Ear infections, Hip Dysplasia, Kyphosis – PediaCast 097

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Topics

  • Ear Infections
  • Developmental Hip Dysplasia
  • Kyphosis
  • Pyloric Stenosis
  • TV Exposure

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Transcription

Announcer: This is PediaCast.

Dr. Mike Patrick: Bandwidth for PediaCast is provided by Nationwide Children's Hospital, for every
child, for every reason.

[Music]

Announcer: Welcome to PediaCast, a pediatric podcast for parents, the listener edition. And
now, direct from Birdhouse studios, here's your host, Dr. Mike.

Dr. Mike Patrick: Hello everyone and welcome to PediaCast, it is episode 97 for Saturday, December
21, 2007. Yes, you heard me right; we're doing a Saturday show. Never done that before, I don't
think I've ever released a show on the weekend, but I didn't quite have my act together enough to
get it out on Friday's, so rather than wait till next week with Christmas craziness on its way, I still
wanted to get this out, so we're doing a Saturday show.

01:01

It's a listener edition; we're going to talk about developmental hip dysplasia, kyphosis of the
spine, also pyloric stenosis among other things. I think this is probably going to be our last show
for 2007. We got the big Christmas week show here for you, it's a full one, we got lots of stuff to
talk about. But you guys are all going to be busy with your families, and the holidays, so I figure
we have one show out. You'll get around to listening to it sometime during the week.
But I don't want to overwhelm you with PediaCast. We'll probably be back very soon after the New Year in 2008, which means that I still need about 20 more reviews in iTunes, and time is running out, so please help me.

02:00

I really wanted to get the 200 reviews by the New Year. You know I've been talking this up for the
last month, and I am so close, but it's going to be tough. I don't know 20 reviews between now
and the first of the year. If you're listening to this and you're on your computer, and iTunes is
available, look and see how many we have. If you have not left a review yet, and we have not yet
reached 200, I would encourage you to 'please' think about doing that for us.

I know, this gets old, I fell like a minister asking for money, like, "Did you give your 10%?" But all
I'm asking for is a review, it'll take two or three minutes to your time, and that's it, and I promise,
once we hit 200, I won't mention it again for a very long time, I promise you that. OK, so what are
we going to talk about today?

Well I mentioned three of the topics, we're also going to discuss ear infections, actually it's going
to be first up, and then we're also have a listener who had a comment about TV exposure, and I
have a question about when I had talked about it in the past, and we'll give you some links to that.
So that is all coming up.

3:06

Don't forget, if there's any topic that you would like us to discuss on PediaCast, it's really easy to
get a hold of us, just go to pediacast.org, that's our home base, and click the contact link. You
can also email pediacast@gmail.com, if you go there; make sure you let us know where you're
from. And of course the voice line is open, 347404-KIDS.

And actually we have a voice question today, and I have two more that just came in today, but I
didn't have a chance to incorporate them under the show. Those would probably get answered
very, very soon after the New Year when we come back and do episode number 98 for you.
Don't forget the information presented in PediaCast is for general educational purposes only; we do not diagnose medical conditions or formulate treatment plans for specific individuals.

If you have a concern about your child's health, call your doctor and arrange a face to face interview and hands on physical examination.

04:02

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 will be back with your comments and
questions right after this short break.

[Music]

Shannon: Hi Dr. Mike, this is Shannon from Uniontown, Pennsylvania, mother of a one year old,
Maddox.

05:00

He is a wonderful, healthy baby except for his ears. He has been suffering with an ear infection
now. For about the last month and a half, he was on three different rounds of antibiotics. Since last round his pediatrician did say, "If this didn't work, we might have to move on to a twice daily, like intravenous, like a shot vaccine, or a shot antibiotic, just trying to nip it in the bud," but it
seems like he had some kind of super bug that it wasn't really getting rid of it with normal
antibiotics.

We did go back and got a good report that the pus and the infected fluid was no longer there,
but he did still has fluid in his ears and he just wanted to monitor it over the next month or so since he's been so prone to this infection for the last six weeks or so.

So my question really is when is time to move on to like an ear, nose, throat specialist where we
don't want more intervention than necessary, tubes, things like that if it's not something that's
necessary for my son, but I was curious on when should you should seek a specialist out, or other opinions on care. Thank you so much for all your information and again we love the podcast.

Bye.

