Crying It Out, Toddler Discipline, Migraines – PediaCast 126

Topics

  • Iron Supplements
  • Teens With Asthma
  • Smoking Bans
  • Crying It Out
  • Toddler Discipline
  • Migraine Headaches

Links

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. It is Episode 126 for Monday, May 26th, 2008, "Crying It Out, Toddler Discipline and Migraines".

I want to start off by wishing everybody a very happy Memorial Day. And I hope you do take a moment of time with your families to remember why we celebrate Memorial Day. No, it's not just a day off work and a three-day weekend. We really need to stop and thank the men and women who had fought and continue to fight to preserve our freedom. And what a great opportunity to teach our kids about the importance of our military folks who keep us out of trouble around the world. Because, it certainly would not be fun to live in a country that's not as free as ours.

I know we have our problems. There's no question on that. It's not the perfect system and it never will be the perfect system. But it's better than a lot of the alternatives.

Of course, Memorial Day weekend heralds the summer movies season. And we saw Indiana Jones And The Kingdom of the Crystal Skull. And I have to say, I absolutely loved it. Before the movie came out over the last, I don't know, seven to ten days, something like that, we watched the trilogy. So we started out with the Raiders of the Lost Ark and did The Temple of Doom and finished it off with The Last Crusade. Not three days in a row or — even would be crazier — all of them in one day. No, but over the course of seven to ten days, the family watched those three to sort of get us ready for the new one.

0:02:34
And it was great. It was really good time, both watching those three again. It's been awhile since we have seen them and then, taking the kids to see the new one. OK, sure it's going to get some bad reviews. It was a bit predictable, but that's part of the fun. Harrison Ford, he looked really old at the beginning. He looked older than I would have expected him to look. I mean, I had expect him to look a little older, but I mean, in the beginning of the movies, he looks really old.

Then as the action rolls, he started to look younger. So, I think that they made Harrison Ford look older than he really looks for that opening scene. I think, because he really did not look like himself. I mean, you know, baggy eyes and wrinkles and just really, that opening didn't look so great. But as the movie went on, he looked younger as he became more active. And again, I think that it was part of it — sort of him coming out of retirement for this adventure.

I loved the nuclear explosion, loved the ants and, of course, you got to love that creepy temple tight scenes. It's just an all-around good movie. I won't give anything away, except to say that they definitely leave it open for another show and a franchise in the future. So anyway, I like those adventure movies anyway.

0:03:59

All right, so what we're going to talk about today? In the News Section of the show, we're going to talk about iron supplements, teens and asthma; and then, smoking bans, in terms of banning the use of cigarettes and how that affects teenage smoking.

And then, we're going to take your questions. We have someone who says crying it out, letting your baby cry it out, causes brain damage. Does it really? We're going to talk about that.

Also, toddler discipline — how do you discipline a young toddler? We're talking 15 to 18-month-old range. You know, right in that age group. Had a good question about that.

And then, we're going to discuss a component of migraine headaches. We're not going to do a whole big talk on it because I think the rest of the show's going to take up enough time. But we're going to answer some specific questions about migraines and maybe we'll save the big everything-you ever-wanted-to-know-about-migraines for a different time.

All right, don't forget, the information presented in every episode of PediaCast is for general educational purposes only. We are not practicing medicine here, folks. We do not diagnose medical conditions and we do not formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at pediacast.org.

And with all that in mind, we will be back with News Parents Can Use right after this short break.

[Music]

Dr. Mike Patrick: 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.

0:06:09

A new study suggest extra iron for infants who don't need it might delay development. This information adds fuel to the debate over optimal iron supplement levels and could have huge implications in the baby formula and food industry. "Twenty-five years of research show problems with lack of iron. So for us to find this result is a big deal, it's really unexpected," said Dr. Betsy Lozoff, University of Michigan research professor at the Center for Human Growth and Development and the study's principal investigator.

US infant formulas typically come fortified with 12 mg/L of iron to prevent iron-deficiency anemia. Europe generally uses a lower amount. In infants, iron-deficiency anemia is associated with poorer development; and during pregnancy, it contributes to anemia in mothers, contributing to premature birth, low birth weight and other complications.

"I thought that behavior and development would be better with the 12 mg formula," said Dr. Lozoff. But the U of M study of 494 children from Chile showed those who received iron fortified formula in infancy at the 12 mg amount used in the US lagged behind those who received low-iron formula in cognitive and visual-motor development by age 10 years. Lozoff stressed most children who received the 12-mg formula did not show lower scores. But the 5% of the sample with the highest hemoglobin levels at six months showed the poorest outcome. Your body needs iron to make hemoglobin, a substance in red blood cells that enables them to carry oxygen. High hemoglobin generally indicates sufficient iron.

