Crying, Belly Buttons, Immunity – PediaCast 134
- Pregnancy and Alcohol
- Bad-Tasting Medicine
- Athletes Promote Junk Food
- Crying It Out
- Belly Buttons
- Illness Frequency
- Alcohol Consumption Can Cause Cell Death Leading To Abnormalities
- Helping The Medicine Go Down
- Professional Athletes Asked To Reject Promotion of Processed Junk Food
- The National Action Against Obesity
- "Killer at Large" (Movie Site)
- MeMe Roth's Nutritional Counseling Site
- PediaCast 108: Babies Rule
- PediaCast 126: Crying It Out
- Mommin' It Up (belly button post)
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Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. "For every child, for every reason."
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 134 for Monday, September 29th, 2008.
"Crying" yeah, one more little tidbit on Crying It Out, it won't last long though.
"Belly Buttons" we're talking about belly buttons and problems you have especially in babies and toddlers.
And then "Immunity" we're talking about the immune system. What is normal in terms of the frequency of illness that toddlers in particular get? How common are illnesses? You hear that all the time from parents in the office.
He's sick all the time. So what's normal? What's not normal? We're going to talk about that in a little bit. So, OK, this is a little bit sad. This is my last show from Birdhouse Studio.
And really Birdhouse Studio right now is just a skeleton of its former self. I mean, as I look around there's bare walls. As most of you know, we are packing up and moving from Ohio to Florida, yes, a thousand miles away.
It's a little sad saying goodbye to Birdhouse Studio but bigger and better things await us. We need a new name for our studio.
We have to have a rental house for about six months. We're building a house in Central Florida. So we'll have a rental house and that one may be we'll call that one "Transition Studio" and then we'll come up with a name for the new permanent studio, which will be some coming up, opening up sometime in the spring. So we'll see how that goes.
All right. Now I know we're a couple of weeks from the last hurricane. I forgot to mention the last show though and I wanted to. Why are we glued to hurricane coverage?
You watch these guys like Geraldo and Jim Cantore, Al – reporting live with the winds.
It's like 80 miles an hour and they're yelling "Oh, there's 10, pieces of 10 flying around but it's not a head level yet and then Geraldo got wacked in the legs and went down. These guys are lucky. The storms wasn't really what they said was going to be in the Galveston, or else they may have been in a little bit more trouble.
But the thing is, we encourage this behavior by watching it. And not only do I enjoy watching it, the other thing is I wish I was the one doing it. [Laughter] No, it's just sick. And I think if I weren't a pediatrician, I probably would have been a weather man.
There was a guy. He got the coolest job but I know they really shouldn't be out there on the beach when the big storms are just coming at Galveston.
Just not a really smart thing to do and yet, I'm living vicariously through them. And I think that's probably why I enjoy watching him so much and probably why others do, too. But hopefully they'll stay safe.
Speaking of the weather people, I also like Stephanie Abrams. She's also in the Weather Channel. Talk about shattering the glass ceiling, Hilary couldn't do it. I don't know if Sarah Palin is going to do it.
But look, Stephanie Abrams on the Weather Channel has definitely shattered the glass ceiling because she's out there on the beach with hurricanes reporting along with the big guys. So I think it's pretty cool. Again, it's just because I wish I was doing it.
That will be my ideal party, by the way. Geraldo, I think, I would invite Shepard Smith because he's out there whenever there's a hurricane in New Orleans. He's always there. And I'd invite Jim Cantore and Stephanie Abrams, too.
So a little peak into my personal life, if I had to have an ideal party those would be the guests of honor.
And of course, I'd invite all of you guys, too. Don't get me wrong.
All right. Things are certainly taking shape with our move and that's the reason for this every two-week shows so a longer gap than I'd like. We're going to have one more two-week gap after this program to help us get a little bit more settled.
And then I hope to start the weekly shows again in mid October. So just one more two-week gap and then we'll be back to the weekly shows after that. If you want to follow along with our move on a personal level, be sure to check out my wife's blog, the Pediascribe, which you can find at Pediascribe.com and my daughter's blog Baggachips, which you can find at Baggachips.com.
And both of those we have links, of course, in the Show Notes for you to find those easily.
OK. And one more bit of business before we get into the "meat" of the program. This is really on a serious note.
I want to say goodbye to my former patients. It's been a great, fantastic, wonderful 10-year run in the practice that I have left. And I just want to say that those of you who I had the honor of providing medical care to your children, I just want to say it really has meant a lot to me. And I want to thank you for trusting me with the care of your children.
Of course, you're still in good hands. I'm leaving you with a fantastic practice and there are plenty of good doctors left there who are going to take really good care of your kids. But I just wanted to take the time to say that it's not "you guys" that have chased me out of Ohio [Laughter], OK? And I will miss all of you. I really, really will.
And those of you who did not come to the office to see me in the final months because this has all happened pretty quickly and you only know about the move because of this program so you didn't see the signs posted in the office.
I didn't to get to say goodbye to you personally, consider this your personal goodbye. So you really have meant a lot to me. Thanks for trusting me with your children but you're still in good hands and of course, you can always drop a line and say "Hi" at PediaCast. Just use the Contact page and say "Hey, what's up?"
All right. So we've got lots coming your way. Don't forget if there is a topic that you would like us to talk about, all you have to do is go to pediacast.org and click on that Contact link. You can also email firstname.lastname@example.org.