06:19

Dr. Mike Patrick: All right, well thank you Shannon, again, from Uniontown, Pennsylvania. Let me just
sum this up very quickly. So we basically have a one year old who's been healthy except for their
ears, and they've had an ear infection pretty much constantly for the last six weeks, they've gone
three rounds of antibiotics, and Shannon is worried this might be a super bug, but with the last
round of antibiotic, he's finely a little bit better, but there's still a bit of fluid behind the ear drums,
and the pediatrician just wants to watch it for right now.

And Shannon wants to know, when is it time to move on to an ENT or ear, nose, and throat
specialist, and when is it time to get a second opinion?

06:57

Well, let me first say that this is definitely a typical scenario that I see very often, and Shannon, I'm sure your pediatrician sees this very often as well. And keep in mind this is not necessarily a
super bug that it doesn't mean that the organism is resistant to all the antibiotics that you've been
using. It could be that the conditions are just right for re-infections.
It's a viral season right now, kids have runny nose and coughs and congestion. Just to talk a little
bit about the anatomy, so you can understand why you get this ear infections and why they can
persist. Remember there's the Eustachian tube, which is a tube that connects the back of the
throat to the middle ear space, and in some kids this Eustachian tube is short, wide, and floppy,
and it's easy for mouth bacteria to get up to Eustachian tube and into the middle ear space. Now the Eustachian tube is lined with these little cells that have hairs sticking out of them.

08:00

And those hairs served to sweep bacteria back down to the mouth so that they stay where they
supposed to be. But when you have a viral infection, that the virus infects those hair cells, they
don't work right, so it's easy for mouth bacteria, just regular mouth bacteria that we all have. It's a
little bit easier for the bacteria to get up the Eustachian tube because those hair cells aren't
working right.

Now if you get more bacteria up into the middle ear space and you have a kid who has a floppy
Eustachian tube, it's kind of wide, it's short, it's easy for the bacteria to get up there, because
those hair cells aren't working right, and then you add to the mixed mucus that blocks the tube or
when the tube flops on itself and sort of collapses.

The mucus sticks it all together, so now what you have is any bacteria that had gone up into the
middle ear space, gets trapped there and can't get back down to the mouth. So the bacteria
stays there, reproduces, it overwhelms the middle ear space, and the body says, "uhuh, you're
not supposed to have this bacteria here", and sends in white blood cells to mop them up, and
then you get inflammation, puss infection , and that's how you get an ear infection.

09:07

It could be that the antibiotic is working; it's just that as soon as you are done with the antibiotic,
the kids got another cold, you got more mucus, those hair cells still not working right, and you just
get a whole new ear infection all over again in rapid sequence. Just because the antibiotic is not working, does not necessarily mean that it's a super bug.

Also there's this concept that we talked about once before on PediaCast, where we think that you can get a membrane of infection inside the middle ear space with this bacteria and the antibiotic
just does not penetrate that very well, and so that maybe another reason why antibiotics don't
work and yet it's not necessarily a super bug so to speak. One of the things that you talked about is what about just watching it when there is a clear fluid behind the ear drum that's not really an
infection anymore.

10:02

The current thinking on that is just to watch it. Used to be ten years ago when I was training that
we would put kids on daily antibiotics to try to keep this fluid from getting re-infected or put them
on an antihistamine type medicine to try to, quote 'dry up the fluid'. Those things just don't work
very well and the current thinking now is just to watch it especially if they don't have any symptoms
with it, and what if they have hearing problem because of this fluid.
There've been several studies that show that there's no long term speech issues related to
having fluid back in the middle ear space over long period of times, this is all pretty much far for
the course and the scenario that you describe sounds just like what any of us in our practice
would do as well. So when do you get a second opinion about all this? Well, the first thing I
would do is express your concern to your doctor and hopefully they'll be able to give you an
answer like I just gave you to try to explain why it keeps coming back? Why we do what we do?
Where we go from here?

11:06

And if you're satisfied with that explanation, great! And if you're not satisfied with it, then it's time
to get a second opinion. But I would get that second opinion from another pediatrician, maybe
even someone in the same practice, because if you get the second opinion from the ENT doctor, they're much more likely to say "yeah, let's put the ear tubes in".