On average, adversely affected children scored 11 points lower in IQ and 12 points lower in visual-motor integration. The overall average score on both tests was 100 and similar pattern was observed for spatial memory and other visual-motor measures.

Lozoff noted that few infants in Chile had high hemoglobin levels at the time since there was no iron-fortification program for infants. And more than 5% of US infants might have high hemoglobin levels in early infancy. In this randomized study, healthy infants without iron-deficiency anemia were given formula with either 12 mg or 2.3 mg of iron from six to 12 months and then followed for ten years. The next step is to test the participants again at age 16.

0:08:36

According to Lozoff, no similar study has been conducted in the United States or elsewhere.

Iron deficiency occurs because babies grow so quickly they often grow out of the amount of iron they are born with. Breast milk is thought to contain the iron a baby needs for four to six months, Lozoff said. Other important sources of iron for infants include iron-fortified infant formulas and cereals, iron drops and meat. Infants are typically not tested for hemoglobin or iron levels before nine to 12 months. It would be premature to recommend earlier testing or to avoid supplemental iron based on this one study's result, Lozoff said. She expects parents to be concerned, but stressed that results must be reproduced in other studies. At this point there's no basis for changing practice, but it's really important that we have continued research on this issue.

Two studies that offer new insights to help adolescents and younger children improve their asthma control were presented by researchers from Cincinnati Children's Hospital Medical Center at this year's annual meeting of the Pediatric Academic Society in Honolulu, Hawaii.

Tough place to meet.

One study found that teens with asthma dramatically overestimate their ability to control the condition, according to Dr. Maria Britto, a physician in the Division of Adolescent Medicine at Cincinnati Children's and the study's co-author.

"We've known that adolescent asthma patients tend to have poorer outcomes than younger children with the condition, and this study shows that teens tend to think they're in control when they may be having difficulty," Dr. Britto said.

0:10:06

The researchers say 74% of adolescents dramatically overestimate their ability to control asthma, especially compared to the teens' own reports of symptoms, their use of rescue medications and the limitations they placed on their own activities. The study included 201 adolescents with an average age of 16.2 years who were observed during clinical trials. The findings suggest that adolescents' perception of being in control may impact whether or not they follow treatment regimens and avoid situations that trigger their asthma condition.

"For those of us who treat teens with asthma, these findings will help us address perceived control versus what is actually going on," Dr. Britto said. "As we have this dialogue with teenagers, our hope is that it will improve their ability to manage their asthma and improve their health."

Improved care for asthma patients was also the subject of a second Cincinnati Children's study presented at the conference. This one founded a creative approach referred to as "unplanned planned asthma visits" resulted in young patients having fewer emergency room and hospital visits. The approach involves physicians discussing asthma with patients every time they come for an office visit, even if those visits are scheduled for totally unrelated reasons.

The author says, "Having regular, planned physician appointments to manage a child's asthma is an integral part of the chronic care model. Unfortunately, many patients don't always keep these appointments," — especially if they're feeling fine — "so the planned opportunity for education of patient and parent is lost. We also know patients see their physicians for other acute problems, so we developed a system to capture these opportunities and turn them into what we call the 'unplanned planned' asthma visits."

During these visits, patients undergo asthma control screening, condition assessment and receive education on asthma self-management. The visit is turned into an opportunity to assess and manage the patient's asthma. Correct medications and effective self management result in an overall improvement in asthma quality measures in patient outcomes.

In a study group of 230 asthma patients followed during the program, the researchers noted a 30% increase in patients with established asthma treatment action plans. The program also led to a 50% reduction in asthma hospitalizations — that's impressive — and a 47% decrease in asthma related emergency room visits over a one-year period — also an impressive number.

0:12:29

A study of teenagers in the US state of Massachusetts suggests that smoke-free restaurant laws designed to protect non-smokers have had an unexpected benefit. They may be stopping a significant number of teenagers from becoming established smokers. The study is the work of Dr Michael Siegel, professor in social and behavioral sciences at Boston University's School of Public Health, and his colleagues. And it was published last week in the Archives of Pediatrics & Adolescent Medicine.

The main purpose of the study was to assess the effect of laws banning smoking in restaurants on the numbers of teenagers starting to experiment with cigarettes, and also if they started experimenting, whether they progressed to established smoking. Siegler and colleagues enrolled over 3,800 Massachusetts teenagers who were aged from 12 to 17 at the start of the study from January 2001 to June of 2002. And he followed them for four years, carrying out three waves of interviews altogether.

All the youths were interviewed at the beginning of the study. Over 70% of them were re-interviewed after two years, and nearly 60% interviewed again after four years, including some who had not responded to interview requests in the second wave. A total of 301 Massachusetts communities were involved. And the researchers used the strength of local restaurant smoking regulations in the participants' town of residence at the start of the study as a primary predictor of starting to experiment with smoking and also of moving from experimenting to established smoking.