If you do that, make sure you let us know where you're from, and of course, the call the voice line is open for calls, 347-404-KIDS. You're more than welcome to ask a question that way as well.
Don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.
And with all that in mind, we will be back with News Parents Can Use, right after this short break.
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New insight has been obtained regarding how alcohol during pregnancy might affect fetal development, according to research performed at the Medical College of Georgia and funded by the March of Dimes.
Fetal alcohol syndrome, according to the Centers for Disease Control and Prevention, affects 1 in 1,000 babies. Pregnant and sexually active women who are not using effective birth control are recommended to refrain from drinking.
Most notably, babies who are the victims of this disease have classic facial malformations, including a flat and high upper lip, small eye openings, and a short note.
These facial clues could provide insight into the mechanism of this process, as well as how much alcohol imposed at what point in development might cause these changes.
Dr. Erhard Bieberich, biochemist at the Medical College of Georgia has focused work on the mechanism that causes problems for children with fetal alcohol syndrome.
Strong evidence has shown that, in just the first weeks of fetal development, usually a period before a woman knows she is pregnant at all; a few glasses of wine in an hour could increase cell death. Death of cells might further develop to form the face, brain, or spinal cord could lead to developmental problems in those areas.
"It's well known that when you drink, you get a buzz. But a couple of hours later, that initial impact, at least, is gone," states Bieberich. "But your fetus may have experienced irreversible damage."
In development, there is always a set of cells that die once they have served their purpose, and a set of cells that move on to form other types of cells.
"There is always a very delicate balance between newly formed cells and dying cells," says Bieberich. It's a very active period of that balance, because usually you develop a surplus of tissue then later melt it back down to acquire a specific shape."
The classic example of this phenomenon is the absence of webbed fingers in newborns, while the fetus maintains skin between the fingers for some time. The digits form because the inter-digital tissue dies. If it did not die, then we'd born with paddles instead of hands with fingers.
According to team, damage may result from the accelerated death of neural crest cells, which help form various types of connective tissue, including bone, cartilage and parts of the cardiovascular system.
At the same time, neural tube cells form the brain and spinal cord. This means the visible damage shown in facial abnormalities may be a signal that future problems could be present in learning, memory, vision, hearing, or other areas.
The cell death can result from disruption of the metabolism of lipids that help control the initially undifferentiated cells due to the alcohol.
Bieberich compares cell loss in mice following various levels of alcohol consumption to the usual birth and death of cells in normal development. The focus lies in the neural crest cells, which among their other functions form the upper part of the skull.
Some of these cells will remain in the brain, and are often controlled by the same factors as the neural tube cells, which might lead to the cognitive and memory problems. While this type of damage may be difficult to identify in mice of this age, it has been shown that damage to the neural crest gene can cause problems in both skull and brain development.
Dr. Bieberich hopes this information will help women understand the true risks of alcohol consumption during pregnancy and help develop a method to reduce the damage. "You have to make people aware of the science behind the risk," he says.
"We are not saying that every pregnant woman who drinks three or four glasses of wine in a short period will have a baby with birth defects, but it does elevate the risk."
Getting little Doug and Debbie to take a spoonful of medicine is more than just a rite of passage for frustrated parents. Children's refusal to swallow liquid medication and their tendency to vomit it back up is an important public health problem that means longer or more serious illness for thousands of kids each year.
In a report presented at 236th National Meeting of the American Chemical Society, Dr. Julie Mennella describes how knowledge from basic research on the chemical senses explains why a child's rejection of bitter medicine and nutritious but bitter-tasting foods like spinach and other green vegetables is a reflection of their basic biology.
"Children's rejection of unpalatable medications and bitter-tasting foods is a complex product of maturing sensory systems, genetic variation, experiences and culture," says Mennella, a researcher with the Monell Chemical Senses Center in Philadelphia.
She says, "Children are born with much stronger preferences for sweet flavors, naturally attracting infants to mother's milk. This heightened preference for sweets continues even into the teenage years. But by late adolescence, kids begin to outgrow this sugary preference."
"A better understanding of the sensory world of the child and the scientific basis for distaste and how to deal with is a public health priority," states Mennella.
She investigates the role of early experience as a child develops their unique sense of taste and smell. In the process, she ultimately hopes to find ways of creating more palatable medicines and getting kids to eat their greens more readily.
"The number one reason for noncompliance among children when taking medicine or eating vegetables is they don't like the taste," says Mennella. "Just look at a child's face when they're eating some of these things."
The root of this bitter problem lies in the human taste buds or taste receptors. While there are only a few receptors for sweet flavors, nearly 30 detect bitterness. From an evolution perspective, this heightened sensitivity to bitter taste prevented early humans from eating toxic plants or other unsavory and possibly poisonous fare.
"Bitter taste is a sensation that evolved to make you not want to ingest something," says Mennella. Unfortunately, most of the chemicals in the pharmacist's cookbook are plant-derived and therefore inherently bitter.
Some of the more potent drugs like certain AIDS medications for children are even less pleasant often smelling very bad and causing mouth irritation. For some medications, masking the bitterness is possible by encapsulating the bitter chemical in pill or tablet form, or by using special "bitter blockers" that numb the tongue's receptors.