I mean, it's one of those things; you call a plumber he's going to do plumbing. You go to an ENT
doctor who's a surgeon, they're going to do surgery, and if you go to them, and that you've
already seen your doctor, I think the ENT doctor's just going to assume that medical
management has failed and that's why you're there. But us pediatrician, or should I say, 'we'
pediatricians can pick antibiotics, I think better than ENT doctors can. I mean we see what is
working in the community, what's not working in the community, because again, we all share this
same mouth bacteria, I know it's gross to think about, but it's true, and so when we see a specific antibiotic in our particular community is working, then we know to use that one.

12:11

Then we'll get into spell where, this one's not working and another one is, and we can see trends
like that, and we see many more kids with ear infections than ENT doctors see. If I send a kid to
an ENT doctor, they're going to do surgery 98.9% of the time. If you go and see an ENT doctor
and you tell them that your doctor's already done some antibiotics, they're going to assume that
you're there for tubes.

Now if you're an ENT doctor out there listening to this and I'm wrong about that, please let me
know. Now there are some other situations in which I would refer to see an ENT doctor. Usually
for me, you get to four or five antibiotics and it's still an acute ear infection, it's probably time for
ear tubes.

13:02

And that's four or five antibiotics, 'bang, bang, bang, bang!' in succession. If you have a kid who
has an ear infection, then two or three months later they get another one, two or three months
later they get another one, I'm not so quick to put those tubes in those kid's ears. That's just me;
we all do things a little bit differently. But remember there are other reasons to go see an ENT
doctors.

For instance, if we looks like there's something called cholesteatoma, which is a type of tumour
inside the middle ear space, or there's a large perforation in the ear drum, or if your child already
has ear tubes in, and there's chronic drainage and we can't get that to stop, then these are all
other reasons for us to send our kids to go see an ENT doctor. But ear infections in the end are
primarily a medical issue and as long as it remains a medical issue, I would trust your
pediatrician, if you want a second opinion; I'd get it from another pediatrician.

14:00

And the ENT doctors are reserved when we think medical management has been exhausted,
and if it hasn't been, the ENT doctor sees that it hasn't been, the first thing really, I want to know
is, why'd your doctor sends you to me? I'm the surgeon in this case. That's just my opinion which is what you asked. All right, our next question, actually I got a couple celebrities who wrote in. At
least there's a celebrity in the podcasting world, and as it turns out, they asked a similar question
about hip dysplasia, so let's go to the questions here, and then we'll get to the discussion.

The first one is from Marie in Omaha, Nebraska, and Marie says, "Hi Dr. Mike, I'm Marie from the Chit Chat Moms podcast, and I've been listening to your show for quite a long time. I really like
the new 30 minute format, thank you for switching. I wanted to ask you a question about a
condition my daughter had when she was born that I don't recall hearing about on your show."

15:00

"My daughter was diagnosed with hip dysplasia in both of her hips at birth. We had treated her
using a pavlik harness that she had to wear for about three months, followed by close monitoring
until she is five years old, she'll be three in March. So far all the well-checks have been good, she was walking at ten months, both legs are the same length. But my question is the pediatric orthopedics specialist wanted ultrasounds of her pelvis every few weeks initially
until her bones were hardened enough to do the x-rays.

We did our first set of x-rays when she was about nine months old after she had been out of the
harness for six months. Her measurements checked out just fine and the specialist wanted x-
rays every three to six months until she turn five. This was kind of alarming to me, because I was
uncomfortable having x-rays done directly to her pelvic area if they aren't absolutely necessary.
It's my understanding that once the hip's socket closes back around the leg bone, then it won't
reverse. I felt the request for that many x-ray was a bit on the excessive side, and I don't want it to adversely affect her reproductive organs or other parts of her body that may be damaged due to
x-ray….

16:05

"After talking to our pediatrician about obtaining a second opinion, she felt that my daughter's
case, we can just monitor her walking and check her hips for looseness at her regular well check
-ups at one-year intervals and not need to do the x-rays every six months. Have you ever
treated hip dysplasia? And what has been your experience with early treatment and long term
development?

Sorry I know this may be a bit rambling, but I thought that maybe a good topic to discuss on your
show even if you don't address my specific situation. Thank you for your podcast; it's a wonderful asset to the podesphere."

That again is Marie from The Chit Chat Moms, and we'll have a link
over to their podcast in the show notes.

And then we also heard from Patty in San Diego, California, and Patty says, "Hi Dr. Mike, I'm Patty, from the Pregtastic podcast. I love your show, I'm wondering if you could talk a little bit about babies with hip dysplasia and typical treatments for the most severe cases of that.

