Fetal Pain and Abortion Policy – PediaCast 110

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Topics

• Fetal Pain and Abortion Policy
• Spinal Muscular Atrophy (SMA)
• Glue Ear
• Contagious!

Links

• New York Times Magazine Examines Views About Fetal Pain, Effects On Abortion Policy
• National Partnership For Women And Families
• Technique Discovered For Repairing Gene Defect That Causes Spinal Muscular Atrophy
• PediaScribe: Mushrooms and Onions and Tape… Oh My!

Transcription

Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every child, for every reason.

[Music]

Announcer 2: Welcome to PediaCast, a Pediatric podcast for parents. And now, direct from Birdhouse Studios, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast. A pediatric podcast for parents. This is Dr. Mike coming for you from Birdhouse Studio; I'd like to welcome everyone to the program. It is Episode 110 for Tuesday, February 19th, 2008.

01:00

Abortion, Glue Ear, and Contagious. But before we get started I had a good story for you. Last week in the office and for those of you who are new to the program first let me say welcome to PediaCast. Thanks for taking some of your time during the day.

I know everybody is busy to check out our program and to take and listen. One of the things I'd like to do is share with you some of the interesting and funny things that happen in the course of practicing in a pediatric office.

Now, we're not breaking HIPAA code here. We're not talking personal revealing information, you see it's more kids say the darkest thing sort of stories and this certainly fits in with that. It was a kindergarten well check-up.

So, as a little girl who's about five years old and in the course of the discussion with mom, I mentioned that the child would need their immunizations for kindergarten. And that by the way, season pediatricians typically will use the word immunization or vaccine and not the SHOT word in front of kids especially if you want to maintain having conversation with the parent because once the kids hears shot it is all over in terms of having a quiet environment to discuss this.

02:18

So, this was a smart little 5-year-old though and she knows exactly what I was talking about. So using the word immunization did not for her one bet and she interrupted our conversation and said "Mom, mom, mom I have to get a shot, what? Huh-huh. What's going on? And so, I kind of went into my typical mode of trying to comfort the child…. And I said "You know, it's OK and other kids your age have to get this shot so that they can go to kindergarten….

If that point I'm using the word shot because she knows exactly what I was talking about. There was no hiding behind words anymore. And she interrupted me, look at me with the most serious of faces and said, well I want my pee back. She had given us a urine example and if we were going to give her shots, she wanted her pee back.

03:11

So, I mean that made my whole day. That was funny because we can laugh during the day. All right one of the thing before we move on that I want to mention.

This past weekend I was introduced to a new game that we played with the family, it's called "In a Pickle… and I have to profess this with saying I have not receive any promotional money from the company who makes this game.

It simply my son's aunt gave it to him for his birthday. And that was in early January and we just got around this weekend to playing at for the first time, because we've been busy and so it was fun. It was really, really, fun. I really recommend it.

The game itself says it's for age 10 and up but I supposed smart kid younger than that would probably do fine with it if they have a pretty good vocabulary.

04:04

It's easy game. It's a stuck of cards and you have to put things in order from what will fit inside what. For just for example, a person would fit in a car and then a car would fit in a garage.

So you're basically just putting smaller things in the bigger things but they have all sorts of cards and so it start to get funny. You know when you're thinking about putting this inside that then you know it's funny, it's funny.

It's really a good time and it can get a little out of hand with exaggerations but then the rest of the people playing both to see if it's something they agree, would fit or it wouldn't fit. OK I know it's a pediatric podcast that I've gone into talking about games, but it's a fun one it's called "In a Pickle…. We played lots of games as a family and there's just only a handful that I would recommend. I mean, it's not like "Oh, I played this game,   wanted to tell you about it because I don't have anything else to talk about…. That's not the case at all, really is a fun game and I'm excited to play it again here soon, so you may would check out that it's called "In a Pickle….

05:12

All right, so what are we going to talk about today Fetal plain and Abortion Policy. No I'm not trying to get controversial here. There is no political agenda, I'm reporting the news.

OK, I'll let you decide what you think and then we're going to talk about, Spinal Muscular Atrophy. It's a rare disease, defects of… it's about 6000 new cases each year in the United States.

So it doesn't affect a lot. Well, I mean that's 6000 that's a lot of families. But I mean in the scheme of things, it's not a ton of families that are affected.

However, the story thus illustrates what gene therapy is all about. And that's one of those words that you hear often but a lot of people don't understand exactly what that is. So, we're going to talk about that, we'll help you understand gene therapy a little bit better.