But many children have trouble swallowing pills, so liquid formulations are needed. Adding sweet tastes and flavors that children like helps the medicine go down.
Unfortunately Mennella says it's extremely difficult to mask the flavors of some of the truly bitter liquid medications. A better understanding of bitter taste receptors may yield new ways of overcoming these unpleasant flavors.
A recent explosion in taste and smell research led to the identification of genes that code for certain bitter taste receptors. Mennella's team showed that a variation in the TASR38 gene is linked to the perception of bitterness in children and their parents.
The researchers found that while parents with this variation were sensitive to bitter compounds, their children were most sensitive of all.
"It's interesting because it may suggest children have heightened bitter sensitivity compared to adults," states Mennella.
Babies begin developing their unique tasting profile while still in the womb. What a mother eats while pregnant and nursing enhances a newborn's acceptance of foods.
"We find that the more a mother eats fruits when she's pregnant, the more a child will accept fruits and vegetables," says Mennella.
The culture a child grows up in also plays a huge role in the development of taste and smell. For evidence, Mennella points to the flavorings found in children's medicine around the world. "In England, lemon flavor is most often added to children's medicine while bubblegum and cherry are more popular in the United States."
When children cannot or will not take medicines in encapsulated form, methods to reduce the bitterness in liquid medications become medically significant. Failure to consume medication may do the child harm, and in some cases, may be life threatening.
Mennella thinks pharmaceutical companies will benefit from more basic research on bitter taste and how to combat it. And I, along with millions of moms and dads, agree.
As a saturation of Americans who are overweight is projected to reach nearly 100% – nearly 100% by 2040 and with 30 to 40% of today's children projected to develop diet-related diabetes in their lifetimes, leading child obesity advocates denounce Michael Phelps' endorsement of Kellogg's Frosted Flakes Cereal, which was quickly followed by his acceptance as being named a McDonald's Ambassador.
They implore the Olympic gold medalist and swimming phenomenon to reject offers to promote junk food. As a role model and Olympic hero to America's children, Michael Phelps and all athletes and celebrities are asked to reconsider any connection to substances suspected as agents of obesity including sugary cereals, soft drinks, and other foods with refined carbohydrates, saturated fats, transfats, and high fructose corn syrup.
"Public figures like Michael Phelps exert a major influence over our youngsters," said Douglas Castle, Senior Advisor to the Children's International Obesity Foundation. "Mr. Phelps is a super athlete by any measure but his judgment regarding the McDonald's and Kellogg's Frosted Flakes endorsements was either 1) ill-advised by his handlers; 2)the irrational product of too much blood sugar; or 3) a sad triumph of greed over good."
"Children's International Obesity Foundation believes celebrities should think twice before choosing to endorse or encourage the consumption of any product which is inherently unhealthy to children, especially if that product is correlated to obesity, diabetes and a myriad of dangerous conditions."
"Octagon Sports Agent Peter Carlisle is making a strategic branding mistake by aligning Michael Phelps to Kellogg's Frosted Flakes and McDonald's. In this era of escalating child obesity and diabetes, the last association Michael Phelps wants is that of "junk food pusher," said Meme Roth, a National Action Against Obesity and the Children's International Obesity Foundation member.
"While Michael Phelps may consume thousands of calories a day and burn them off through Olympic training, America's kids aren't so lucky. They're fat, sickly and have little hope of accomplishing a single sit-up much less Olympic Gold."
See? There are people who are more cynical than I am. "Kids are watching, and Michael Phelps' going for the quick cash of pushing junk food at the expense of children tarnishes his image similar to an association with cigarettes or alcohol would."
"National Action Against Obesity and the Children's International Obesity Foundation implore Michael Phelps, and all celebrities and athletes, to reject offers to push more sugar, fat and hazardous calories onto America's kids."
The Children's International Obesity Foundation recently endorsed the controversial obesity documentary "Killer at Large" as a film that reveals the true story behind the many hidden causes of America's obesity epidemic.
The organization is working with the filmmakers on a November fundraising screening and obesity awareness gala in New York City.
"As we set out to look at the causes of obesity in our file," Killer at Large," we found that one of the most prevalent contributors to childhood obesity is the overwhelming amount of advertising directed at our nation's youth that confuses unhealthy food with messages of wellness."
"Michael Phelps' endorsement will undoubtedly influence more children to nag their parents for products that endanger their health so that they can go home, consume these products, and gain weight instead of becoming gold medalists," insists "Killer at Large" producer Bryan Young.
"This is unconscionable and we hope that Michael Phelps reconsiders his endorsement contracts."
As for Kellogg's, such sugar-laden brands are struggling with their images so they are investing marketing dollars in "exercise". Telling children to exercise rather than eat right takes the spotlight off Kellogg's role in promoting empty calories for kid consumption.
For example, Frosted Flakes funds little league baseball, track clubs like "Girls on the Run" and the American Youth Soccer Organization – America's largest youth soccer league.
While the practice of celebrities inducing children to consume junk food is illegal in many countries, it's left to industry self-regulation in the U.S.
Kellogg's recent promise to stop marketing junk food to the under-12 set has gaping loopholes allowing them to push sugary cereals such as Frosted Flakes onto unsuspecting children. The nutrition label reveals scant fiber and protein, along with a heaping 12 grams of sugar, which is equal to three teaspoonfuls for a modest three-quarters cup of Michael Phelps-emblazoned Frosted Flakes.