17:01

We have two hip babies who both have bilateral hip dysplasia, and went through all the options
for treatment including wearing the dreadful Spica cast for 12 weeks each. One is still in her
rhino brace for nights and naps at 16 months. I would like the public to hear more about hip
dysplasia to educate them in why kids maybe in a Spica cast, and no, we did not break their
legs. Or with the straps and Velcro on a pavlik harness is actually for when they see a baby in
one.

And also, to make aware the symptoms of an infant or toddler with hip dysplasia. Happy
holidays to you and your family." And that's from Patty from Pregtastic, and we'll have a link over
to that podcast in our show notes as well. So let's talk a little bit about developmental hip
dysplasia. This is a term that we use to describe really a spectrum of conditions which the
femoral head to the head of the femur has an abnormal relationship with the acetabulum.

18:00

Now the acetabulum is part of the hip, and, the hip is a ball and socket joint, so when we talk
about the head of the femur, that's the ball, now we talk about the acetabulum that's like the cup
or the socket in the hip and this is where the hip comes together. Now inside mom, when babies
are developing, the femoral head, so the ball part of this ball and socket joint actually grows at a
faster rate than the acetabulum or the socket part, which is part of the hip bone.
Keep in mind; these structures are still mostly cartilage at the time of birth. They haven't actually
turned in to bone yet, and as it turns out, that by the time babies are born, the femoral head, the
ball part is only about 50% covered by the socket, or the cup, the acetabulum which is part of the
hip bone. So it's only in about 50%, eventually it's covered most of the way.

19:01

So, in the weeks following birth, the acetabulum, or the cup part, the socket part, starts to grow
faster, it deepens and eventually it covers much, much more of the ball part or the femoral head,
the head of the femur, the big bone on the thigh. Now, what happens in the developmental hip
dysplasia is that the femoral head grows at an even faster rate or the acetabulum grows at a
slower rate or combination of these factors so that in the end less than 50% of the femoral head
is covered by the socket.

The Ball part of the joint, less than 50% of it is covered by the socket part and basically less
coverage means that the ball just isn't deep enough in the socket to be stable. And so what
happens is then, when the doctor does the examination of the hips, you feel a little click, a little bit of a laxity or in more severe cases a clunk as we call it or even dislocation of the hips if it's really
severe.

20:10

Now, how often this is happen? Well, it's seen in some degree of seriousness from the very mild
to the very severe in about 1 in 100 birth. So this is fairly common, and 20% in kids, it's bilateral,
so it affects both sides. In 80%, it only affects one side, and when it only affects one side, the left
hip is three times more likely to be involved than the right hip.

Risk factor for this is being a girl. So it's 45 times more common in girl babies, compared to boy babies, if your baby is breech, then it's seven times more likely to have developmental hip
dysplasia. And we think this is because of decreased mobility of the hips when the baby is
developing.

21:00

So if they kind of crunched up, and breech presentation remember is when the legs are facing
down instead of the head and they can't move around as well because the bigger part of the
uterus is up toward the top, and so if their feet are down on the smaller area, then their legs aren't
moving as much, and so a decrease fetal mobility is another risk factor. Breech presentation
would be one of those, but there are other things that can cause the baby not to be able to move
as much including if the baby is large for gestational age, which you see with moms with
diabetes during pregnancy.

Also if there's twins, or triplets, or quads inside, the more babies, the less room, they can't move
as easily. And also, a condition we call oligohydramnios which is just a decrease in the amount
of amniotic fluid, so it's hard for the baby to move around because, then gravity's going to be
affecting them much more, and they can't just kind of float around and move easy.

22:00

And then there's also a genetic component to all of this. So family history is also involved if
there's a one baby in the family with developmental hip dysplasia, subsequent babies, there's a
little bit more of a risk that they could have it as well. So when do doctors look for this? Well
definitely during the new born exam, at the two weeks exam, the two month exam, the four month
exam, the sixth month exam.

Basically any time we see a baby who's under six to nine months or so. By that time if their hips
continue to be stable, it's unlikely that something is going to develop. But it can develop after the
two week exam, so it is important to keep checking that. There's a specific manoeuvres that we
perform on the hips, and they basically have the name of the man who develop or fought of these
manoeuvres to try to screen for a developmental hip dysplasia.

And they have names like the Ortolani, and the Barlow, the Coleman. These are all just little
manoeuvres that doctors do with the hips, so we're just filling for hip instabilities, or filling a click,
a clunk, or a frank dislocation, which is lot less common.

