Toilet Seats, Baby Poop, Fifth Disease – PediaCast 140
- School Lunches
- Teenage Smoking
- Toilet Seats
- Vaccines – IM vs SC
- Starting Solids
- Baby Poop
- Fifth Disease (Erythema Infectiosum)
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 Summer Land Studio, here is your host Dr. Mike.
Dr. Mike Patrick: Hello everyone and welcome to PediaCast a pediatric podcast for moms and dads. It is Episode 140. I can't believe it a hundred and forty shows. When I started this, I wasn't sure it was going to turn out. I was wrong and I am having fun with it despite the fact that I've been putting this show off for the longest time. I'll explain why in just a couple of minutes.
It is Monday January 12th 2009 and I'm calling this one Toilet Seats, Baby Poop, and Fifth Disease.
I love my job as it relates to this podcast. I mean where else can I talk about toilet seats and baby poop and not get in trouble for it especially in front of thousands of people. I'd love that.
I know as a doctor I'm supposed to be a distinguished professional bu the little boy in me still just likes to say poop. You guys out there know what I'm talking about.
I hope everyone had a happy holidays. The break is over. Weekly shows are back and worried listeners, please relax. I can't tell you how many e-mails that I received saying, "You're missing in action. Where are you? Did you stop doing the podcast? Help, where did you go?" And we're here. I had some distractions you know, the holidays were crazy. And you know it's friends and family so that was busy and definitely distracting.
The Florida sunshine, OK I'm a northern guy living in Florida for the first winter and I'll tell you the sunshine and blue skies is distracting. I know those of you who are dealing with 20 degree weather or lower right now and who knows how many inches of snow in your yard and driveway. I know you're not feeling so bad for me but look, it's distracting. And when I should be working in the podcast, we're out rollerblading or riding bikes or doing something like that. But I promise you that I will behave myself and start setting aside time everyday to work on the show because I do love doing it. I'm just explaining, you know I'm a new Florida resident. Once this is old hat, then the sunshine I guess won't be as big of a deal. Yeah, right.
I would like to welcome all of the new listeners out there. Before I do that, there's one more thing that's been a distraction and that is Summer Land Studio. Summer Land Studio is what I kind of dubbed this transition studio. That probably would have been a better name for it because it's just stuffed into the corner of a bedroom on some rickety furniture and so that's not really been all that motivating either. In about another month, we're going to be in Thornhill Studio which will be our permanent home for the foreseeable future. So this is just sort of a transition thing. 'Cause we didn't want to really want to unpack in the transition home while our house was being built. So I'm using some really old bookcases as a desk and it's really wobbly, it's just it's not ideal and so that has been part of my lack of motivation as well. But in about another month we'll be in Thornhill Studio and that studio is fabulous.
Custom built, I'm just really excited about it and so I can assure you that my motivation level will increase a hundred fold once we are in Thornhill Studio.
OK before I interrupted myself which is never a good thing, I want to welcome all the new listeners out there. This time of year we always have an influx of new listeners and looking at the numbers of downloads of our last couple of podcast I can tell that there have been an influx of a lot of people.
By the way, thanks to to everyone; new listeners and old listeners. Last year we had a half a million downloads. Unbelievable, a half a million downloads 500,000 downloads of PediaCast and I want to thank all of you old listeners and new for helping to contribute to those numbers. But we'd like to be even bigger so please spread the word and let everyone know about PediaCast. But again welcome to the new listeners. I keep interrupting myself, I have to stop that.
We do have an influx. Why? Because of the iPods and iPhones and gadgets and things that people get for Christmas, they go out, they found out about podcasts, they look around to see what's out there, they find PediaCast and there you go. So welcome to all of you.
All right. I did mention briefly what three of our topics are going to be, but for those of you who are my regular listeners and know that is by far it. There's going to be lots more that we'll talk about during this episode. Toilet Seats, Baby Poop, and Fifth Disease. Also School Lunches, Teenage Smoking, Magnets, Vaccines; IM versus Sub Q, what's that all about, and Starting Solid Foods. We had a listener who wrote in a question regarding that, so we'll cover that topic.
