it seems like that's kind of a bad set-up to begin with.

Now altogether, they looked at 1,942 admissions. 1,394 before implementation of this computerized systems and 548 afterward. Now of these, 57% or just over a thousand were admitted to the intensive care unit and all of these patients they looked at, 75 children died. So 3.9% resulted in death of the child.

1:09:04

Now each child was assigned a standardized risk of death score based on their presenting diagnosis and their initial work-up. So they looked at what was wrong with these kids, what they were coming in for, what their labs or x-rays looked like and then they… there was a standardized test that they could put in the information to give them a risk of death score.

Now the risk of death scores in the admitting diagnosis categories was similar for both groups. So they basically picked cases or groups of cases that seemed similar. Okay, so what were the results? Well, the death rate prior to implementation of this computerized physician order entry system was 2.8%. So all the kids they looked at, 2.8% of them resulted in death.

Death after the implementation of this system was 6.6%, so it went from 2.8% to 6.6%. So that's a substantial increase in the death rate after this physician order entry system. Now does that mean that this is what caused in increased number of deaths?

1:10:13

No. Because there's so many factors. Again, time of year, maybe afterward, it was a worse season of RSV or worse season of diseases that have a higher risk of death. That's possible. You have to look at were they the same people working from beginning to end? There's just so many different variables that are very difficult with this sort of study to control for. So you can't necessarily say that's what it was.

Now the authors did note, however, that the following problems were associated with their particular computerized physician order entry system which makes you think, well, this did have something to do with it.

Here's what the problems they noted. There was an inability to preregister critically ill patients so that medications could be immediately available when the patient arrived and critical test could be pre-ordered and scheduled. So they had a way for that to go to the computer system instead of having everything ready.

1:11:11

A routine medication order required an average of 10 clicks to identify the medication, the route, the dose, the interval and confirmation of all the information. Physicians and nurses were locked out of the system while the pharmacist process an order, delaying additional order input and communication bandwidth for wireless devices sometimes exceeded capacity and the computer screen would then appear frozen, creating additional delays in order entry.

The computer physician order entry system had some automatic stopped orders for medications including antibiotics which were enacted without physician notification. So the doctor ordered the antibiotic, the system would say, oh, that doesn't seem right. We'll just stop it and then how would the doctor know there was a problem.

They system used did not have any ICU or intensive care units specific order sets before implementation and the entire hospital went online in just six days. The global effect on the pharmacy and the intensive care unit interface after implementation of this system was that delays in administration of critical antibiotics and emergency medications occurred in greater than 50% of patients.

1:12:26

The authors conclude that although computerized physician order entry holds great promise as a tool to improve care by reducing human errors during healthcare delivery, the areas with time-sensitive processes like intensive care units who require careful integration and skillful human machine interfaces to prevent unintended care delays and bad outcomes.

And my point with this is doctors with clinical experience, especially in high-risk care areas such as the emergency department, intensive care units and the operating room must be involved with development of these systems from the very beginning of the program design. Now the software companies don't want to pay the high cost of physician consultation, but imperfect systems that put lives at risk is just not acceptable.

1:13:17

Okay, and finally in our research segment, urinary tract infections not prevented by antibiotic use. What's this all about? Well, after your first childhood urinary tract infection, daily antibiotics and those of you with children who had had first-time urinary tract infection as a young child know exactly what I'm talking about with daily antibiotic use after that.

But that daily antibiotic use may not prevent another such infection and may actually increase the risk that the next urinary tract infection is caused by resistant bacteria according to a new study in July 11 issue of the Journal of the American Medical Association.

And the first large study of children diagnosed with urinary tract infection in a primary care pediatric setting, researchers from the Children's Hospital of Philadelphia reviewed the electronic health records nearly 75,000 children with at least two clinical visits in the Children's Hospital of Philadelphia pediatric healthcare network between July 2001 and May of 2006.

1:14:18

The researchers found that 611 children had a first urinary tract infection and 83 had a recurrent UTI. Children between ages three and five, Caucasians and those with severe bladder kidney reflux has the highest risk of recurrent UTI. Receiving a daily dose of preventative antibiotics was not associated with a lower risk of recurrent urinary tract infection.

The majority of children with first urinary tract infection were female, Caucasian and two to six years old. Most did not have an imaging study performed and did not receive daily antibiotics to prevent infections, said Dr. Patrick Conway, primary investigator of the study.

We found that daily antibiotic treatment was not associated with a decreased risk of recurrent urinary tract infections, but was associated with an increased risk of resistant infections.

1:15:11

Currently at Cincinnati Children's Hospital Medical Center, Dr. Conway conducted the research while at the Children's Hospital of Philadelphia and while he was a Robert Wood Johnson clinical scholar at the University of Pennsylvania. More definitive studies such as clinical trials are needed to look at this issue, said Dr. Ron Keren, a general pediatrician at the Children's Hospital of Philadelphia and senior author of the study.

But given these findings, it is appropriate for pediatricians to discuss with families the risk and unclear benefit of daily preventative antibiotic treatment after a child has had a first urinary tract infection. UTIs are common in children. In fact, of all children born in one year, 70,000 to 180,000 will have a UTI by age six.

The American Academy of Pediatrics practice guidelines for management of children after first UTI, recommends an imaging study to evaluate the presence and degree of bladder kidney reflux, a condition found in approximately in 30% to 40% of children who have had the urinary tract infection.