23:08

Now I would explain to you how to do them, but I'm not allowed, because it's actually a trade
secret. It'd be like someone from Coca-Cola giving you the recipe for the soft drink, or magician
explaining their tricks. I can't tell you because otherwise you might try it at home and next thing
you know I'd be out of a job. Because it's too hard to explain, and really, there's no reason for you to need to know, if you want to know, go to medical school. Now there are other things that can cause, especially the subtle clicks.

One of the more common things is just sort of soft ligaments in the hip joints, the ball of the femur may be appropriately covered by the socket but the ligaments that surround the hip are a little bit loose, and that can cause a little bit of a click that is normal. And this is actually interesting; often it's caused by hormones.

24:01

If you think about it, one of the effects of estrogen is to loosen the hips to make child birth easier,
if you think of it from a functional stand point. When mom's pregnant, the estrogen that she's
making loosens her hips up, and that helps with child birth. Well this estrogen crosses the
placenta, it goes into the baby's body and that can loosen the baby's hips up as well, and so this
is one of the reasons why we might feel a little bit of a hip click that ends up not being a true
developmental hip dysplasia, so this is something that we think about.

Generally the way that I do it if I feel a subtle click in a baby, in the first couple of weeks will
recheck it in a couple of weeks and if that hip click is still there, then we get the ultrasound to look at how much of the femoral head is covered by the acetabulum or the socket. And in my
experience, what I find is that if I feel a hip click at two weeks about half of those are gone in a
couple of weeks and we can sort of explain that away is being the estrogen affecting the joint,
making it little bit laxed.

25:04

And then about half of them still have the click there and we get the ultra sound. We do the ultra
sound instead of x-ray because, again, the bones that are involved here are still mostly cartilage
at this point not bones, they don't show up on x-rays very well and that's the reason we do the ultra sound. Now of those getting the ultra sound in my personal experience, I find them about half of
those ultra sounds are normal, so they have more that 50% coverage of the ball part of the joint
with the socket.

These are still just probably estrogen effect that will resolve, then we continue to recheck them
when they come in until it does resolve. But then the remainder of those kids, the other half that
we sent for the ultra sound, they usually do have a developmental dysplasia of the hip so they
have less than 50% coverage of the ball with the socket part of the joint.

26:00

And so, those kids do get orthopedic referral. Now the kids who we fill the very first time they
have more of a clunk, it's much more obvious, or if you can dislocate their hip, that's going to be
an immediate orthopedic referral and get the ultra sound, and get things moving, just a subtle
click that we sometimes follow before we do the ultra sound or send them off. So what do you do for this? Well, it really depends on the degree of progression and some degree, the preference
of whichever orthopedic doctors treating your child, so if you have a mild case, if there's a subtle
click and the ultra sound shows that there's 40% coverage instead of 50% then the orthopedic
doctor may say, "OK, we'll just watch it."

Close observation and we'll get another ultra sound in a couple of months and just go from there. If it's a little more moderate, less than 40% coverage, then they may recommend a pavlik harness. And I'm going to have a link in the show notes for this, and it shows a picture of one so
you can see exactly what I'm talking about.

27:02

But it's the serious of straps and Velcro, and it keeps the legs flexed, so the knees are up, and it
keeps the legs 'abducted', which is the knees being apart. So basically, this harness keeps the
kid's legs in a position that the knees are up and apart. If you think about the child birth position,
it's kind of similar; the knees are up and apart. And this position keeps the femoral head and the acetabulum, so the ball and the socket in an ideal position for continued development.
The harness is used until the coverage exceeds 50% and there're no more clicks on the exam,
and this usually takes a few months. It's this have to be worn around the clock, it's used most
often during naps and at night time, because the ‘use it around the clock' would interfere with
development; we don't want to do that. As long as you get the harness started at an early enough age, it is successful.

28:01

Actually in about 95% of these mild to moderate cases. The more severe cases, and especially
those that are dislocatable, those are going to require more stringent fixing the joint in the
position that's supposed to be in. And these are the kids who are going to get the Spica casts,
so they're going to actually have casts that keep the legs in the position I just described. And
then for some of them, they're even going to need surgery with internal fixation of the hip joints in
order to keep the orientation correct and keep them from becoming dislocated while the body is
continuing to heal, and hopefully, to develop appropriately.