Also you'll notice that our News Parents Can Use section is revamped. So it's 2009, might as well start doing things a little bit differently. You'll find that to be a little more concise. A little easier to understand, easier to follow as you're listening. It's taking a lot more work, but I'm basically rewriting the stories from scratch. I think that you'll find an improvement in the news department. If you do find that to be true, drop me a line because if I start to get lazy and just using what's already out there which it's OK-ly written, quickly written I should say, as opposed to my rewrite, if you think that I'm doing a better job of it, please shoot me a line and then that'll be motivation to keep doing it because it did take a lot more of my personal time, which is another reason that this episode took a little longer to get out. But OK I'm making excuses.
Don't forget, if there's a topic that you would like us to talk about, all you have to do is go to Pediacast.org and click on the Contact link. You can also e-mail firstname.lastname@example.org. If you do the e-mail, please include where you're from because that's always interesting and of course you can also call the voice line 347-404-KIDS which translates to 5437. So if you want to ask your question or if you have a topic suggestion or a new story that you think would be interesting to the audience, please pass those things along either at the Contact link at Pediacast.org, at email@example.com or 347-404-KIDS.
And as we always do in the introduction section of the program we have our little disclaimer. So all of you new listeners out there and aimed at you and everyone else who has listened for a long time after 140 episodes, you could probably recite this without any problem at all.
So everyone together.
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 and arrange a face-to-face interview and hands on physical examination.
And with all that in mind, we'll be back with our brand-spanking-new News Parent Can Use right after this short break.
All right. Up first in our News Parents Can Use is a story from the School Nutrition Association and they recent report saved by the bell as economy sinks school nutrition program participation rises.
According to the report nearly half a million more US children are participating in free and discounted school lunch programs this school year compared to last year.
Why? According to the School Nutrition Association it's because of high unemployment and family efforts to save money. The data which comes from school districts in every corner of America shows a whopping 79% increase in the number of kids eating free lunches and the 65% increase in those eating discounted lunches.
There's good news and bad news associated with this data. The good news is kids are eating better because these free and discounted meals are part of the National School Lunch Program which means the food must meat dietary guidelines set forth by the Federal Government. For example, no more than 30% of calories can come from fat and no more than 10% can come from saturated fat. In addition, school lunches must provide at least 1/3 of a child's weekly allowance of protein, calcium, iron, vitamin A, and vitamin C.
Another study, this one by Dr. Alice Jo Rainville of Eastern Michigan University showed students who eat school lunches consume fewer calories from fat, eat three times as many dairy products, twice as much fruit and seven times the number of vegetables compares to students who pack their lunch from home. So more kids are eating free and discounted lunches at school and these school lunches tend to be healthier than home-prepared packed lunch. So that's great, but let's face it, there's no such thing as a free lunch, right? I mean somebody has to pay. And who is the biggest payer? Well that would be the American tax payer.
Free school lunches are subsidized by the Federal Government to the tune of $2.57 per free lunch but that doesn't cover the entire cost. When you take into account the food, labor and other kitchen expenses, the average total cost of a school lunch weighs in at $2.92 per meal, leaving the school with an additional 0.35 cents to cover. And the expense is even greater for full-priced meals. Children who don't qualify or discounted lunch pay an average of $2.08 per meal, leaving schools with an 0.84 cent deficit on each non-subsidized lunch and all those cents add up. We're talking 4.5 million dollars a day of unreimbursed lunch expense paid by US schools. Which is why School Nutrition directors are calling on congress to provide economic relief.
Hey, if banks and auto plans and cities and States are lining up for a hand-out, it makes sense that the lunch lady should get in line too. By the way you may be wondering who qualifies for free and discounted lunches; free lunches are limited to those whose household income is less than 130% of the national poverty level or $27,560 for family of four, and discounted lunches are available to those making 130% to 185% of the national poverty level which works out the $39,220 a year for that same family of four.
So $2.08 per meal. I don't know. It just seems like a bargain to me for a lunch. Maybe it's because I've lost a little bit of perspective since we home school, but I don't know. I know from a parent's point of view, you got three kids, $2.00 a day that starts to add up. But we're talking lunch here so I don't know. You know the schools are wanting the government to bail them out, but maybe they should charge more reasonable amount to cover their cost. I don't know. OK maybe that's the free market person in me.
Teen smokers. We're going to keep with the school theme but we're going to move from lunches to smokers.