The researchers took into account three measures — moving from non-smoker to experimenting, moving from experimenting to established smoker which they defined as smoking 100 or more cigarettes in one's lifetime, and then they looked at an overall progression to established smoking.

0:14:20

The results showed that teenagers in towns with strong restaurant smoking bans at the start of the study were 40% less likely to progress overall to established smoker status, compared to those living in towns where the bans were weaker. The observed link between strong restaurant smoking bans and overall rate of teenagers becoming established smokers was entirely due to an effect on the transition from experimentation to established smoking, wrote the authors.

The researchers conclude that local smoke-free restaurant laws may significantly lower youth smoking initiation by impeding the progression from cigarette experimentation to established smoking. Siegel told the press that the local restaurant smoking bans were effectively sending out the message that it was no longer socially acceptable to smoke in public. "I think that decreases the appeal of smoking to adolescents," said Siegel in a report in the LA Times.

Kids' perceptions of how many people are smoking is a major factor in whether they decide to smoke. Around half of the states in the US have introduced smoking bans in restaurants, which is appearing to have greater impact on teenage smoking than media campaigns and taxes on tobacco.

All right, that concludes our News Parents Can Use. And by the way, that's also news that fellow pediatricians and family practice doctors and nurse practitioners and medical assistants and the like can also use.

All right, we're going to take a quick break and we will be back with your questions right after this.

[Music]

0:16:15

Dr. Mike Patrick: OK, enough of the serious stuff. We're going to have a little bit of fun with our Listener's Segment, at least with this first question. This comes from Michelle in Livonia, Michigan. She says, "I was very upset to hear that you support the cry-it-out method. Here's some research for you. Hope you take it in consideration." And she sent along an article from the National Post called "Crying It Out Damages Baby's Brain" by Dr. Stephen Juan.,

Here's an excerpt from the article: "Can leaving my baby to cry it out cause brain damage? Research suggests it can. Some experts warn crying out causes extreme distress to the baby and such extreme distress in a newborn has been found to block the full development of certain areas of the brain and cause the brain to produce extra amounts of cortisol, which can be harmful.

According to a University of Pittsburgh study by Dr. M. DeBellis and seven colleagues, published in Biological Psychiatry in 2004, children who suffer early trauma generally develop smaller brains.

A Harvard University study by Dr. M. Teicher and five colleagues, also published in Biological Psychiatry, claims that the brain areas affected by severe distress are the limbic system, the left hemisphere, and the corpus callosum. Additional areas that may be involved are the hippocampus and the orbitofrontal cortex.

The Science of Parenting by Dr. Margot Sunderland points out some of the brain damaging effects that can occur if parents fail to properly nurture a baby, and that includes not allowing them to cry it out. Dr. Sunderland, the director of education and training at the Centre for Child Mental Health in London, draws upon work in neuroscience to come to her conclusions and recommendations about parenting practice.

In the first parenting book to link parent behavior with infant brain development, Dr. Sunderland describes how the infant brain is still being sculpted after birth. Parents have a major role in this brain sculpting process. Dr. Sunderland argues that it is crucial parents meet the reasonable emotional needs of the infant. And this is helped along by providing a continuously nurturing environment for the baby. Allowing a baby to cry it out when they are upset will probably be regarded as child abuse by future generations."

0:18:29

All right, I don't even know where to start with this one. So, first, I have to say, shame on the author of this article, Dr. Stephen Juan. Shame, shame, shame, shame, shame.

And let's take a crack at this. I'll tell you why this is so, so shameful.

The first article that he cites is from the 2004 — actually, it's a 2004 article — it's called "Pituitary Volumes in Pediatric Maltreatment-Related Post Traumatic Stress Disorder". And it was actually written not only by Michael DeBellis but also, Lisa Thomas. Now, I don't think the good doctor, Stephen Juan, even read the article because it does not claim that letting babies cry it out causes brain damage.

This article, I could find the abstract but I had to read the whole article to find out exactly what they did to see if his use of this article was good or not, in terms of supporting his position. And the only way that I could read the article, I had to pay for it. It was like 30 bucks to download this darn thing. So I did, I paid the 30 bucks, I downloaded it.

Here's what the article says, the study actually looked at 61 kids who were four to 17 years of age. They weren't even babies, all right. They're 61 kids who are four to 17 and these were kids who are seeing psychiatrists and carry the diagnosis of post-traumatic stress disorder secondary to extreme maltreatment and neglect.

0:20:07

OK, let me say that again. The study looked at 61 kids, four to 17 years of age who were seeing psychiatrists and carrying the diagnosis of post-traumatic stress disorder secondary to extreme maltreatment and neglect. OK, they're not babies, and their only issue was not that the parents let them cry it out. And these were kids who were subjected to extreme maltreatment and neglect so extreme they were diagnosed with post-traumatic stress disorder and were seeing a psychiatrist.