The severe cases are the ones who are going to get the Spica casts and possibly surgery
associated with that. Those are not all that common. In ten years of practice, I've seen a handful
of kids who need that, but we see a whole bunch of kids with hip clicks that go away without much intervention at all.

29:00

Why is this important? It's obviously important in these kids whose hips you can dislocate,
there's no question. What about these subtle ones? The issue here is that the femoral head, or
the ball part of this joint has just one blood vessel going to it, and if that blood vessel becomes
compromised, if the hip scrunches in a way that it's not supposed to, because the relationships
aren't exactly right.

And if you get decreased blood flow to the femoral head, because there's not another way for
blood to get there, part of the bone or cartilage can die, and we call that a vascular necrosis.
And that's a bad thing. It causes chronic pain, later on in life it can cause ambulation problems,
decreased hip range of motion, unsatisfactory hip function and chronic pain, and the hip is an
important joint.

30:00

You may not see those kinds of problems until kids are teenagers, or even young adults. This is
one of those things where we intervene during infancy to prevent chronic hip pain, chronic hip
range of motion issues, hip function issues later on in life, but it's important to take care of that at
an early age to avoid problems on down the road.

Because if you don't, you may end up needing artificial hip as a young adult, if it's something that
is not taken care of. In terms of follow up, usually the orthopedic doctors follow them up pretty
closely, especially if they're in the pavlik harness, or if they're in a Spica cast. But once it seems
to be resolved, there's enough coverage of the joints, the ball is in the socket well, and there's no
more click.

Usually they just have a yearly follow up with the orthopedic doctor, they usually do get x-rays of
the hips every year, and they do that through age five or six.

31:00

I would say that's the pretty much standard of care where I practice. I've not heard of kids with
resolved disease needing x-rays every three to six months, as suggested by Marie. And my
guess is, and again I can't speak for why this doctor recommends this, but of course, you should
ask him why? My guess is he was probably burned once in his life for following the rules.
The standards of care we can say is, same every year, get the x-ray; see him sooner if there's a
problem. But, if at some point in his past, a kid had recurrence of it, and then he didn't catch it
because he hadn't seen him for a year, and then they have joint problems, and then he gets sued, even though he followed what most orthopedic doctors would do in that situation.

Well, when you go through an experience like that, you become more conservative. So he's
going to say, "Hey, fine, I'm going to get x-rays every three to six months, and dog gone, I'm
going to find every single one." That's how our system works unfortunately. It sounds like, Marie,
you brought your concern to your pediatrician you guys together came up with a game plan, that's how we got to approach this.

32:02

Now I'm not going to say whether that game plan is right or wrong because that's not my job, but I think you did the right thing in talking to your pediatrician and coming up with a plan together.
And again, where I practice the standard to care would be to see him, and once it's resolved
about once a year afterward ad get the x-rays till they're about five or six years old.

OK, so thank you to Marie from Chit Chat Moms, and Patty from the Pregtastic podcast, and
again we'll have links to their shows in the show notes, and then I also have a link to information
on developmental hip dysplasia from the American Academy of Orthopedics Surgeons, and it's
in that site that they have a picture of one of this pavlik harnesses. So, if you're interested in that,
head on over the show notes at pediacast.org.

OK, moving on, this is Karen in Pataskala, Ohio, and being from around that area, you'll notice I pronounced it correctly. I think a lot of people would call it like "Pa-tas-kala," but it's "Patas-kala."
33:00

And Karen says, "Hi Dr. Mike, I just listened to an old PediaCast about scoliosis. I have a 15 month old who is diagnosed with kyphosis; I'm always worried if he bumps his back that it will hurt him. Is there anything I can do to keep the curve from getting worse, sometimes when he sits, he looked so slumped over, and then when he's standing, you can hardly notice? Could this have been caused by genetics?

Thank you for sharing your knowledge with us, Karen." Kyphosis and scoliosis, and a curvature
of the spine are what we're talking about, those are almost certainly caused by genetics and they
definitely run in families. Scoliosis is a lateral curve or a curve to the side with the spine,
kyphosis is a curve forward, so the face is looking down to the floor, so to speak, and lordosis is
a curve backwards, so the face looks up to heaven up to the Lord, lordosis, that's how I
remembered it in medical school.