A study from Finland and published in the February 2009 issue of the American Journal of Public Health says. "Female teen smokers are more likely to be overweight adults compared to non-smoking teen girls and the girls who smoke 10 cigarettes per day or more appear to be at the highest risk.
The study followed over 4,000 boys and girls born between 1975 and 1979 and data was collected by way of questionnaire at ages 16 and 24. Half of those surveyed reported smoking during the teenage years of those 16% of the boys and 9% of the girls smoked more than 10 cigarettes a day. And by age 24 nearly a quarter of the men were overweight compared to 11% of the women.
For the boys, researchers found no correlation between smoking and weight gain but for the girls the relationship was remarkable. Those who smoked more than 10 cigarettes a day as teenage girls, were more than twice as likely to be overweight in adulthood. Of course the next question is why? The report gives two possible explanations.
First the difference could be biological perhaps tobacco and gender specific hormones interact differently in boys versus girls, causing an increase in appetite and fast fat storage but only in the females. A cultural explanation was also presented. Perhaps teenage girls are more likely to smoke in an effort to stay thin, but later as adults they either stop smoking or the cigarettes lose their ability to curtail appetite. In the former group, eating snacks replaces cigarettes and weight gain ensues.
Whichever explanation holds true or maybe there's a third explanation out there representing the real truth, but whichever holds true, the bottom line remains teenage girls who smoke have a higher risk of being overweight as adults and it's a fact which gives moms and dads another weapon in their arsenal of anti-smoking strategies.
From teenage smokers, we move to potty training toddlers and a warning from doctors in the United Kingdom.
According to an article in the December issue of BJU International, British physicians are seeing an increasing number of penile crush injuries resulting in urological emergencies and requiring overnight hospitalization and possible surgery. The culprit: heavy wooden and ceramic toilet seats. That's right, ornamental toilet seats. They're all the rage in Europe with sky rocketing sales and numerous models to choose from. But buyer beware, toddlers are lifting the seats and letting them go only to find the seats crashing back down and crashing penises against toilet rims. Ouch.
UK doctors have come up with five ideas to make your bathroom safe.
1. If you have a toddler in the house, don't be tempted by a fancy toilet seat. Stick with a light-weight plastic one.
2. Consider using a seat that features a slow fall with reduced momentum. They cost more but marketly decrease the risk of injury and the degree of injury as well.
3. Household with male toddlers should consider leaving the toilet seat up after use even though it contradicts the social norm and the wishes of most women around the world.
4. Teach toddler boys to hold the seat up with one hand and guide their penis with the other the entire time they are peeing. And finally,
5. The most important of all. Parents: supervise your children until you are absolutely certain they can urinate responsibly and safely on their own.
I do have to make one comment with those recommendations. If you leave the toilet seat up, you do risk a toddler falling in into the toilet. Babies and children have drowned in toilets before. So if you have a kid in the house that you're worried could lean over and fall in and be able to get them self back out, then that may not be a good idea. Just a little aside, but most toddlers are probably going to be fine with that.
Magnets are another danger in the home especially if they are swallowed in paird. Magnet pairs can stick together across bowel walls causing obstruction, reduced blood flow, infection, and perforation which can lead to sepsis and death.
Report from the Cincinnati Children's Medical Center and published online in the Journal of Pediatric Radiology says, "More parents are aware of this risk but they don't seem to be doing anything about it." As complications from ingested magnets continue to be common place around the world.
Researchers took a close look at 128 recent cases of swallowed magnets from 21 different countries. Surgery or endoscopy was required with nearly every case and one child did die from infection and septic shock. Magnets are components of many toys; unfortunately manufacturers are not required to post warning labels on the box. This is a serious oversight because the vast majority of cases involved magnets from toys with many well0known brands represented.
The study recommends prompt treatment when magnets are swallowed. Unfortunately the symptoms of magnet ingestion may be vague in common place including nausea, vomiting, and crampy abdominal pain. And while parents may be tempted to pass those symptoms off as a virus, it's important to also consider magnet ingestion, if you have a toy with magnets in the house and if your child is prone to putting objects in his or her mouth.
And it's not just the little kids you have to watch. The majority of reported cases involved kids older than three; kids who are old enough to answer the question why. "Why did you swallow those magnets?"
Researchers asked that question and received a number of interesting responses ranging from: "I thought it would be fun to" to "I really like the taste." I'm not making that up.