OK, so these kids, these 61 kids were compared to a 122 healthy non-maltreated kids with the similar distribution of ages between the two groups. And then, what they did is they did brain MRIs on all the kids in both groups and measure the size of their pituitary gland. That's it.
And what did they find? Well, they found that there was no significant difference between the two groups. In other words, pituitary volumes of kids with post-traumatic stress disorder did not differ from the pituitary volumes in healthy kids.

I'm not making this up, folks. I mean, this guy — that's why I'm saying shame, shame, shame, shame, shame. I mean, he's using this article, he's using the fact that he can cite a scientific article to prove a point. Except that the article doesn't prove his point.

Now, they did find that in the post-traumatic stressed kids, the size of the pituitary gland before puberty compared to the size of the pituitary gland in the same kids after puberty was slightly more of an increase in the healthy kids. But this result was minimal and it was not statistically significant.

0:21:59

So what did the authors conclude? Well, they said, "Our findings may suggest developmental alterations in pituitary volume in maltreatment related pediatric post-traumatic stress disorder. This finding may be associated with stress-related differences."

Now, compare that with the article by Dr. Stephen Juan who said, "According to a University of Pittsburgh study by Dr. M. DeBellis and seven colleagues…"

Actually, there's only one colleague.

"… Published in Biological Psychiatry in 2004, children who suffer early trauma generally develop smaller brains." Sorry, Dr. Juan, but that's not an accurate description of that study.

[Verbal Noise]

Dr. Mike Patrick: We're going to give you a buzz on that one.

OK, so let's go on to Dr. Juan's next point which is actually even easier to address. He said, "A Harvard University study by Dr. M. Teicher and five colleagues, also published in Biological Psychiatry, claims that the brain areas affected by severe distress are the limbic system, the left hemisphere, and the corpus callosum. Additional areas that may be involved are the hippocampus and the orbitofrontal cortex."

OK, he says they're affected but you noticed he doesn't really say how they're affected. But where he got this information is also from a 2004 article — which again I read and I don't think he did — called "Childhood Neglect Is Associated With Reduced Corpus Callusom Area". Once again, the subjects weren't babies, they were all older kids and they were all psychiatric patients who had been abused by their parents. Again, they did MRI scans and compared them to healthy non-abuse kids and they found that various portions of the brain, most notably the corpus callosum was smaller in the abused kids.

And this time, the results are statistically significant. But again, these aren't babies and crying it out was not the only difference between the two groups. These were older kids who'd been abused enough to wind up seeing a psychiatrist. So Dr. Juan still gets another buzz.

0:24:05

[Verbal Noise]

Dr. Mike Patrick: OK, I tried to find a good sound file I'll use as a buzzer. And I searched and searched, I just couldn't find one that was good enough. So, I thought, you know, I'll just give them that [Verbal Noise]. That would be good enough.

[Laughter]

Dr. Mike Patrick: OK, and I also want to point this out. Could it be that parents who abuse their kids have smaller brains? And could it be that the abused kids inherit smaller brains from their small-brained parents? The study doesn't address that possibility at all, but of course, it's a very real possibility. And I think it would have been a better study if they had also compared the kids who were abused, take their parents who did the abusing and see if they had smaller brains, too. Because, I bet they did.

That's my hypothesis. That's the next study that I would do. I bet these kids who were being abused had small-brained parents who were abusing their kids and they inherited their smaller brains. OK, it's a very real possibility.

OK, what about this book that Dr. Juan say? It's "The Science of Parenting" by Dr. Margot Sunderland. Well, it sounds great on the surface, right — The Science of Parenting. But, unfortunately, the sorts of studies that she references are just like the ones we went over.

Does her book describe this great study which takes two large groups of infants and exposes one group to crying it out and gives in to every wanton demand of the other group so there are no tears, and then take brain MRI measurements at the beginning and end of the study period to see if the cry-it-out group has smaller brains than the spoiled group? No, that study isn't in the book because there is no such study. The author takes basically poor research and forms opinions around it.

I like this review of the book at Amazon. This reviewer said, "Do not waste your money on this book. Consider the chapter on discipline. The same tired old folk wisdom is trotted out with absolutely no scientific defense. Yes, the author recommends time-in — where you talk to your kid about why they behave the way they do and the fact if you can see if you can figure out the problem together — which you can't really do with a baby."

[Laughter]

0:26:22

Dr. Mike Patrick: "She also recommends time-out as the last resort with one minute for each year of age. Where on earth did this recommendation from timing come from? What's the empirical evidence for one minute per year of age? It's so standard that it's really questioned and here it is again — just another author's opinion and just the same opinion of millions of other people. A tad disappointing."