1:16:15

If the child has bladder kidney reflux, daily antibiotic treatment is still recommended by the American Academy of Pediatrics practice guidelines in an attempt to prevent recurrent UTIs. Kidney bladder reflux occurs when urine in the bladders flows back into the ureters toward the kidneys during urination. So it goes the wrong way.

It is thought that a child who has this type of reflux is at risk for developing recurrent kidney infections, which over time can cause damage to the kidneys. However, Dr. Conway summarized the majority of children have low-grade reflux and this low-grade reflux was not associated with an increased risk of recurrent UTI in the study. So what's a doctor to do with this information? I mean me and the exam room, oh, what do I do with this?

1:17:02

You've got the American Academy of Pediatrics practice guidelines which have not changed at all yet, basically says if you have a young baby who has urinary tract infection for the first time, you do these studies to see if they have reflux of urine back up toward the kidneys when they urinate. And if they do have that, then you put them on a daily antibiotic to prevent recurrent infection and then you reevaluate them in maybe six months later to see if that reflux is still there and you leave them on the antibiotic everyday as a prophylaxis until you restudy him.

And again, that may sound crazy to some of you like a put a kid on an antibiotic everyday for six months, what about resistant bacteria, but that is the standard of care still according to the American Academy of Pediatrics practice guidelines. And any parent out there who has dealt with this knows that they probably had their child on a daily antibiotic. Now this study is basically saying that maybe we should think about that and not do that.

1:18:05

So when does a doctor change his practice? Again, we talked about this a couple of weeks ago. It's a tough decision because on the one hand, you're upholding the direction of what is the standard of care, that's what the lawyers are going to hold you up to, and then the newer research that comes along that may be a very good research. You want to do the right thing. So you're pulled in that direction.

You know, what would I do? I think I would follow the current clinical AAP guidelines and yeah, I'm more of a conservative guy though and I think would air, at least on the side of getting the study done, and talking the parents about risk versus benefits. And if it were my kid, I'd probably put him on a daily antibiotic. At least for now, until there are more clinical trials on that.

But you see, practicing medicine is not always black and white. There's definitely lots of gray areas. Alright, we are going to wrap up this episode because we are running way over, but you know, it's the show's birthday. We're allowed to go over on that day, right? [laughter]
1:19:05

Alright. We'll be back with our outro in just a few seconds. And then we'll have a special song for you at the very end, so you want to stick around for that.

[Music]

Once again, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, what do you do? Call your doctor and arrange a face-to-face interview and hands-on physical examination.

1:20:11

Also, your use of this audio program is subject to the PediaCast Terms of Use agreement which you can find at pediacast.org. PediaCast is licensed under an attribution non-commercial, no derivative works creative commons license. And for more information on this copyright license, please visit pediacast.org and click on the Creative Commons Link at the bottom of the page. If you're interested in using PediaCast material for a commercial project, please email pediacast@gmail.com for details.

Thanks go out to news partner, Medical News Today, research partner Devon Technologies and this week's sponsor, Mariner Software. Website and feed artwork are brought to you by Vladstudio. Be sure to visit Vlad's website at vladstudio.com and of course, we have a link to that in the side bar of the website at pediacast.org. You know, you really just as beautiful artwork and it's great for nurseries and the children's rooms and that his prints are available at his website for ordering.

1:21:10

Of course also, thanks to all the loyal listeners out there by subscribing, listening and contributing to PediaCast week after week. You are the ones who keep this project going and of course, thanks to my family, Karen, Katy and Nick. Thanks for the time, thanks for the love and thanks for your never-ending support.

Reminders, if there's a topic that you would like us to discuss or if you are a healthcare professional and would like to contribute to the program by doing an interview, let us know. Just go to pediacast.org, click on the Contact link or email pediacast@gmail.com or call the voice line at (347) 404-KIDS.

Promotional materials are available on the poster page of the website. The PediaCast Shop is open for t-shirts. And iTunes reviews again, we have 80 right now and if we could get a hundred for my show's birthday present, that would be awesome. I mean you guys, would really rock if you could give me 20 reviews in the next week. So please, if you've not done that, please do so.

1:22:13

Also be sure to dig us at digg.com. That's easy to do. And then the Third Annual Podcast Awards will be coming up here soon and there's a link to those in the side bar. Speaking of awards, congratulations goes out to my lovely wife, Karen. She actually has won three awards for the PediaScribe here recently. She won the Bloggy Husk Class Clown Award. You have to read some of her post to understand why. She's also a Rockin' Girl Blogger and she won a Blogging Community Involvement Award.

So be sure to check out the award-winning PediaScribe and if you like what you see, be sure to vote for PediaScribe in the Bloggers Choice Awards and we make it easy for you. Simply click on the link in the blog's side bar. You can find pediascribe.com at pediascribe… I'm sorry, what am I talking about?

1:23:04

You could find PediaScribe, Karen's blog, at pediascribe.org or go to pediacast.org and click on the side bar link.

Okay, we started this last week and we are going to continue it. This week's feature music is brought to you by IODA Promonet. It's from Re-Bop Records and if you like the song, there's a link to download it absolutely free for your personal use as a DRM-free mp3 file that you can download right in our Show Notes. And if you really like the music and would like to support the artist by purchasing the entire album, there are links for that as well in the Show Notes.

So the artist in this case is the Re-Bops, the album is Funny '50s and Silly '60s and the track is itsy bitsy teeny weeny yellow polka dot bikini. Okay, I know it. It's not the most politically correct song out there, but come on, it's fun! The rest of the album is great too with a Purple People Eater and Wooly Bully and Witch Doctor so be sure to check it out.

1:24:07

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

[Music]

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