"That's no breakfast of champions," said Roth.
The activists behind this stand against celebrity endorsements of unhealthful foods have two main goals for 2008: 1) Draw attention to the need for day care centers to be 100% junk-food free, "because children under five deserve environments full of healthy options, not marketing venues for junk food producers," added Castle.
And number two – Urge parents and restaurants to refrain from serving soft drinks to children. Soft drinks, along with some sports and energy drinks, are linked to obesity and diabetes, along with tooth decay and osteoporosis.
On a larger scale, National Action Against Obesity has three main goals: Expelling junk food from schools; eliminating obesity- and disease-accelerating substances from the food supply; and breaking the obesity cycle, while encouraging exercise across all ages.
You can find out more from the National Action Against Obesity by visiting their website. And as always, we'll have a link for you to that in the Show Notes at pediacast.org and we'll also have links there for you for the film "Killer at Large" and MeMe Roth's nutritional counselling website, so that's all available for you in the Show Notes over at pediacast.org.
All right. That wraps up our News Parents Can Use and we will be back with our Listener segment right after this.
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All right. Welcome back to the program. First stop in our Listener segment is Curtis.
Curtis says, "Dr. Mike, I just listened to your PediaCast 108 about Babies Rule. You advised to let an 18-month old cry when it's bedtime. We have a four-week old baby and she cries uncontrollably at times. She is usually consoled by a bottle, or my wife, or I rocking her. She usually does not go to sleep until 2 am and is usually crying and waking us up at about 5 am."
"Right now, she sleeps next to us in a bassinet. After she is fed and her diaper is cleaned, she cries, cries, cries. My wife cannot stand to let her cry and I've tried to talk her into letting the baby cry it out, after of course all of her needs are taken care of."
"I'm worried about her learning bad habits and ruling the house. Of course, we don't want to torture our child. Our pediatrician advised us pretty much to feed her when she cries which is what we have been doing, so we really have no schedule at all."
"She's still very young. Is she too young to cry it out? What age should you just let them cry? Thanks, Curtis."
All right. So thanks, Curtis. I really do appreciate you writing in. So in my Episode 108, we talked about an 18-month old who needed to cry it out, and Curtis has a four-week-old baby and wants to know if the principles that we talked about with "Crying It Out" at 18 months of age apply to a four-week-old baby. And I'll add, and if they do, why? And if they don't, why not?
I do have a link in the Show Notes to Episode 108 for those of you who may be interested in going back and listening to that. I also talked about "Crying It Out" in research associated with that in Episode 126, and we'll have links to both of those episodes in the Show Notes.
OK. First of all, let's describe what crying it out is. Exactly, how do you go about doing this? The tenets of this actually stem from the writings of a sleep specialist at Boston Children's Hospital back in late '80s, early '90s, by Dr. Ferber.
And he had a book out called "Solve Your Child's Sleep Problems" that described this "Cry It Out" method. Now there has been a recent controversy about this method whether it causes undue emotional distress to infants. And I talked about that in some of the past episodes so I'm not going to dwell on that here.
So what is exactly is Crying It Out? Basically, you put a child who's having sleep problems to bed and of course, you do, as Curtis mentioned, you want to make sure they're not hungry; they don't need diaper change; they're not too cold; they're not too hot; they're not in pain.
So you want to be convinced that the only reason they're crying is because they want you to pick them up and they want to be held; and they want to socialize and they want to be with you; and you have things to do. And it's bedtime. It's time for your child to go to sleep.
So basically, what you do is you put the baby to bed awake – that's an important part of this because if they go to bed and they are asleep when you lay them down, when they wake up, the last thing they remembered is you were there holding them and suddenly you're not there anymore.
So you want to put them to bed awake, in that way, if you they wake up in the middle of the night, there where they were when they fall asleep. They recognize that.
So you lay them. They start crying because they don't want to be there. It's not bedtime in their mind. They want to be held. So you let them cry for, let's say, 10, 15 minutes and then you peak your head in the door and you see and let them know "Hey, I'm here. Love you."
But it's all business. You don't pick him up. You just say "Hey, I'm here" and you walk out. Then they start crying again and this time you let him go a little longer so let's say, 20 minutes.
Basically, repeat the cycle and then let him go 30 minutes; repeat the cycle. Let him go 40 minutes. You basically make it longer each time with the hopes that eventually they cry themselves to sleep.
And if they wake up in the middle of the night and they start crying, you basically do the same thing, starting with about 10 minutes, then 15, then 20, then 25 and let it go through that cycle again.
The second night you do this, instead of starting at 10 or 15 minutes, you start at 20 or 25 minutes and the third night you start at half an hour. So not only each time that you peak in on them do you make it a little bit longer before you peak in, you also make each subsequent night that you're going through this last a little bit longer.
Now the first time question that parents always ask is how long do you let them go? What's the longest that you let them cry? And the answer to that is, how long do you want them to learn that that's how long it takes to get you to come in and pick him up?
Because you can have a very stubborn baby who cries for an hour, mom can't stand it anymore and she goes in, picks the baby up.
The baby learns if I cry long enough and hard enough and I'm persistent enough, then I'm going to get what I want. Mom comes in and picks me up and then it becomes much more difficult to extinguish this behavior.