06:03

And then Glue Ear and Contagious. How long are you contagious when you're sick?

Don't forget if there's a topic that you would like us to discuss on PediaCast, it's easy to get hold of this, just go to Pediacast.org, and click on the contact link you can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, 347-404-5437. The information presented in PediaCast is for general educational purposes only.
We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child's health, call your doctor and arrange a face to face interview and hands on physical examination.
And 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 all that in mind, we'll be back with News Parents Can Use right after this short break.

[Music]

07:26

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. You can visit them online at Medicalnewstoday.com.

Now I normally don't profess new stories but I really feel like I have to, so that there's no misunderstanding with this because I really, really don't want a flood of email over this. It is a news story regarding abortion.

I don't have any political agendas. I do think this affects parents and is appropriate to talk about on PediaCast because like it or not, when there's an abortion, there's a baby involved.

08:08

Now, whether you want to call it a fetus, or a baby and you know it's a potential human and again I'm not going "Yeah, nay… but it is inside a mom. This baby, this developing is inside a mom.

A mom is a parent and this is a pediatric podcast for parents. So, OK. I'm driving this under the ground. I know, it's just kind of want to the story because I do think it's an interesting one.

The New York Times Magazine recently examined different views about fetal pain among medical experts. Law makers and advocate as well. As how such views affect abortion policy?

According to the Times Magazine, some research including studies conducted by Sunny Anand, a pediatrician at Arkansas Children's Hospital and a professor at the University of Arkansas has suggested that fetuses can feel pain beginning at about 20 weeks' gestation.

09:07

However a 2005 review of 2000 medical journal articles that involves fetal pain studies found that fetuses do not have the capacity to feel pain until about 29 to 30 weeks gestation.

The review was conducted by Mark Rosen and Colleagues at the University of California-San Francisco and published in the Journal of the American Medical Association.

According to the times magazines some researchers believe that fetal response interpreted as pain are just reflexes to the fetuses environment. Still other researchers including University of Birmingham Physiologist, Stuart Derbyshire believe that pain is not inherent at birth but rather is a learned experience during an infant's first year.

Marc Van de Velde – an anesthesiologist and pain expert at the University Hospital Gasthuisberg in Leuven, Belgium – said the debate is "irrelevant" as to whether to give anesthetic to a fetus when performing a prenatal surgery. "We know that the fetus experiences a stress reaction, and we know that this stress reaction may have long-term consequences – so we need to treat the reaction as well as we can.

10:13

However, the debate about fetal pain is "not irrelevant when applied to abortion," the Times Magazine reports. Since 2004, antiabortion groups have cited fetal pain in their efforts to restrict or ban abortion.

In 2004, Anand testified as an expert witness in a case involving the federal ban (S3) on so-called "partial-birth" abortion. Anand told the court that he assumed the procedure would cause "severe and excruciating pain" in fetuses beginning at 20 weeks' gestation.

After Anand's testimony, federal Judge Richard Kopf in his opinion said it was impossible for him to determine whether a "fetus suffers pain as humans suffer pain." Kopf ruled against the law saying it was unconstitutional on other grounds, but the law was upheld in April 2007 by the U.S. Supreme Court.

11:04

According to the Times Magazine, Anand's 2004 testimony "helped clear the way for legislation aimed specifically at fetal pain." Sen. Sam Brownback, Republican from Kansas in 2004 and every year since has introduced a bill he called the Unborn Child Pain Awareness Act.

The measure would require physicians to tell women seeking abortions at 20 weeks' gestation or later that their fetuses could feel pain and offer to deliver anesthesia "directly to the pain-capable unborn child." Anad quote that's what they have to say, that we're going to give anesthesia directly to the pain capable unborn child.

State-level legislation similar to Brownback's bill also has been introduced in 25 states. Five states Arkansas, Georgia, Louisiana, Minnesota and Oklahoma – have passed the measures into law. In addition, abortion counselling materials in Alaska, South Dakota and Texas mention fetal pain.

12:08

Laura Myers, an anesthesia researcher at Children's Hospital Boston and Harvard Medical School who analyzed Brownback's measure – said abortion clinics do not have the necessary equipment to administer anesthesia to fetuses.

Brownback's bill "makes a promise that the medical community cannot fulfill," Myers said, adding that providing fetal anesthesia during abortions would be an experimental procedure that could carry health risks for the woman, including infection and bleeding.