"Also, the author is very keen on ignoring bad behavior and praising good behavior such as giving stickers, et cetera, in order to motivate more good behavior in the future. But again, no empirical evidence is given for the efficacy of this." So as it turns out, The Science of Parenting isn't really so scientific at all.

And now, I'm not disagreeing with the advice that Dr. Sunderland gives in her book. It's just not very scientific. I mean, I'll agree that in older kids, discussing why they did things and why they did it and "Let's figure out the problem together," I'm all for that. Again, you can't do that with a baby.

I'm all for time-outs and I think a minute for your baby's just probably good. That's my opinion. It's not based on any science, but it is based on experience. So, I mean, I'm not stomping on this book, but it doesn't do what Dr. Juan wants it to do, and that is to confirm through science that letting a baby cry it out until they finally go to sleep is going to cause brain damage. It does not say that all. So Dr. Juan gets a third buzz.

[Verbal Noise]

Dr. Mike Patrick: Finally, Dr. Juan says allowing a baby to cry it out when they are upset will probably be regarded as child abuse by future generations. I don't think so, Dr. Juan.

So Michelle, you may be upset to hear that I do support the cry-it-out method. And the reason I support it is because it usually works in three or four nights, folks. I mean, if you stick with it and you let them cry, and you let them cry, and you let them cry, and they figure out that they're not going their way by crying, they stop. They stop because they figure out that it's not worth the energy because they're not going to get what they want.

0:28:22

So, I don't think it's this horrible emotional problem. In ten years of practice, I've never seen a kid that if you let them cry it out does it for more than three or four days. It usually works very quickly.

So anyway, if you ask me, Michelle, the one you should really be upset with is Dr. Juan, because he fooled you by slapping together an article with more holes in it than Swiss cheese. And you should be upset of yourself too, Michelle, for taking everything you read online as truth, without doing some of the homework yourself.

OK, let's move on. I told you that one was going to be fun.

[Laughter]

Dr. Mike Patrick: Jessie, in Madison, Mississippi says, "Hi, Dr. Mike. I have a 16-month-old daughter. She is starting to hitting me on the face and on the arms when she doesn't get her way. I tell her no in a stern voice but this doesn't really seem to get the point across. I'm assuming she learned this behavior at day care. I know she has been bitten several times there and this may be how she defends herself. I don't really know how you feel about spanking her hands or other body parts at this point. I don't want her to think hitting is OK and I'm afraid if I spank her or pop her hand, she'll think this is normal behavior, too. Do you have any advice for a new mom regarding effective ways to discipline at this age? Thanks for your time."

OK, I'm going to take a quick drink here, because I still have this scratch on my throat that I had last week. I think it's allergies. We're right in the midst of Ohio pollen season and I just got the stuffy mucus also. I know it's more than you want to hear, but I'm just explaining why I need to take a break to take a sip.

OK. And you know, me and post-production don't work out very well.

0:30:02

A 16-month-old discipline, it's a tough subject. And at 16 months, I'm still all for just ignoring and redirecting. I mean, there are some 16-month-olds out there who are going to be able to understand right from wrong. But I don't think that most 16-month-olds are quite there yet.

Now, after that last question, I'm a little self-conscious of opinions here. But there really isn't any research out there on toddler discipline. So all we have to go on is experience an opinion. So, that's all I can give you here.

So my opinion would be that a firm no is probably not going to help you out too much. Because if a young toddler doesn't yet fully understand the meaning of no, which is likely, then you run the risk of your child trying to smack you so they can hear you make this loud low-pitched sound. That's kind of cool, it's cause and effect. "If I smack mom and she makes this "NO!", it's a cool noise that I don't hear very often. That's awesome. I can make her make that noise. And so, I keep doing it." So I'm not a big fan of the firm no at this age.

What about spanking or hitting him or popping him on the hand? In other words, what about physical discipline at 16 months of age? Well, I agree with your assessment, Jessie. You run the risk of your daughter not understanding the meaning. And then, you are modeling the very behavior you are trying to get rid of. She smacks you, you smack her. She giggles and smacks you back. It quickly becomes a game and before you know it, she's hitting you more often because she wants to play the game. So, that's not really a good strategy either.

In terms of her learning this behavior at day care, that is very likely. It could be a defensive move as you suggest but I think it's more likely that she's learned it because someone is hitting her at daycare. And if there biters around, there's probably hitters around as well. And so, she has a role model at the day care to teach her these things and that wouldn't really surprise me at all.

0:32:07

So my next question becomes, do they have enough staff? Are there too many kids in the day care for adequate control? Why is she getting hit and bitten at day care? And that's definitely something to look into.