34:00

Scoliosis is going to be much more common than kyphosis or lordosis, and these things are
most commonly seen in the teenage years, during periods of rapid spine growth, and when the
curve reaches a critical level as determined by x-ray, then it can start to cause functional
problems or pain, and that's when we usually refer to the pediatric orthopedic folks. Kyphosis in
infancy is unusual but it's not unheard of, that's called congenital kyphosis and it is at a pretty high risk for progression as the spine grows when you see it at a young age.

And all of these kids should be closely followed by a pediatric orthopedic doctor. Treatment
usually involved is just observation as kids get older, there's some exercises they can do the
strengthen the muscles around the spine, good posture, anti-inflammatory medications, and then
finally external bracing, and then the more severe cases are going to need surgery with
straightening with fusing abnormal segments of spine together or using internal fixation rods to
keep the spine straight as well, these are all things that the orthopedic doctors do when it
reaches a critical level.

35:11

Now Karen had asked about, she's worried that if he bumps his back, it'll hurt him. Very unlikely
that, that would happen, the bone is strong, it's just curved the wrong way, it's not anymore fragile
the bone itself, getting bumped really won't hurt it, it's just something that happens and you don't
really have to baby it, you just treat them like a normal kid unless a doctor that has seen him tells
you otherwise.

All right, if you're interested in more information on kyphosis including congenital or kyphosis in
babies which is a lot less common that it is in teenagers, I do have a link for you in the show
notes there, as well to the American Academy of Orthopedic Surgeons, and we'll have that link
in the show notes.

36:00

All right, Jen is next up from Jersey City, New Jersey, and Jen says, "When my son was five
weeks old, he had surgery to correct pyloric stenosis, I don't believe you've addressed this
before, now months later we find out our son is listed on New Jersey's special child health
registry, it's unnerving to know our child's on a list that includes some serious conditions. Is
pyloric stenosis congenital?

He didn't have it at birth, and why or why not, in your opinion should a child be registered for
pyloric stenosis? Thank you, love the show." All right well before we talk about the registered
part, let's review the disease. Like many conditions, there is a genetic component to this, so let's talk about what is pyloric stenosis. The pylorus, it's just a fancy name for the valve that connects
the end of the stomach to the beginning of the small intestine.

It's a muscular valve, and its job is to let digested food in to the small intestine and prevent that
same food from travelling back into the stomach.

37:00

So, it's basically a one way check valve to use a plumbing term, and with pyloric stenosis, what
happens is the muscle of this valve begins to thicken shortly after birth, so it is congenital, you just don't see the effect of it until they're about a month old because at about that age, and this is
more common in boys, by the way. Girls get the hip clicks, and hip dysplasia, boys get the
pyloric stenosis. Usually by the time they're about a month old, the thickness reaches a critical
level and it becomes so thick that the passage way between the stomach and the small intestine
becomes blocked, food can't get through, pressure builds up, and projectile vomiting begins.
These kids start to lose weight, they got dehydrated, basically just goes downhill from there, they
get pretty sick quickly. Also because they're vomiting stomach acid up so much, they get
electrolyte imbalances in the body, and if those become severe could lead to seizures. So what
do you do for it? Well treatment is a surgical in most parts of the world, that's the standard of
care.

38:00

A simple slit is made in the muscle and this relieves the obstruction, and then over time that little
slit that's made heals up and everything's fine. So it's a pretty simple surgery, it takes care of it.
Now in some part of the world the surgery is not standard especially where they don't have skilled surgeons to do it, so an alternative way to treat it, which is not done much in this country, but in
some parts of the world, it's done and that's the pass feeding tube through the pylorus and
provide tube feedings directly into the small intestine for couple of months.

Eventually this muscle thickening does regress and so surgery is not always needed, but you
have to deal with the couple of months of tube feedings, and at least here in America, we don't
have that kind of patience, we want the quick fix and usually surgery works pretty well. More
information on pyloric stenosis from E-Medicine, and WebMD, so check out the show notes and
we'll have a link to that, some good information on pyloric stenosis.

Now, if you have a child with pyloric stenosis and you live in New Jersey, why would you be on the special child health registry? No clue, no clue at all.

39:04

I'm sure it's the legislature that did that, probably there is some special interesting, if you're on the special child health registry, I bet you have access to some resources that other people don't have access to and someone lobbied the legislature and wanted pyloric stenosis included on there.

All the kids that I've ever, in ten years of practice that I've ever seen with pyloric stenosis ever
have the surgery, and then they're fine the rest of their lives with no complications or problems
from it. I don't know why you'd be on a special child health registry, but in New Jersey you are
and it probably is because of the government. I wouldn't worry about it, don't lose sleep over just
forget about it. All right, and we have one more to go through here.