Rosen said that anesthesia during fetal operations is necessary to prevent complications but that administering anesthesia during abortions could endanger the woman's health. It is not "erring on the safe side" to endanger a woman's health by administering fetal anesthesia before an abortion, Rosen said.

OK, so by the way before we discuss this. This story is presented with kind permission of the National Partnership and you can view the entire daily women's health policy report. Research the archive or sign up for email delivery at their website.

13:10

The daily women's health policy report is a free service of the National Partnership for Women & Families, and published by the Advisory Board Company. For more information you can visit nationalpartnership.org and as always we'll put a link in the show notes.

OK, whichever side of the fence on there's a few interesting things I think in this. A lot… when we think about abortion, you really don't think about the fetus potentially experiencing this as a painful process.

And this whole notion of what is pain, I mean the University of Birmingham physiologist Stuart Derbyshire assertion that pain is not inherent at birth but rather a learned experience during an infants' first year.

14:00

Is that crazy or what? OK I mean may be this is just a little bit – I don't know may be my brain just can't grasp that. Personally I have been involved in performing circumcisions and arterial sticks and spinal taps on babies during the first week of their life.

They feel pain. The difference between doing circumcisions without a local anesthetic and with a local anesthetic can be great. And there's definitely a response – would not… is it pain? Are they feeling pain? I think they are.

OK. At least when they're born and after whether they can feel pain when fetus inside mom, I don't know, we never been able to ask. But right after they're born I don't think that… I think pain is inherent at birth and I don't think that Stuart Derbyshire, the physiologist from the University of Birmingham is going to be or change my opinion on that.

15:12

There was some other interesting things in this article for instance, I think it's always interesting how the wording of things gets a place to be… to have an agenda. And again whether you're pro-abortion, against it or pro-life.

Whether you are, take it on a case by case basis. You know when you put in your literature that we can deliver anesthesia directly to the pain capable unborn child. Just a loaded statement, isn't it? OK, I think I've said enough about this.

You know I thought that was an interesting article. OK, this was is interesting too. We talked a little bit about this in the introduction. Researchers at the University of Delaware have discovered a noble technique that acts like a spell checker for correcting a misspelling in the DNA code to repair the defective gene that causes spinal muscular atrophy or SMA.

16:11

This hereditary neuromuscular disease is the number one genetic killer of children under two years old. Babies born under type 1 SMA the most severe form of the disease cannot walk, crawl, sit unsupported, lift their heads or breathe normally. And 50% die before their second birthday.

This research is published in the January 14 online edition of Experimental Cell Research. The study was supported by nearly half a million dollars in National Tobacco Settlement funds to the state of Delaware. The research grant was awarded through the Delaware Health Fund.

"Think of it like a spell-check program-we're erasing the wrong letter in the DNA code and putting the right one in,… said Eric Kmiec, professor of biological sciences at the University of Delaware. Kmiec collaborated with research scientist Darlise DiMatteo and undergraduate Stephanie Callahan on the discovery in his laboratory at the Delaware Biotechnology Institute.

17:07

The technique has shown promising results in tests in mice and is now poised for development by OrphageniX Inc., based in Wilmington, Delaware. The start-up company was incorporated in 2005 to commercialize University of Delaware-patented technologies for repairing genes that cause rare, hereditary, "orphan… diseases, so named because they have not been "adopted… by the pharmaceutical industry for the development of treatments.

That's kind of sad, isn't it? That there are diseases out there that they're just are enough people affected for the pharmaceutical companies to want to come up with treatment for. That's so sad.
According to the Families of Spinal Muscular Atrophy, an international, non-profit organization, the disease affects one in 6,000 babies born, and one in 40 people is a genetic carrier.
I got to pause again, so that means I was totally wrong in the introduction. I said it affects 6000 families and I remember seeing 6000 but now that I'm reading the article, it's one in 6000 babies born. That's so; it's a lot more probably than 6000. You do the math.

18:15

Spinal muscular atrophy is caused by a mutation… OK look folks it's not a professional program I realized that.  Spinal muscular atrophy is caused by a mutation in the SMN1 gene, which affects the motor neurons, the nerve cells in the spinal cord that control the muscles of the rib cage and limbs, which are essential for breathing, swallowing, sitting and walking.

OK now here's where the science comes in. and I don't think this is going to be over your head. If you took a high school Biology class you can understand this.