OK, so how would I handle this? Well, I would eliminate modeling behavior at home and day care. So you don't want anyone hitting her at home or at the day care. And then, I think that redirection is a good first move. You know, she starts to hit you, just get her mind on something else , "Hey let's look at this picture." Just sort of ignore it and not give any response to it that would make her want to do it again to get that response again.

So, I think your best bet, at 16 months again, we're talking is just to sort of move on and, "Hey look at the mirror, here's the baby. Oh, it's you. Let's look at this." And really, just try to ignore it and redirect.

Now, if this fails, then the next thing that I would do is just completely and totally ignore her whenever she does it. And you could gate off a room, make sure it's toddler safe. No TV, radio, no good stimulation kind of stuff, nothing she could pull down on herself, outlets are all covered. It's safe, it's toddler safe, it's gated off. And when she starts hitting you, if she's not responding to redirection and she keeps hitting you, just immediately put her in that room by herself and ignore her for five minutes.

Now, I know she's only just over a year old. So the standard would be ignore for one minute. But this isn't really a true timeout because she's allowed to move. You just aren't paying her any attention for five minutes. And so, she's hitting you to get your attention, if the opposite happens every time she hits you, then it's likely that she's going to stop doing that and try to figure out a better way to get your attention.

Now, the only pitfall here is if your child likes the room and likes to be alone and starts hitting you to get in that room and have some alone time. Then, that's not going to work very well to extinguish the behavior.

0:34:07

So in the end, I think redirection at this age is going to work well for you. If not, the ignoring strategy should do the trick, especially since the problem is happening at the time when she is trying to get your attention. And since hitting her gets her the opposite of what she's after, ignoring her for a few minutes should help extinguish the behavior and motivate her little brain to figure out a more appropriate way to get her point across.

And, of course, you're going to have to make sure she's not getting hit at day care, too.

OK, let's move on. Shelly in Luxembourg. Yes, the country in Europe. Shelly says, "Hello from Luxembourg, Europe, Dr. Mike. I've loved your show ever since I found it six months ago. You really provide an informative and entertaining service to us parents. My question to you is about possible migraines in a preschooler."

"My otherwise totally healthy five-year-old daughter has recently, within the past four months, about once or twice a month, had episodes that seem to be like migraines. She would complain of a headache behind her eyes, according to her, and be really irritable and whiny for a short time, maybe ten to 20 minutes, then she'll vomit. And very shortly thereafter, she will most often go to sleep for half-hour to an hour. Once it's over, she's totally fine again and in good spirits. The episodes seem to occur mostly when she is overly excited or overly stressed."

"I understand migraines have a genetic component, however nobody in either family has migraines. And I wonder if there is a potentially more serious problem that I should be seeing a neurologist about. In general, are migraines common in this age group and how should they be treated? Do migraine just come on like this in a certain age? Will she suffer from them her whole life? Thanks so much for your great show and for answering my questions."

OK, so a five-year-old with the possibility of migraine headaches. Now, again, I'm going to focus on answering your questions, Shelly, rather than doing a migraine mega-talk with everything you ever wanted to know about migraines. And we'll save that for another time, because there's lots and lots we could cover. We could talk about etiology, what starts the process of migraines, pathophysiology, how does the migraine cause the symptoms that you are seeing, what are the typical symptoms, what are the atypical symptoms, what triggers, how do we prevent it, how do we treat it. And we can go on to all that, but I'm just going to focus on your questions today, Shelly.

0:36:33

So how common would a five year old with migraines be? Well, not incredibly common, but not unheard of either. I mean, I'm not seeing five-year-olds with migraines everyday in my office. But you know, once every couple of months, I'll see a young kid with migraines. Maybe, even once a month. So a five-year-old, maybe that's a little less common; ten-year-old, more common. But it's not unheard of. So it's definitely a possibility.

And I will say this, Shelly, what you described could certainly be migraines. I mean, the description makes a good case for migraine to being the problem. Now, I would like the migraine answer more if you told me there was a family history of migraine, especially beginning in young childhood. If you told me, "Yeah, I've had migraines since I was five and my mom had migraines since she was in kindergarten", then, I'd feel more comfortable saying, "Yeah, it's probably migraine." But I don't think we can make the diagnosis of migraines based only on this history. Even though it's likely, I wouldn't make the diagnosis based on the history especially without the family history there.

I would want to make sure there isn't something going on inside the head first. You know, like a tumor, for instance. I mean, I don't want to scare you, it's probably not a tumor. But I think there's good cause to scan a child's head with these symptoms. Maybe with a CAT Scan to start with or without contrast to make sure that there's not something inside the head like a tumor or other things that would be causing this.

0:38:09

I've seen a couple of kids, too, with something called a Chiari II malformation and that also could cause this kind of symptoms. So anything that can cause increased intracranial pressure could cause recurrent headaches with vomiting. And so, I think that any toddler, young child, with these symptoms deserves a scan of the head.