Now I know there are critics out there who're going to say this is terrible. Babies have needs. They're going to feel abandoned. They feel lonely. They're going to be depressed because you're not coming in. It creates anxiety in their lives and this is just tantamount to emotional torture.
But I have a different view of that. And my experience with this is that it works, and most of the time it works really well if you stick to your guns, I mean usually, within a week. And that is my personal experience with my own children having done this and with my patient's children having described the method and hearing feedback that it works.
Now, does it always work 100% of the time? Of course not, I mean, there's going to be stubborn kids that just it goes on and on. You've got to come up with a different plan for them. But I would say 99% of kids, it works very well.
Now the next question becomes "When can you start doing this," which really is Curtis' question. Can you start doing it in a four-week old? If it's OK for an 18-month old, is it also OK for a four-week old?
When can you start? There's no right or wrong answer here. I mean, the reason to do this is because your family has needs and those needs of the family have to be balanced with the needs of the baby.
Young infants certainly have needs and parents must meet these needs. And they do have the need to be close to other humans to bond, to socialize. And in the first couple of months, that's great.
Those needs work out well with your family's lifestyle especially when mom and/or dad have time off from work so you have the time and the opportunity to meet those needs that the baby has and to promote togetherness.
And that's great. However, life catches up. Maternity leave expires. Parents need to sleep. Babies though still have these needs to be with you and to bond and all of these things which is fine. But at some point, the babies need has to be balanced with the family's needs and so you have to start looking at the whole picture.
The baby is becoming part of the family. And so at some point, the needs of the family have to come into play when thinking about the needs of the baby. So at this point, when the needs of the family are, hey, we need sleep because we have to work in the morning.
The baby still has their needs and they're figuring out how to manipulate the family. The baby's needs trump the family's needs and it is at that point when the Cry It Out method works.
And so really it's not so much when do you do it based on when it is safe for the baby. It's really more at what point does the baby need to fit with the family and that's going to be really different from family to family.
Now I find, usually around four months of age, but this is not written in stone. It's going to differ from family to family. It's going to differ from situation to situation. But I find usually around four months of age is when, enough is enough, and it's time for the baby to start blending in with the family.
And the whole idea with this is in the beginning the baby's needs do trump the family needs. It's understandable. And I think, Curtis, for you, at four weeks of age, you're probably still at that point, when it's OK for baby's needs to trump family needs.
But at some point the baby does have to become a member of the family. Baby's got to blend and the needs of the family have to be balanced with the needs of the baby. Obviously, some needs are more important than others. They get hungry. Their diaper needs change. They might too warm or too cold.
I have pain from an ear infection or erupting tooth that needs to be addressed and that's fine. You certainly want your baby to be comfortable. But if the baby's only need is to socialize with mom and dad at three in the morning, and mom and dad have to function at work the next day, it's not a safety issue. It's not a hunger issue. It's not a pain issue.
This is the time when family and baby needs have to be balanced and I think this is the time when the Cry It Out technique comes into play. So when exactly can you start doing it?
There's no right or wrong. But I find most often it's around that four-month timeframe that it's as good any.
So I hope that helps, Curtis, and thanks for writing in.
OK. Next up, we have "Belly Buttons" that we're going to talk about. This comes from Emily from Mommin' It Up. Momminitup.com. It's a great parenting blog that you want to check out.
And Emily says, "Hi, Dr. Mike. My daughter is four years old and has always had a thing for her belly button." "She rubs it when she is nervous, almost like it's a replacement for sucking her thumb or something.
She actually pulls it out so that it's more of an outie than an innie and I have pictures and the full story on the blog at Momminitup.com.
"I'm just wondering if she can cause any damage to herself by doing this or if it's a harmless habit. Thanks, Emily."
And this is Emily from Mommin' It Up and I actually have a link in the Show Notes to her post about this question. So you can see pictures of exactly what we're talking about. So thanks for writing in, Emily.
I took a look at the pictures and first off, I have to make a disclaimer here.
I can't make a diagnosis or give specific advice based on a blog post. [Laughter] You can imagine. But I can tell you my personal opinion from what I'm seeing and then you can discuss my opinion with your doctor. That seems reasonable.
So in the first picture, we have a classic innie, and in the second picture we have a classic outie. And this transformation occurs after your daughter has been playing with her belly button. So how can this happen?
First in order for this to happen, there has to be some extra skin that's tucked into the belly button when it's an innie. OK. You mean you can't stretch. The skin doesn't stretch on command.
I mean the potential for that outie skin to be out has to always be there just when it's in innie mode that skin is tucked in. Now why would she have this extra skin?
That becomes the next question.
And it's likely that at the some point or even currently that she either had or she has an umbilical hernia, either now or at some point in the past. And I can't really tell from the picture.
If she was in front of me, and I can do a physical exam, I can give you a better idea if that was a hernia that used to be there, or a hernia that's still there now.
So let's talk briefly about umbilical hernias in babies. Basically first you have to understand that the abdominal wall develops two sheets of muscle on each side of the abdomen. So there's basically two sheets of muscle and then just some connective in the middle.
And what happens during development is that muscle wall meets in the midline. Now as it grows across the abdomen on each side, and then it meets in the midline, there usually is a gap at the level of the belly button.
Why would that be? Well, it's because blood vessels have to dive down and reach the umbilical cord. So if the muscle wall there closed up completely, it would scrunch those blood vessels and it cut off blood supply.