Each gene is made up of a length of DNA, a code composed of the four chemical units that make up the genetic alphabet: A for adenine, G for guanine, C for cytosine and T for thymine.

19:00

OK these are amino acids and I'm sure if you took high school biology you learn about this.

In spinal muscular atrophy, a defect occurs in the SMN1 gene. There's a letter out of place, there's a T or thymine which is an amino acid occurs where there should be a C or cytosine, that amino acid. As a result, the gene doesn't make a protein that the motor nerves in the spinal cord need to survive, which leads to the gradual atrophy, or wasting, of the muscles.

To replace the function of the defective SMN1 gene, the UD research team used a gene in the human body that is nearly an exact copy, it's called SMN2.

Then they introduced a small fragment of this healthy gene's DNA, so it's a genetic "bandage… referred to as an oligonucleotide, see even I tripled over that one – into a diseased cell, triggering the cell to heal itself.

So the cell itself doesn't have the right code to make this protein that the muscle needs. So you inject the correct code in to the cell so that they can make the proper protein, interesting.

20:10

Test of these techniques in mice with spinal muscular atrophy conducted by Jackson Laboratory in Bar Harbor, Maine showed very promising results with the development of healthy muscles in the animals Kmiec said.

"Babies with SMA die early in life, but if we can deliver the healing agent to the appropriate cell, we can help address this horrible disease. We're not looking at a cure, but we hope this technique could lead to a series of treatments that could alleviate the symptoms and improve the quality of life of patients,… Kmiec said.

Patients with the less severe, Type III form of spinal muscular atrophy would be targeted for initial human trials. Although individuals with Type III SMA suffer from a range of muscle weakness and fatigue quickly, the disease generally is not life-threatening at this stage.

"What we've discovered-this gene spell-check-sounds very simple, where you erase one letter and put the right one in,… Kmiec noted, "but finding the pathway has taken a long time, since 1994. Now, with this latest development, we've taken a laser shot out of the primordial soup.

21:10

It's a chance…What is that mean? It's a chance finally to make a difference for families with this disease…. OK so Dr. Kmiec I'm not sure which mean about the laser shot in the primordial soup, but OK, I'm with you other than that.

When I first heard the story, reminded me of movie Jurassic Park, I mean remember when the visitors to the complex watch dino-DNA movie, remember that, so here we are 15 years later and researchers are kind of on the brink of really manipulating DNA and human cells to fight disease.

Moving it out of the laboratory and into the clinical setting, so this is exciting stuff, we're not resurrecting dinosaurs here, we're replacing one amino-acid with another, but hopefully this will improve the lives of people affected with this condition. It's amazing really and it opens the door possibility for application in the many, many more disease processes.

22:07      

All right, so a little bit about gene therapy, see now you understand that a little bit better. Let's take a break and I'll be back to answer some of your questions right after this.

[Music]

22:46

And welcome back to the program, it's the time in the show when we take your questions and try to provide some answers to you. First up, it comes from Russia; this is Nicolai.

He says, "Hello Dr. Mike, this is Nicolai from Moscow, writing to you, again, in your PediaCast 100, you talk about ear infections and ear tubes, my daughter Macia, who is now three and a half years old and has had three weepy ear infection over the course of the last five months after she's started going to kindergarten in September.

23:15

We took her to an EENT doctor today and she diagnosed Macia with Glue Ear condition.  She took X-Rays and it appears that Macia's adenoids are swollen and causing liquid to stay in the middle ear.

The doctor's recommending adenoid removal but both my wife and I are not sure whether we should the operation or wait for a few months and perhaps try a less invasive approach first such as ear tubes. What is your professional opinion about adenoid removal and what advice can you give us? Thank you for your excellent Podcast, best regards, Nicolai….

Well thanks for your question Nicolai. A glue ear, the medical term for this is Chronic Serous Otitis. Now let's break that up, Chronic means it's lasting a long time. Serous means there's fluid. Otitis means inflammation of the ear.

24:06

So this is long lasting fluid and serous is more of a clear fluid whereas purulent is more of a pussy fluid. So this is more of a clear fluid that's there for a long time behind the ear drum, and even though it's got the word "otitis… in it which would technically mean inflammation in the ear, there's not a lot of inflammation with this condition it's really just sort of a clear glue-like gooey material that is behind the eardrum.

So in order to understand this a little bit better and for those of you who have our long time listeners, some of this is going to be a better review but hey the more you hear something you better yet the better you understand it.