Now, let's say I've done that and it's negative, which is usually the case. Next thing, I would do is say, "Well, probably, it's migraine" and try a migraine prevention drug. And at this age, a good one to try is one — the brand name is Periactin — generic, it's called cyproheptadine. It's an anti-histamine and it's also an anti-seratonin agent. It got a good safety profile for kids. It's not expensive. And if you try that and the episodes go away with the medicine, then I'd feel comfortable saying we have the correct diagnosis. I mean the history matches, the head CT's negative, we try a medicine known to prevent migraines and that medicine makes the symptoms go away, I'll feel comfortable saying it's migraine.

Again, I'm not telling you that this is what your doctor needs to do. I'm just telling you if I were confronted with this situation in my office, given the facts that you've given me, this is where I would go with it. And then, I would probably continue that prophylactic drug for three to four months, the periactin, sort of to get through a season. And then, I would try it off and if the headaches return, I would start it again for another three to four months. Repeat that cycle over the course of a year, that way you can see if it's seasonal. I mean some kids might need the medicine every Spring. Some are going to need it every Fall. Some are going to need it only in the Spring and the Fall. Some are going to need it all year round.

So if allergies are the trigger for the migraines, you want to find out when their allergy season is and give them the prophylactic drug during that season.

Now, of course, allergies aren't the only trigger. So keeping a diary of when these headaches are occurring is also a good idea, so you can try to identify any triggers that seem to be causing the headaches and then avoiding those triggers.

0:40:14

Now, in terms of, do migraine just start out of the blue? The answer is yes. I mean they have to start sometime, right? So it's always going to be out of the blue unless they start having migraines from infancy which is pretty hard to diagnose. Because, you know, the kid's just crying, they can't tell you they have a headache. How many kids cry and spit up?

So, you know, it's going to start at some point and it's always going to seem like it's starting out of the blue. I guess they may start more sporadically, may be happening once every couple of months and then getting to the point where they're happening once or twice a week.

So if allergies or immune response is the trigger, remember there is this process of synthesization and we've talked about that before. So it is common to be fine with some exposures and then, the immune system at some point decides it doesn't like that exposure anymore, starts making antibodies and, wham, you start having problems and migraines can result from allergies. Of course, not in everybody but in some. And this can occur at any age, kids and adults alike.

Now, what if the migraine prophylaxis doesn't stop the episodes? OK, so let's say the head CT was negative, you try some periactin, and the headaches don't go away. It doesn't do anything, what do you do now? Well, the next thing I would probably do is check an MRI instead of a CT at that point because you're going to get a much clearer picture and there can be some more subtle problems inside the brain that can cause increase in the cranial pressure.

So MRI would probably be good next step. Like an EEG looking for seizure potentials because there are some seizures that could do this, too, where you get headache and then vomiting and then you're kind of out of it for about an hour afterward with no shaking. There's something called a complex partial seizure and there are temporal lobes seizures. And these are things that can show up as kind of funky behaviors and headache and vomiting could go along with that. Doesn't come to mind first but it is in that sort of down low in the differential diagnosis.

0:42:15

And so, if things aren't working out and you migraine prophylaxis is not working, then getting an MRI and an EEG might be a good next step. If nothing turns up with that and the symptoms continue, that's the point that I would personally send the kid to a pediatric neurologist.

There are other migraine prophylactic medicine options such as beta blockers like Inderal, Depakote, Topamax. These are all more expensive drugs, have more potential for side effects and there's less of a long running safety experience in kids with these medicines. So certainly a pediatric neurologist is going to feel more comfortable prescribing those things than a primary care doctor. And there are other diagnoses to consider as well. The child might have to have a spinal tap with opening pressure to rule out, something called pseudotumor cerebri. Lyme disease, other autoimmune diseases can cause these kind of symptoms.

So, again, all these are unlikely, 99 times out a 100, you try the periactin and it goes away. But you know, when you aren't resolving symptoms, you have to keep looking. So that will be my approach.

When should your doctor refer to a pediatric neurologist? That depends on their experience and their comfort level with dealing with young kids who were suffering from headache problems. I mean, they may want to go ahead and just do the referral to the pediatric neurologist right at the get-go. Let the pediatric neurologist order the CT scan or try the periactin. So it just depends on your experience and how comfortable you are with these kinds of symptoms.

Anyway, I hope that helps, Shelly. We will talk about migraines again in the future because there's really a lot more that we could say about migraines but I guess I will save that for another day.

All right, that concludes our Listener Segment for this Memorial Day. We'll be back and we will wrap up the show after this break.