So there normally is a gap around the belly button. But after a baby is born and the umbilical blood supply stops, that gap is quickly filled in with muscle. And so, there's not an issue.
In some babies, there is a delay in this closure. And so what can happen is that the intestine themselves can bulge through that area where the muscle hasn't come together. This is what we call an umbilical hernia.
And when a loop of intestine actually pushes up through that area where there is this lack of muscle, then the belly button gets hump and you have an umbilical hernia.
It's usually harmless but very rarely, and this is really rare with umbilical hernias.
With any hernia, there is the potential for the loop of intestine to get through that defect in the muscle wall and then muscle contracts, or too much intestine went through; and now it can't get back out. And that is called a herniated hernia. I'm sorry. It's not. [Laughter] It is a strangulated hernia. That's what was I was trying to say.
So if you have a hernia that is squished and it can't go back to the intestinal loop, can't get back to where it's supposed to be, then we call that a strangulated hernia because the muscle is strangling the intestine and the intestine can't pop back down to where it's supposed to be.
Now the danger with a strangulated hernia is that – incarcerated hernia is another name for it.
One problem with that is that the blood supply to that loop of intestine can become compressed from the muscle and that can cause death of that section of the intestine, which can then cause lots of problems, including the digestive system not working properly.
It can lead to infection of that area of the intestine because it doesn't have good blood supply. And it can lead to death of the person through sepsis because the intestine is full of bacteria. And if you have a defect, it doesn't have good blood supply.
Bacteria can get into the bloodstream and so this is a very dangerous situation when the blood supply to a loop of intestine becomes compromised because the loop is being compressed by muscle, and that's basically an incarcerated or strangulated hernia.
In the inguinal region, instead of just the loop of intestine being cut in a single layer of muscle, it actually is stuck in a whole long canal and so there's much more risk in the inguinal or groin region for a hernia to become incarcerated or strangulated down there.
So inguinal hernias, which are down in the groin area, on the right or the left, that's a different situation. Those can become incarcerated pretty easily so you have to be real careful with those.
But in umbilical hernia, it's just sticking through a thin layer of abdominal muscle wall and it's much less likely to become stuck. So if you have a kid that's got one of this, when that hernia is sticking out, like once a day you want to give it a little push, usually it pops right back in and you let go, it might pop back out. Not a big deal.
But if there's ever a time that you push on it and it won't go back in or it seems tender, you want to bring that up with your doctor immediately.
It's not one of those things that you wait till the next day. You call them right away. If you can't get a hold of him, you take your baby to the emergency room.
Again, that's only if you push on it and it won't go down. Now usually you push on it, it goes down. You let go, it comes back up. That's fine. That's fine. But you do want to check it and just to be sure because every now and then you will get an umbilical hernia that can become strangulated or incarcerated. But again, it's rare with umbilical hernias.
Now the natural course of this is usually they just go away on their own. Usually you have a kid. You have the umbilical hernia there when they were an infant. And as time goes by, the defect closes on its own and the whole situation just resolves.
And usually by the time that they're school age is when this is gone. Now one of those old wise tales or myths kind of things, grandma used to say, to tape a fifty-cent piece over the abdomen to keep the hernia, to keep that bulge from appearing, to keep that loop of intestine from going through that defect in the muscle wall, to tape a quarter on it, to tape a fifty-cent piece on it, to keep it in.
Not a good idea. You can have allergic reaction to the metal of the coin. You can get infection down under there. You can get ulceration of the skin. It's just a bad thing you don't want to do it.
It's a little unsightly when your baby has a bulge of the belly button where the skin is humped out and sticking out. It's a little unsightly.
But look, it's going to go away. It's temporary. And if you have a kid that gets to be a school age and it's still there and they don't want to wear their swimsuit because they're embarrassed about it, then at that point, surgical correction of this is going to be acceptable.
But for the littler babies who have this, usually it goes away on its own, why put your baby at risk of complications from anesthesia and surgery when it's something that's just going to resolve on its own.
So for the littler kids, we usually just leave it. For the older kids, where it persists, which is unusual. Usually it corrects itself. By the time their school age then you can think about getting it fixed.
Now contrast this with the kind of hernia that is located above the belly button or below the belly button, but still in the midline, those usually do need surgical correction. It's usually just the ones that are right at the level of the belly button that resolve on their own.
And the reason they resolve on their own is because development is still going on and the muscle wall meeting there in the middle is still something that the body is doing because that's a normal part of development for the muscle to come together. And that's the last place where it typically comes together. And so that's delayed until that kid is a little older.
It's still part of development. But if you have a hernia above that or below that, it's usually a defect in the muscle wall in the middle that's not going to fix itself because the body is not programmed to fix itself there.
And so those usually do need a surgical correction. Also, if you have an umbilical hernia in an older kid or an adult and you never had one there before, that also is likely a secondary defect in the muscle wall there and those are more likely to require a surgery because, again, the body is not programmed for the muscle to come together there a second time if the defect occurs.
So I hope this is all making sense. The presence of that hernia stretches out the skin. So when the hernia is reduced or when that defect in the muscle wall – I shouldn't say "defect". It's more of a delayed closing of the muscle wall there.