Let's talk first about anatomy, so if we're going from the outside-in, you've got your ear canal, you've got your eardrum, which is what vibrates when sound waves hit it, behind the eardrum is the middle ear space which has three little bones that take the sound in from the eardrum to the inner ear, if you remember in this again from biology class.

25:13

And then the Eustachian tube is a little tube that connects the middle ear space to the throat and it's just to help equalize pressure on both sides of the eardrum, that's the purpose of it. And the adenoid is a lymphatic tissue kind of like the tonsils and so it's sort of a first line of defense against bacteria.

Invaders that aren't supposed to be there and if they get big though, they can't compress the Eustachian tube and so if you had some fluid in the middle ear space that otherwise would drain down into the back of the throat if the Eustachian tube is compressed by enlarged adenoid, then that fluid might stay there.

So it does make sense that an enlarged adenoid could lead or cause this gluer condition and someone who already had an ear infection and now the fluid can't get out because the adenoid is pushing on and compressing the Eustachian tube.

26:10

So basically, the drain is being pushed on. So hopefully this is making sense. Now here's the question though, the question becomes, if you have this condition, so if you had an enlarged adenoid and it's compressing the Eustachian tube and you have a chronic fluid in the middle ear space, is this something that you need to address, number one, and if you do need to address it, what are your options?

OK, so first let's talk: Do you need to address it? With this chronic serous otitis or glue ear, as I said there's not a lot of inflammation there it's just this left over fluid from a previous infection.

So usually there's no pain, so pain typically is not an issue, there is a little bit a hearing loss and there's hearing loss because you have fluid in a space that has supposed to have air in it, so the ear is going to work best when there's air and not fluid in the middle ear space, be it's a conduction issue.

27:19

So if you have this condition you are going to have a temporary mild hearing loss. Now there have been several very large well done studies that show chronic serous otitis is not associated with long term hearing loss so in other words once the fluid's gone, hearing returns to normal and it is not associated with language delay.

So if you have a kid with fluid behind the eardrum and they have speech delay, you can't blame that delay on the fluid because there been several very, very large sample size well done studies that we've talk about here before that show kids who have chronic fluid in their eardrum.

A lot of them have language delays but a lot of kids with normal ears also have language delays and there's no difference between the two groups when you look at large sample size, no statistically significant difference.

28:11

Now, will adenoid removal help clear the fluid? Well, probably will, because basically not compressing that Eustachian tube anymore and the fluid has somewhere to go. We'll putting ear tubes, which is little piece of plastic with a hole in the middle.

So it's like a little tunnel putting that in to the eardrum, well that clear the fluid, sure because then it could just drain out, but at what cost? What cost? So you look at the cost of living someone with a serous otitis, they have short term-temporary hearing loss and really that's it, but what's the cause of doing in getting rid of it?

Well if you put ear tubes in there's a risk with anesthesia and you're poked on the hole to the eardrum put a piece of plastic there, there is a scar risk and a more and more rising that people who have ear tubes is infants particularly if they have more than one set of ear tubes are at the higher risk of more long term hearing loss because of scar tissue on the eardrum.

29:15

Now is that mean that ear tubes are always bad? No. Because if you have a kid who has recurrent acute otitis where it's really an active infection with inflammation and pain and a lot of pus and pressure on the eardrum and the eardrum ruptures, that's an even bigger hole with lots of inflammation present.

So you got to get a bigger scar and if you have that happening over and over again you're going to get a lot of scar tissue on the eardrum. So in that case it's better to do it under a controlled setting. Put the little ear tube in and you get a smaller scar.

So I mean, ear tubes have their place don't get me wrong, but why go to the anesthesia risk and the scar risk if you have a temporary condition that's not associated with language delay and it's not causing any pain.

30:00

Getting your adenoids out is an even bigger deal because now you not only have anesthesia risk but you're mocking around by the airway. You can have bleeding complications, a secondary infection associated with that surgery.

So, is this something that you really need to treat surgically in a kid who doesn't have any pain? Who's hearing loss is not profound, is going to be temporary? This is a kind of thing where personally if it was my kid, I just want to watch him for a little while.

How long, how long do you watch him? Well certainly, for several months and in the vast majority of cases this is going to go away with no after effect. Now, not everybody follows this typical pattern for chronic serous otitis, I mean what if there is discomfort?

What if the kid really is having pain even though there's not an acute infection there, I don't mean cute is in pretty, acute means, a bad infection with inflammation and bacteria, sometimes with viruses.