Autism was a common threat among the older kids who swallowed magnets representing 16.2% of those over age three. So parents with autistic children should be especially vigilant. The study authors conclude by saying, "Toy manufacturers should warn parents about the hazards of magnets, but until they do, public education is the best line of defense. Ultimately it's up to parents to know about the dangers of magnets, to make smart decisions about the toys they bring into their home and to supervise their children when they play.
All right. That concludes our new and improved News Parents Can Use. If you thought that was better than they have been in the past, please shoot me a line and let me know. That would be motivation to put more work into the news section.
We will be back with answers to your questions right after this.
All right. Welcome back to the program.
First up in our Listener Department is Sarah from Annapolis Maryland. Sarah says, "Dr. Mike, thanks for your podcast. I'm really just curious, why are some vaccines given IM and some sub-Q?"
OK. What is this IM and sub-Q mean?
IM is intramuscular and sub-Q is subcutaneous.
Intramuscular means that the shot is given deep in the muscle either in the upper arm or the thigh or the buttocks. And subcutaneous means that the shot is injected just under the skin. So it's a shallower-type shot.
So why are some shots given IM and some sub-Q?
In general, IM or intramuscular, the deep ones give you better immunogenicity (I love that word), immunogenicity, so you have a better immune response when the vaccine is given deep in the muscle. Also you have a less localized skin reaction and so that is the preferred route for vaccines.
There is an exception, the MMR which is the measles, mumps, rubella vaccine and the Varivax or the chiken pox vaccine; those are given subcutaneously and why? These appear to have better immunogenicity when given subcutaneously.
So the manufacturers basically test the vaccine both intramuscularly and subcutaneously and then measure the amount of antibodies formed against that vaccine and figure out which one does a better job. And for most of the vaccines, the answer is intramuscular but, for MMR and Varivax or the chicken pox vaccine and the measles, mumps, rubella vaccine; it is better to give those subcutaneously because you have a better immune response.
What do those have in common?
Those are both live attenuated viral vaccines. So these are live viral vaccines. Attenuated means that they cannot infect you, if you have a normal immune system. So it's much less likely you'll get sick from the virus, it's an attenuated virus, it's been bred to be less infectious so to speak, but you still form a reaction to it which gives you protection against the real potent variety of virus that's out there.
So you would think then that, "OK all live attenuated live viruses should be given sub-Q." Well that's not necessarily true as it turns out the influenza vaccine which is also a live attenuated virus, it works well intramuscularly. So that's the way that it's given. The polio vaccine, used to be given subcutaneously, it by the way is a killed virus, so it's not a live attenuated virus. It's a virus that cannot infect you, it's a killed virus but your body forms immune response to it. That one used to be given subcutaneously even though it's not a live viral vaccine, but now it is acceptable to give that one intramuscularly.
So basically, each vaccine is tested using both routes before being approved and the person giving the injection should follow the directions on the manufacturer's insert to know how that particular vaccine should be given. But in general, IM is the preferred route. You have less skin reaction with that one but again, for the MMR and the chicken pox vaccine, you get better immune response if given subcutaneously. So even though you get more of a localized reaction with the skin, the benefit outweighs the disadvantage of that reaction and so you do it that way.
By the way, this is sort of interesting. How do they make live attenuated viruses?
These viruses, so like measles, mumps, rubella and the chicken pox virus; these viruses are human-specific.
So what you do is give a large population of the virus, so you just get a whole bunch of the virus and actually you inject it into a foreign host that is not supposed to be able to able to get infected with it because these are human-specific viruses and a good example of what they use is an embryonated egg. So you have an egg with a chick embryo in it and you infect the chick embryo with this load of virus.
Most of the virus will die. Why? Because the chick is not a human but some members of the population of virus will have a mutation and that mutation will allow it to infect the foreign host. And then those members will replicate themselves and be the only ones to survive in the chick host. Then the virus is recollected at some point down the line from the chick embryo and so now you have selected out the virus that can infect the chick embryo, and all the ones that infect humans die. So then you inject that group of virus into a human host and those are the ones with the mutation, so they can infect chick embryos but they can't infect humans very well, but they're similar enought to give good protection against the human-infecting members of the virus population.