This is from Linda in San Diego, California, and Linda says, "Hi Dr. Mike, first let me join so many others before me in thanking you for this podcast."

40:00

"I discovered it about eight months ago when I was home with a colicky new born, who pretty
much wouldn't sleep unless she was moving. During the first four months of her life, I spent
countless hours walking and driving around with her, desperately trying to get some much
needed sleep. Listening to PediaCast on my iPod really help pass the time during those weeks
and thought me a lot too, I really appreciate that you spend time piercing and at times critiquing
the studies in the news that you site instead of passing on the high level sound bite like a lot of
media do. Now that my daughter is, I'm happy to report, the world's happiest baby and a good sleeper, and I'm back at work part time. I don't have as much opportunity to listen as diligently so I hope you haven't already covered this topic.

41:00

I'm curious about TV and videos and my little one, I believe the American Academy of Pediatrics
recommends that babies under two years should not be exposed to TV at all and I've read
descriptions of a few different studies that seem to show negative effects of television. One
linking it to a higher incidence of ADD, another showing the infants who watch baby Einstein
videos had worse scores in vocabulary or language acquisition and even one that drew a link to
autism, though that seemed like a very big stretch from the description.

Not having read this studies, I don't know how to evaluate them and making the decision about
how much and when to expose my daughter to television. Don't misunderstand, I'm not eager to
expose my little one to TV at all, but I can see that if she gets a little older, it's going to be harder
to limit her exposure and I mostly curious about what the scientific evidence tells us about the real dangers or even benefits of television. I can see how enthralled other babies and toddlers are
with shows like Sesame Street, The Wiggles, Baby Einstein, Barney, etc."
42:03

"I want to know how to pick my battles on this topic, thank you in advance for any insight you can
provide and keep up the great podcast." We're going to take the easy route on this Linda, we
have had several discussions of TV and kids, and I'm going to have links to those show, there's
four of them that where we talked about it with quite a bit of substance. The first one was way
back in PediaCast number seven and we talked about TV viewing habits in school age kids.
In PediaCast number 15, we talked about TV and rainfall, being related to autism. In PediaCast
number 40, we talked about TV viewing for babies and toddlers, and here recently in PediaCast
89, we talked about TV violence and looking at it as a public health threat. So PediaCast 7, 15,
40, and 89, and if you go to the show notes at pediacast.org, we'll put links to all of those, so it's
real easy to listen.

43:07

All those topics did look at the signs and were infused with my opinion as always, so check out
the show notes for that. OK we are running way, way over, so I'm going to take a quick break and we'll come back and wrap things up right after this.

[Music]

Dr. Mike Patrick: Don't forget, if you'd like to listen live as we record PediaCast, if you go to pediacst.org click on the live link.

44:03

There are directions on how to do that. It's pretty easy, it's free, all the tools you need and
directions are right there on the live page at pediacast.org. When do we do it? Usually between
seven and eight o clock hour, Eastern Time, during the week, in fact it is 7:18 pm Eastern
Standard Time as we speak on a Friday, so there you have it, right in the target zone. I'd like to
thank Nationwide Children's Hospital for providing the bandwidth for this show, also to Vlad over vladstudio.com for providing the artwork, and of course thank you to all of you for joining us and
being a part of this show, sending in your questions, your comments, and all of those things.
If you've send in a question or comment, or call the voice line and we haven't got in to you, I do
have a backlog of questions. I try to get a good variety of things, so don't be offended if we don't
get to your question, I get to as many as I can, they're just isn't enough time in a day to get to all of them.

44:58

Don't forget iTunes reviews, trying to get 200 folks by the end of the year, don't know if I'm going
to make it, need 20 more, so if you haven't done that, please do. We also have poster page, you can print out posters and hang up at doctors' offices, bulletin boards, churches, nurseries, all
those kind of things, so check that out. Also the PediaCast shop is available; it's in the side bar
at the website at pediacast.org.

OK so this will be the last show of 2007, so I'll better say Merry Christmas, Happy Holidays,
regardless of your religious persuasion. I hope everyone has a great time with their family, and
of course Happy New Year, be safe, all those things. I'm just sending you my love folks. So, until
next time which will be in 2008, this is Dr. Mike saying "stay safe, stay healthy, and stay involved
with your kids,… so long everybody.

[Music]

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