31:00

So, if they have pain even in the absence of those of infections, although that is so unusual, you got to think of they have that much pain or probably is an active infection there or if with there's fluid there they keep getting recurrence of ear infections, of acute ear infections that are actively infected with pain and inflammation.

Over and over and over again and in between they have this fluid that just not going away for many months or if they do have profound hearing loss, we say that it's temporary, it's mild hearing loss. But you do have to look at on a case to case basis and if your kid's life is affected by it and you really think he's not hearing in class, he's not listening to what you're saying and it's interfering with this life, then you could make a case that we need to get rid of the fluid but most cases you're not going to need to do that.

So in those cases, where there's a lot of discomfort or where there's a recurrent acute infection or profound hearing loss associated with it then the risk of the ear tubes and or the adenoids being taken out may be worth the benefit.

32:02

But really for most kids, the risk is going to out weight the benefit, I mean because they're doing fine and it's going to go away. Now I will say this, so let me just do this because you got to do, you have to take this one kid at a time and look at each of it on a case by case basis.

That's where we can't practice medicine here and that's why I can't say, "Nicolai, this is what you need to do…. OK, I can't do that, what will I say though, is that if this were my child, given the situation that I have described, living in the United States, having EENT who do the things here that they do, then I would do this.

I would say, I won't do anything, I just watch it as I mention, but then if the fluid is not going away after many, many, many months and or they're having pain or recurrent infection or profound hearing loss then I'm go to tube route first without doing the adenoid removal, because it's less invasive and less the anesthesia time, there's less complications associated with it and then if that's not working and it reoccurs.

Then I would think about taking the adenoids out, but again that's me and my kid in the USA and you have to keep all those factors in mind.

33:19

Because Nicolai, for instance, I don't know these EENT doctor that you're using but may be she's done hundreds and hundreds and hundreds of adenoid operations and seen kids do really well with it, with low complication rate because she's really, really good at performing this and may be she's only put in five sets at ear tubes.

OK, now what would you want the doctor to do, you got to also look at the experience of the person who's hands your hand and with their comfortable with and that sort of things. You got to keep that in mind too, all right, so I hope I did answer your question Nicolai, thanks again for writing in, always a pleasure to hear from you, from Moscow, Russia, I just love doing this.

34:00

All right, let's move on, this is from Rachelle in Annapolis, Maryland. OK so, Annapolis is not quite as exotic as Moscow but we still love you Rachelle.

Rachelle says, "Hi Dr. Mike, I have a question about being contagious and the common cold, I've heard that usually you're contagious for the first three days, oh I'm sorry, first 3 to 5 days of a cold, usually after this window you're not contagious anymore, does everyone goes back to work or send their kids back to school, after this window or at least after 1 to 2 days.

I have a baby who's two months old and we have plan to stop by a friend's house, she's had a cold for the past week and it's on the mint but it's still at the feeling the in effects of her cold. We'll be postponing our visit but you got me thinking when she said: I'm not contagious anymore.

What exactly does this mean? Can you have the end symptoms of a cold and not be contagious or are you always contagious until you feel completely yourself again? Who's such a small baby, I'm being extra cautious but with an older child, where is the line of contagious versus not contagious?

35:04

For example, I remember you saying sometimes you have to go to work having a cold in the winter, how do you deal with being around well babies with a bit of a cold? Love the show, I'll post my iTunes reviews soon, I promise, thanks, Rachelle….

All right, great questions Rachelle, really and thanks for writing in and thanks for the iTunes review that hopefully you are going to follow through it because those are so important, great questions really. In the answer to this great questions, are more complicated then they may first appear.

First you must understand what causes the symptoms of an infection, it's usually not the organism itself, so what are that organism is still alive and contagious or dead.

The symptoms are not dependent upon whether you're contagious or not contagious, it's really the symptoms are the side effects of your body dealing with the microorganism that has invaded your system, you make mucus to trap and flush out the bacteria or virus, you cough to keep the offenders out of the airways and out of the lungs.

36:13

A fever is a by-product of inflammatory chemicals that your body makes. We think that the fever helps kill off certain microorganisms and not likely helps your immune system to also function more effectively.

So these symptoms are your body's defense mechanisms at work and when we're trying to get rid these symptoms we aren't doing our bodies any favor undermost in most cases. You can imagine that if you're sort of humanize just a little bit and that's not the word I wanted but I think what I am talking about here.