So the mutated members are collected from that chick embryo and the vaccine is created and then this also explains why people with egg allergies should avoid vaccines, let me just say, this used to be that people with egg allergies, it was thought that they should avoid all vaccines with egg in it which would be the MMR, chicken pox, and the influenza vaccines because again influenza is also a live attenuated virus. Because the MMR is only given a couple of times and the chicken pox vaccine is only given a couple of times, those are considered OK even in the face of egg allergy. But if you have a kid that you know has an egg allergy and they're getting those vaccines, you still want to watch them closely after they receive it for allergic reactions.
However, the flu vaccines since it's given year after year after year, people with egg allergies at least right now the current recommendation is that they should avoid getting the flu vaccine because if they have an egg allergy, particularly if they have an egg allergy that's accompanied with hives or wheezing, that sort of thing. But the reason that there's egg in these shots is because to make live attenuated virus vaccine. You infect the chick embryo and collect the surviving virus which is better at infecting chicks than humans. And when I say chicks, I'm not talking about good looking girls. [Laughs]
OK. It's that little boy in me again. I'm sorry.
Kristen in Sussex Wisconsin. Kristen says, "Hi, Dr. Mike. First let me start by saying thank you for the show. I'm a new listener and have been enjoying your podcast. I have a question about when is the best time to start solids? I have a five month old who is exclusively breastfed. He weighs in at 17.5 pounds at his four month check up, yeah he's a big boy. So he is at the top of his growth chart for weight. My pediatrician suggested that I wait to start him on solids until six months since he appears to be getting a haul of the nutrition he needs from breastfeeding. I understand this theory. However, my son is not sleeping through the night and I am wondering if starting solid foods will help him sleep longer. I had a different pediatrician for my first son who had me start solids with him at four months and he started sleeping through the night right around the same time. I'm not sure if this was a fluke or related to the start of solids. Why is there such a difference of opinion on this between pediatrcians and what do you suggest to your patients? Thanks for your help, Kristen."
Thanks for the question Kristen.
What this boils down to is the art of medicine versus the science of medicine. And this sort of question really falls under the art of medicine. You take science into account but there is an art of medicine to deciding these kind of things.
We know that babies do not have a nutritional need for solid food until six months of age and may be even little bit later than that. We know that early introduction of solids carries choking hazards, there's more chance of food allergies to develop and something that we have to be sensitive to these days is too rapid of a weight gain because solid foods tend to me more calorie concentrated.
So basically from four months of age to six months of age, they still don't really have this nutritional need for food yet. So food is really for fun and practice. And it's become a little bit more en vogue now to wait a little bit longer because of this choking hazard, more chance of food allergies and too many calories. So four to six months of age is fun and practice. You can do some stage one foods.
Why stage one foods?
Well, they're soft so there's a lower choking risk, they're bland so there's lower risk of developing allergies against them, and they have a lower caloric concentration. So stage one foods here and there starting in between four and six months of age is great, but they don't need three square meals a day with solid foods until they're six to nine months of age.
So what to do?
I would definitely wait until at least four months of age to start solids. And then if you're going to start solids between four to six months of age, I would stick to only stage one foods with a slow introduction to new food, something new every few days. That way if they have a reaction to something, you know exactly which food it was that caused the reaction.
Some doctors though are now recommending you wait until six months or even a little bit later to start solid foods especially if you have a baby who's on the big side and you want to avoid over weight and obesity issues down the raod. And then these same doctors would say, "Look, we want to wait until six months or even a little later because they still have a choking risk, there's still an allergy risk, and they're still getting too many calories.
So what's a mom to do when you have one doctor who looks at it as OK to start at four months and another says wait till six months?
Well, you have to do what I've talked about on the show time and time again and that's to look at risk versus benefit. I mean it always boils down to that when we have to make a decision, doesn't it?
So what is the benefit of starting solid foods before six months of age?
Well, variety in the diet. Babies like that, you know it's kind of fun to introduce new foods, to see what they're reaction's going to be. You make the baby happy because they at some point want what's on your plate and you're anxious to have them try new things. So fun and variety and it is true, a lot of babies sleep longer if you feel up their belly with some solid food before they go to bed.
But then, you got to look at one of the risk. The risks are choking, although more so if they're less than four months of age; less risk of choking as they approach six months, and then the risk of allergies and the risk of too many calories and getting big.