0:44:05

[Music]

Dr. Mike Patrick: All right, as always, thanks goes out to Nationwide Children's Hospital, audiblekids.com, Vlad Studio, Medical News Today, my family and, of course, listeners like you.

Karen's PediaScribe blog: "Taylor Mason is so funny. How funny is he? Well, he's so funny that next time I will go to one of her shows, I'm going to wear Depends." That's Karen's quote, not mine.

So, who is Taylor Mason? He's a comedian. He's a family-friendly comedian. But let me tell you, even though he's family-friendly, he is funny. We first met Taylor on a Disney cruise. He was one of the featured entertainers. He does music, he does a ventriloquist act which is just really great. It's clean fun and we liked him so much on the cruise ship. We saw him every chance we could get.

This was back like in 2004, I believe. And we bought his DVD, we bought DVDs for other people, share them with other people; and really, just sort of became a fan.

He's been on some TV shows and, of course, whenever he's on TV, we try to watch him. And as it turns out, he's on a comedy road trip right now. So we went, saw him live again about a week ago. And we took a picture of him with the kids and with his puppets that he uses to his show, a picture of him when he saw him on the cruise and he was gracious enough to sign it.

And, of course, he knew right away it was from the Disney cruise because I think he saw the backdrop and the curtains and with the stars or something on there. So he knew, and he's like "Oh, you're on the Disney cruise and saw me!" And I think if we see him a third time, he'll remember us. Because it's a little weird for someone to bring a picture up and say, "Hey, can you sign this picture that we took of you three or four years ago?"

0:46:31

So anyway, you may want to check Taylor Mason's website. He does have DVD's for sale at the site. They would make a great Father's Day gift idea and what fun to watch family friendly comedy with dad on Father's Day. So you got to trust me on this one. He's extremely talented and just so, so funny, safe for the entire family and you can check him out at Taylor Mason, taylormason.com. I also have a link in the Show Notes. And you can read Karen's blog post "Taylor Mason Is So Funny" and there's a link to that in the Show Notes as well at pediacast.org.

My daughter, my teenage daughter wants to start a blog. Now, as a web safe-conscious dad, if my daughter is going to start a blog, her father is going to read the blog. And not only that, all of you are going to read the blog as well, if you want to. So there's not going to be any mischief on the blog of my teenage daughter. So coming soon, baggachips.com, like all that in a baggachips, baggachips.com. It's not up and running yet, but it will be soon and you can visit my teenage there and it will also be safe for the whole family. Trust me.

All right, reminders, the PediaCast shop is open for your shopping pleasure. We have t-shirts, tote bags and the like. So check that out.

Also, iTunes review are oh so helpful. They really are. If you found PediaCast through iTunes and started listening because of all the great reviews we have there, please take a moment to add to those reviews because it really does help keep our numbers up. It keeps us high in the listing so people can find us easily. So your reviews on iTunes are very, very important.

The Poster Page is available. You can download PDFs to advertise the program for us, hang them up on bulletin boards all over the place where it is allowed. And, of course, we do have a listener's survey that helps us out a lot too. If you haven't taken a moment to do that, we have a new one. If you only did the old one, please take 30 seconds to do the new ones really quick, nothing like the old one. And we do need your data on the new one even if you did the old one. So the Listener Survey is available for you.

0:48:47

You'll notice that we don't charge any subscription fees. There's no little button in the side bar for PayPal to say "Hey, pay me, give me 20 bucks." I'm not begging for money, I'm begging for reviews and poster downloads and t-shirt sales, which we don't make any money off of, but it just helps spread the word.

All right, I hope everyone had a great Memorial Day and that you have a great week. Even if it's not Memorial Day when you listen to this, if you didn't do it, take a few minutes to talk to your kids about the meaning of Memorial Day. So they can have a clear understanding of why we celebrate it and the importance of our Armed Forces in letting us be free in the United states of America, where I can have a podcast and say whatever I want. And you could, too.

Until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids.

So long everybody!

[Music]

2 thoughts on “Crying It Out, Toddler Discipline, Migraines – PediaCast 126

  1. Please read the article by Darcia Narvaez, an Associate Professor of Psychology and Director of the Collaborative for Ethical Education at the University of Notre Dame. Her research explores questions of moral cognition, moral development and moral character education. She has developed several integrative theories: Adaptive Ethical Expertise, Integrative Ethical Education, Triune Ethics Theory. She has written dozens of research articles and chapters. She spoke at the Whitehouse's conference on Character and Community. She is author or editor of three award winning books: Postconventional Moral Thinking; Moral Development, Self and Identity; and the Handbook of Moral and Character Education. She is editor of the Journal of Moral Education. 
    She presents a scientifically supported alternate view to "crying it out,"
    http://goo.gl/sL1sc

  2. Pingback: PediaCast 134 * Crying, Belly Buttons, Immunity | PediaCast

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