I mean you can imagine what your body would say, it say, "Hey dude, stop trying to help, you're only making my job harder…. I'm sure you get rid of the runny nose but now how do you expect to trap these microorganism and get rid of them for you?

Or you're going to take this cough medicine, "Hey dude, my body, this is your body talking, you got to cough to keep this junk out of your lungs, it's there of a reason!…

37:12

Now fevers, you know you do, kids feel so miserable with fever and you do run the rest of febrile seizures which are in dangerous we've talked about on before. I'm not saying don't treat fevers or not to treat pain but it is true though that when we take care of these symptoms, we are sort of making it more difficult for our bodies to make us better.

OK that's attention, you're question has nothing to do with symptoms, let me get back to contagious. Knowing this, OK knowing this that these symptoms are an indicator of whether the organism is really still alive and your body unable to be passed on. Absence of symptoms is a pretty good of indicator, OK, if you don't have any symptoms you're probably not contagious.

38:01

But presence of symptoms is not, so the symptoms usually last longer than the contagious period. So how do you know? Certainly you're not contagious anymore in most cases before the symptoms are gone, the symptoms are going to last longer than the contagious period that's what I am trying to say.

So how do you know when you're not contagious anymore? That's the question. And it'll be nice if there was an indicator light like "Ding, OK, you're not contagious anymore!… or it would be nice if we could say, OK from the time of the first onset of fever or from the time the fever is done, it's going to be one day or three days or five days or seven days and you're going to be OK.

But the exact period of contagiousness depends on a lot of factors, it depends on your immune system's ability to fight the disease, it depends on have you interfere with the body's ability to fight the disease, another example of that is you got a kid who has croup, you put him on a steroid because they have so much stridor which is cause by inflammation around the airway.

39:10

So you put him on a steroid, it makes the airway inflammation go down but steroids decrease the immune system's ability to fight infection, so have we then prolonged the child being sick or contagious because we've given him the steroid which interferes with the immune system.

Airway is more important, OK, it didn't matter if the airways are going to close and your child is going to die right? So you got to do the steroid if you're worried about their airway and so they're going to be contagious longer, it's going to take their body longer to fight it off.

But if you have a kid who has very mild stridor, it goes away quickly, they've got this sparky cough, how many parents out there go to their doctor wanting the steroid, because the steroid going to make them better. See, that's the issue that we get put in as pediatricians and get them going off attention here, but we see this is a lot.

40:02

You know the parents wants the symptoms gone and the steroid is going to help the symptoms go away but are they going to then be sick longer or contagious longer because we're putting them on a steroid.

Again, if you need a steroid because you're really worried about their airway, you can do the steroid. Really the best practice as a parent, is go with what your doctor thinks and don't try to control the situation.

OK, because there's a time for it, there's a time not to do the steroid. Here I go again. OK. It is not croup. See this is my ADHD kicking in folks, you figure that out.

So, a good rule of thumb, if it's a viral illness… a viral illness you're going to be most contagious during the fever period. You're going to be moderately contagious for the next day or so. And then you're going to be mildly contagious for the next few days after that.

If it's a bacterial infection then you're usually not going to be contagious any longer with the bacterial infection after you've been on an antibiotic for about 24 hours.

41:10

So the classic example of this is, you've got a kid with strep throat, you put along the antibiotic, let say after you've been on an antibiotic for 24 hours, you're not really contagious anymore. Now the caveat here is a lot of bacterial infections get started because of a viral infection.

So I mean you got a kid with a cold, runny nose, or viral upper respiratory infection 4 or 5 days later you got an ear infection. The ear infection you put him on an antibiotic, that's not going to be contagious but the underlying viral infection might still be contagious.

So you got to keep that in mind that being on antibiotic for 24 hours helps the bacterial infection not be contagious but if there's also an underlying viral infection that still could be contagious even though you're on an antibiotic.

42:00

Now having said that there's an exception for example, tuberculosis is a bacteria and it's highly, highly, highly contagious and remain so for days to weeks even after starting treatment. So, a lot of bacterial infections aren't that contagious compared to viral infections.

But again, there's exceptions in tuberculosis as one of those. But for example, ear infections and sinus infections are not very contagious because it's your own mouth bacteria migrating into the middle ear space or migrating up in to the sinuses and the problem is the bacteria stuck there and they're not going anywhere, I mean, that's the problem after all.