Other disadvantages with feeding is that as you introduce solids, it becomes more work, you have messier and bad smelling poop, I'm just trying to think of everything here, and you get a picky baby. Because one you start giving them all these different solids, there really is no going back and they're going to have their favorites and so then you get into some food battles and do you really want to start that before you have to?
Your first doctor thought the benefit outweighed the risks and disadvantages and your current doctor thinks that risks and disadvantages outweighed the benefit. And I think you as mom really have to look at your family here to decide which philosophy is right for you. You know if mom and dad both work outside the home or otherwise need a full night sleep, then the risks are pretty low and the benefit of a baby sleeping through the night may be a pretty big benefit to the psychological health of mom and dad.
And by the way, why do babies sleep longer with solid foods?
The belly is not as quick to empty with solid foods, there's a slower transit time, it takes the body longer to digest it and move it along. So you have this feeling of fullness that lasts longer. And also solid foods tend to have more complex carbohydrates which are able to keep the blood sugar higher longer, which delays low blood sugar, which delays the waking up and feeling hungry.
On the other hand, if mom and dad is staying home or working from home, or has a schedule or a temperament that allows frequent night time feedings, then the benefit of babies sleeping through the night might not be such a big deal. Or there may be other factors. For instance, your mother-in-law maybe saying, "Hey, when are you going to start feeding that baby?" And you are sick and tired of hearing her say that. There may be another kid in the house and the baby really wants more solids and what the toddler's eating and is really pitching a fit, and then again it comes down to your family. Are you going to put your foot down and tell mother-in-law, my doctor says it's OK to wait, just chill out and leave me alone. Or is it going to be more psychological beneficial to the health of mom and dad to say, "OK, fine we're going to give this baby some solid food."
It all boils down to your situation. Personally, I would start solid foods at four months. Again this is me, I'm not telling you to do it. But I'm not very good with delayed gratification and the fun factor would be important to me. OK, sleeping through the night is pretty important too. And the allergy research research is shaky at best and my kids were not chubby babies, so the calorie issue was never really an issue in our house. But again you have to decide for yourself.
And so instead of answering your question, instead of telling you Kristen what you need to do, hopefully I've presented a way by which you can make the decision for yourself. Just look at the advantages and disadvantages and go from there.
Mary in Greenup Kentucky is next up. Mary says, "My three month old has a bowel movement once a day. Sometimes it comes out as hard little balls that have a dark color? What is this and do I need to talk to my doctor about it?"
It's been a while since we talked about baby poop. Character, color, and frequency are all highly variable during the first year of life. So before I answer your specific question Mary, let's talk about baby poop.
Let's talk about it in terms of character, in terms of color, and in terms of frequency. What is normal?
In terms of character, a mustard like consistency is typical, but it can be looser and still be normal almost to the point of watery, but not quite, it can be thicker and still be normal like mush or oatmeal, it can even become clay-like or hard little balls – and that can still be OK. And we're going to talk about when it is OK and when that isn't OK in just a minute.
In terms of color, yellow with darker specks or seedy is common during the first few months and that changes as solid foods is added to the diet and it also changes as bacterial population setup shop in the bowel. So the mix of bacteria that you have in the intestine is also going to dictate the color to some degree. Normal color can range from yellows to greens to browns and it often fluctuates between those colors especially as babies get older and start to get more bacteria in their intestine and as they start to eat solid foods.
We worry about reds and blacks because they may indicate bleeding in the GI tract. A bleeding high up in the tract is going to cause black stools particularly black-tarry or like coffee ground-type stools and if bleeding is occurring low in the intestinal tract, then you're going to see red.
Now having said that, there are other things that can cause the stool to be red and black which aren't bleeding in the intestinal tract. So it's not panic time if there's red or black, but it's something you want to bring to the attention of your doctor so they can figure out if it's blood or not.
For example, early poops in newborns is called meconium. It's a result of ingesting amniotic fluid and that tends to be black and tarry. So the first few days of life, it's OK that they're having black and tarry stool. That would be expected. Also iron in the diet can create black stool and some bacterial mixes can create very dark colors of stool as well.
And reds especially maroon can also be caused by iron in the stool. Omnicef is an antibiotic that is known to precipitate iron from vitamins and food and cause the stool to sometimes take on a maroon appearance, but if you test it for blood, it's negative.