Once that occurs, you've got this extra skin because when the hernia was there it stretched out the skin. And the extra skin may usually be tucked in but it can become "untucked" when you mess with it.
So the extra skin that's there is not really a problem. I think that's probably what's going on with your daughter, Emily. She probably had an umbilical hernia at some point in the past. You may not have noticed it.
It may have been one of those things where it was out when she was lying down and covered up in her Onesie and you just missed it. And when you have her undressed, it was in and was never out, or you may think back and think "Oh, yeah, when she was two months she did have a little bulge there."
So I think this extra skin is what's happening. It's normally tucked in and she's figured out that she can pull it out. What's going to happen with that extra skin? Usually, it goes away on it's on. Usually it gets some fat filled into that area. Their belly gets bigger. The skin stretches out in different directions and over time that extra skin just resolves on its own as your child grows.
And if it doesn't though then the extra stays and if that becomes a cosmetic issue, it can always be removed surgically.
It's more of a cosmetic issue not a medical issue. It's more cosmetic.
OK. So let's get back to Emily. If I were just looking at that second picture, I'd say it looks like an umbilical hernia. I mean, it doesn't look like she has just pulled out extra skin. It actually domed and it looks like she's got an umbilical hernia.
But pictures can be deceiving. Now I can't tell from just the pictures. So I definitely bring that with your doctor. And you might want to show him that picture at the time of the examination because if the belly button is flat when he sees you, if he looked at that picture, looking at it, it looks like an umbilical hernia.
So if it is an umbilical hernia, you have your answer. And maybe your daughter isn't really messing with her belly button just to play with it. Maybe she has figured out how to make the hernia "pop out" and she likes doing it.
Because usually if you do bear down like you're trying to stinker or have a bowel movement, you can make that intestinal loop pop up through that hole. And she may have figured it out that if she rubs the belly button and pulls on it and then pushes down then she can make it pop up.
It's cool because she's born then [Laughter] so it's like "Hey, I can make this happen. This is pretty cool."
Or maybe as the hernia comes out, it hurts a little bit so she's rubbing it to make if feel better and then she's not really pulling it out as much as the hernia is showing itself. And she's messing with it because as it's coming out it hurts a little bit. That's possible, too.
So again it's hard to say in a podcast from looking at the picture and a quick post. You know what I'm saying? On the other hand, maybe she doesn't have an umbilical hernia there anymore. She had one in the past and you're just seeing the extra skin from the old hernia.
So in any case, whether it's a resolved hernia with extra skin or an active hernia, either one, it's unlikely to be a problem.
It's most likely to go away on its own over time. But again, this is not something I can say for sure in a podcast by looking at a couple of pictures. But I bet I'm right.
Definitely, check out Mommin' It Up and the belly button post so that it makes some sense with these pictures. And there'll be again a link in the Show Notes at Pediacast.org so you can find that.
So I hope that helps, Emily. And if there's further questions, just let me know.
OK. And finally in our Listener segment this week, we have Travis in Miami, Florida. Travis says, "Hello, Dr. Mike. I've a question that may seem odd but here it goes. My wife and I have a happy and healthy two-year-old daughter who's only had one cold in her life."
"We both work and we're very luckily because my wife's mother lives almost next door to us. She's been caring for our daughter during the days since she was three months old. We always try to avoid other sick children and wash our hands regularly."
"But are we doing her a disservice by not exposing her to more germs? My co-workers children seem to be sick every few weeks. Should we just count our lucky stars? Thanks to your podcast. It's a resource that every parent should take full advantage of."
All right. Thanks for writing in, Travis. I really do appreciate it. So let's talk a little bit about Immune System 101 because if we just talk rather briefly about the immune system, I think these all make up perfect sense to you, in terms of how often kids get sick.
Basically, you get expose to a pathogen, which may be yeast. It could be virus. It could be bacteria. It's a microbe. And you get exposed to it. And you get sick. You get the infection.
The immune system fights off the infection. It makes antibodies to fight the infection. And it also develops memory so that the next time that pathogen comes along it can make antibodies more rapidly to fight it off.
So basically, every illness you have to get once. You have to get sick with it. Your body mounts an immune response. You make antibodies. You're able to then deal with it the next time it comes very quickly because your body can make the antibodies real quick because it develops memory for fighting that infection.
And when we give immunizations, we're just tricking the body into thinking it had that illness so that it will make antibodies, so that when the illness really comes you can fight it off quickly and easily.
So how many times your kid gets sick? How many times were they exposed to pathogens that they've never been exposed to before? And that's going to depend on how many pathogens are out there.
There's lots – I mean, there's lots of different hundreds and hundreds of different viruses, hundreds of different bacteria and bacterial strains and then all the yeasts. And so kids get sick a lot. And they get sick a lot because their immune system is a blank slate.
Now that's not so true for the little ones. From the time that they're born until they're four to six months old, they have some of mom's antibodies that were passed through the placenta and then go to the baby's blood stream.
So littler babies tend to be a bit more healthy because they have some fighting power. However, because this is passive immunity, when they get sick, they're relying on mom's antibodies to fight those things off.
They're not really making their own antibodies and developing memory. So that's why, if a little baby like they're six weeks old and they happen to get chicken pox, they're probably still going to need the chicken pox vaccine when they get to be a year old because they don't really develop memory so well, because they were relying on their mom's antibodies to fight off the infection.