So they're not very contagious but again the underlying viral upper respiratory infection that leads to the ear infection or sinus infection or sinus infection is contagious. And then you got skin stuff to think about. Things like impetigo, ring worms, scabies.

Most of these are not going to be contagious after 24 to 48 hours of treatment. So in the end here you got to think about, is it a virus, is it a bacteria, is it on the skin, how's that transmitted, what's the transmission route? Is it airborne, is it what we call fecal-oral, like the rotavirus and salmonella, those sorts of things are fecal-oral.

43:17

So you got to look at all these different variables, so it's just another example that medicine's not easy, that's why you have to go to medical school to practice medicine and really I think your best bet with this is to ask your doctor. I mean give your doctor the details of your specific situation and ask for their advice because there just too many variables and to many diseases to make a blank statement here.

Now how do I keep my germs away from well babies? That's a good question and there's three answers. Answer number one, hand washing. Answer number two, hand washing. Answer number three hand washing.

OK, before and after each patient contact you got to wash your hands. As parents you got to do in, as a doctor I got to wash my hand whole day long.

44:03

Also I try my hardest not to cough in the exam room. If I have to cough I try to do it in to my… like my upper arm, so I'm not coughing in to my hand. You want to cover your mouth when you cough but I hate doing it with my hand, even then if I wash my hands right away, as a parent you're still thinking – he just cough in to his hand and now he's touching my kid.

So, I try not to do that but you don't want to cough in to the open air either, even if you cough away from people it still going to spread throughout the room. So, I try to cough on the upper part of my arm, I guess.

You got to remember too we talked about this before. This symptoms are going to last longer than the contagious period. So you got a bad cold, you're contagious for a few days but that cough they can linger.

You know, it can linger for 2 or 3 weeks easily. And so goes to the doctor they're coughing and you just make this assumption they're contagious but not necessarily.

45:03

One of the thing too I wipe the business into my stethoscope with alcohol hand gel before I'll examine well-babies especially in the midst of flu season when you might be seeing some sick kids in between, that's really important too because the stethoscope can transmit disease pretty easily.

So, any doctors or medical students put there listening, it's easy to forget but please wipe off in to that stethoscope in between patient just like it's important not just washing your hand may be not quite as important but it's important.

If I have a fever, yeah you shouldn't go to work if I have a fever usually.

All right that wraps up our listener segment. We'll be back to wrap up the show, right after this.

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46:15

All right thanks to all the Nationwide Children's Hospital for providing the Bandwidth for our program. Also Medical News today and Vlad over Vladstudio.com. And of course thanks to all of you for taking time out of your busy day to listen to PediaCast, we really appreciate that.

What is scotch tape have to do with onions and mushrooms where you can find out on the Pediascribe blog. Karen did a great post on that. Just look up for the link on the show notes.

Also don't forget the PediaCast shop is open we have t-shirts, no mark up on our part. What we pay is what you pay. And just help spread the word about PediaCast and if you wear your shirts on vacation this coming spring or summer be sure to get a picture with your PediaCast t-shirt on and we'll run a contest and have pictures up I think that'll be fun.

47:03

We also have a poster page on the website at pediacast.org just click on the poster link and there's some PDF files you can download free and hang up on bulletin boards. So thanks for spreading the word and let another parents known about the shoe.

OK our next program is going to be on Thursday. And we're going to do an interview. Now we talked about abortion here today which is more of a pregnancy type issue, I realize but on Thursday, we're going to do another pregnancy-type issue.

But again moms today are moms so deal with it. OK we're going to have some pregnancy discussion as we go along here plus many of you with kids are also expecting a second or a third or you will be expecting.

So, sometimes pregnancy issues do come and to play here, and I think do belong on the show. So we're going to talk about on Thursday, Kick Counting, whenever I say that I wanted to say kick boxing, I don't know why. Was it… like kick boxing rules of the tongue instead of kick counting but this is Kick Counting, where you count your babies kicks and it helps you to monitor the health and well-being of your baby and our special guest is Dr. Diep Nguyen, LA based Obstetrician and she came up with a very neat method for moms to use to keep track of kicks.

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It's a non-invasive low cost but accurate measure of a baby's well-being. So be sure to tell your expecting friends who aren't listening to PediaCast yet about the show on Thursday because it's going to be a good one. I really have a good feeling about this one. So you want to check this out that will be on Thursday.

And until then this is Dr. Mike saying, "Stay safe, stay healthy, and stay involved with your kids….

So long everybody.

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