So it didn't make a lot of their own or develop memory for that infection on their own. So once kids get to be four to six months of age, then every time a new pathogen comes along they're going to get sick.
If they're in a day care center, that's going to happen a lot. They're going to expose to lots of things and so you can have a kid that's sick every couple of weeks. And until they've had each illness that is in that population of kids, they're going to get sick every time someone comes along.
The advantage to that is by the time they get to school age, they've had most of the pathogens that are in your community and so they tend to be a lot healthier. And just going along in that same fashion, as a pediatrician, when you go into pediatrics and you first start out, you get sick all the time because you were exposed to a set of pathogens that were coming in your community when you were growing up.
But then when you got and started practicing, it maybe in another community, there may be different strains, different viruses and so you get sick all the time. And if you're a nursing student, when you're on a pediatric floor, what happens, you get sick all the time.
If you start working in a pediatric office, you're a receptionist, let's say, when you first start, you get sick all the time because you're basically get – it's just like you're a kid again and you're getting all the pathogens that all the kids in the community have.
But then you stop getting sick because you've developed immunity against all these things. When I go through flu season, I'm pretty healthy even though I'm with kids that are sick all day long because I have had all of these illnesses and have my own immunity.
And I'm convinced that pediatricians have super immunity because we've been getting exposed to so much. So the kids that are in day care and get exposed a lot, they're going to be less sick when school starts.
Now in your case, Travis, I think that the fact that your child is with your mother-in-law and secluded from other sick kids, they're very healthy now. They've only had one cold but just you wait.
[Laughter] OK. Once they start school then they are going to be exposed to everything and probably are going to be sick a lot, until they've been exposed to it all, which could take a couple of years.
For most of these kids, you're either going to get sick a lot early before school starts if you're in day care or, if you're more secluded, you're going to get sick a lot when school starts. You're going to get sick a lot at some point because that's how body works. That's how the immune system works.
So what do you do? Does this mean that you should intentionally expose your child to germs sooner, or put them in a crowded day care, instead of a more secluded situation so that it'll be healthier when school starts?
On the other hand, if you have a kid who's sick all the time and they're in day care, should you pull him out and put him in a more secluded environment so that then when they go to school, when you could say, well, it's OK if they get sick all the time in school because they're a little older and they can handle it better.
You know what? I don't think you should do either of those things. I think you should just live your life.
And if your life situation dictates that your kids are in a crowded day care situation and they're sick all the time, you go with that. And just realize – I mean the whole reason to even talk about this is to understand, not necessarily to change.
So if your family situation is such that you have to put your kid in a crowded day care and they're sick all the time, look at the bright side. They're getting all the stuff now but they are going to be healthier when school starts, when they're a little older.
And if you have a kid that's secluded and they're not getting sick and you're thinking, "Oh, man, they're going to get everything when they start school." Yeah, deal with it. OK, yeah, they're going to get sick a lot. And talking about this is just understanding, what happens and why it happens.
It's not to say that you should do one or the other. I mean because there's also a benefit to grandma watching her grandchild and being able to bond.
I'm sure your grandma loves it. I'm sure your daughter loves it. And so I wouldn't pull them apart just so your child can get sick. The bottom line is here. You got to live your life and understand the consequences of what's happening from a science point of you. And it just makes more sense. I mean that's the whole thing here.
So I hope it helps. I will point out. There's always exceptions. If you have a kid who gets frequent severe infections, they get frequent pneumonias. They're getting frequent strep that's not going away.
They keep getting – they have eight ear infections in the course of a year. OK, then there's more going on. Is there a problem with the immune system that they keep getting things, the same things over and over again?
Could it be that the immune system is not taking care of things as soon as they can? So now you get more significant illness. Certainly, you can't – if a kid gets sick all the time, you got to look at the whole story.
So if you have a kid that gets recurrent pneumonias, recurrent strep infections – anything recurrent that is severe, obviously, you want to let your doctor know. And of course, if it's pneumonia, your doctor probably told you so they already know.
But my point is that you can't blame severe frequent illness just on how the immune system works. We're talking more mild colds here. So obviously there are other things that can cause more significant illness in a recurrent fashion that your doctor will want to know about.
All right. So I hope that all makes a little bit of sense for you, Travis, and that we got your question answered.
By the way again, if you have a question that you would like us to talk about here in PediaCast, just go to website at pediacast.org. Click on the Contact link. You can get a hold of that way or email email@example.com. If you do that, let us know where you're from. That's always appreciated.
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All right, we're going to take a quick break and we will be back to wrap up the show, right after this.
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All right. Hopefully this will be our final two-week gap. So I will be back in mid October. I think it'll probably Monday, October 13th and then we'll be back to a weekly schedule after that.
That's the plan anyway. And I think it's going to be very realistic that will give us time to set up in our new place, our digs. And for about six months, I think it will be transition studio because it's a rental house with a lot less room than we have here.
And then once we get the new house built which is just behind Bay Lake, just north of Disney, in the Central Florida area. We're really excited about the lot that we have and the neighborhood we're going to be living in, very, very excited about it.
So that will be a brand new – we'll have some kind of big extravaganza when we move into our new digs more permanently. So we'll see you back in a couple of weeks.
And until then, this is Dr. Mike saying, "Stay safe, stay healthy and stay involved with your kids….
So long everybody!