So if you see a red or black, again it's not panic time, but I would see your doctor to have the stool tested for blood. It's an easy test that can be done in most doctors' offices.
So color; reds and blacks, bring it to someone's attention, pretty much any other color is going to be OK.
Now, the frequency of baby poop can range from several times a day to once a week and that still can be normal. How in the world can once a week be normal?
If you have a baby with really good absorption, so what they're eating is getting absorbed and there's not a lot of residue, it's going to take a while for enough to accumulate to be able to poop it out. Also a lot of the bulk of stool is bacteria, and if a baby has low bacterial counts in their intestine, they're also going to have very little residue. So once a week can be normal for some babies, and several times a day; everytime they eat having a little bowel movement can also be normal.
So with all these ranges, how do you know if there's a problem? And this also comes down to the art of medicine versus the science of medicine.
Let's take color out of the picture. We know reds and blacks might be an issue and kids that have those colors in their stool should probably be tested for blood, all the other colors are OK.
So let's focus on consistency and frequency. The big question becomes, is there a baby problem or a poop problem or no problem at all?
What I mean by this is you have to look at the baby and this is where being a doctor and seeing lots and lots and lots of babies comes in very handy. What I mean by this – Is the baby happy? Is the baby growing well? Is the baby healthy? If the answer to all those kind of questions is yes, then I would just let nature do its thing regardless of what's going on with the poop. I mean, why fix something that's not broken? And in this case, I would tell that to pesky relatives. If you have a mother-in-law who's saying, "That kid, his poop is hard and they're only going once a week. Why isn't your doctor doing something?"
I wouldn't let that, if your doctor is saying, "It's fine." Listen to your doctor. And in this case this is one where I wouldn't give in to your relatives 'cause it's one thing that cave into feeding. 'Cause either way it's probably fine whether you start or six months. But when caving in leads to test and medications, then I'm not so gung ho on it.
On the other hand, if the baby is fuzzy all the time or they're not gaining weight well, or they're vomiting, or they're not feeding well, or they have excessive abdominal distention, then I would certainly take a closer look and decide if maybe this is a child who's having constipation issues.
One caveat that's kind of important here is, just because a baby is fuzzy and then poops and then is not fuzzy, does not mean that there is a poop problem, especially if that poop falls into the range of normal. Babies cry for lots of reasons and when they cry they tense up their bellies and they bear down. And what happens when you tense up your belly and bear down? Ever do that while sitting on a toilet? Yeah, OK you poop. So you have to be a little bit careful how you interpret things because you don't want to subject babies to unnecessary tests or medicines if there's really not a relationship between crying and pooping other than when they cry they bear down and they poop. So you have to sort of keep that in mind.
So a baby who's fuzzy and has a soft stool once every three days may very well not be constipated. On the other hand, if that same fuzzy baby has a very hard formed stool every three days and the only time they're fuzzy is right before they poop and they push and push and push and push and finally get out this hard thing, this little balls or shaped like clay once every three days, this is where again the art of medicine comes in. Now I'm thinking, OK maybe we do want to loosen up and see if the fuzziness goes away, and if it does, then you know that was an issue. If you loosen it up and they're still fuzzy the same amount and still pooping now soft stool every time they're fuzzy, then maybe it wasn't the stool to begin with. So some of these you have to sort of look retrospectively to figure it out.
So what if a baby and this really comes down to your question; What if they have a hard formed stool, let's say actually 'cause said they had it everyday. What if they had a hard formed stool every three days but they're not fuzzy?
I'd say just leave them well enough alone and let nature do its thing.
So let's go back to Mary. You have a three month old who does have a bowel movement everyday, it's a dark color, hard little balls and you want to know if this is a concern and should you talk to your doctor about it.
Right out of the gate, I'm going to say, "Yes. Talk to your doctor about it." That's what they're getting paid for and hopefully he or she will tell you what I'm telling you. But they'll also be able to examine your child, ask you more questions. Those are things I can't do in this venue and they are extremely important. But I can say what else will your doctor be looking for and what else will he or she ask when you present this problem to them. Well, the answer really is the things we've been talking about:
Is the stool dark enough to be considered black, is there red color? If so, I'd test it for blood.
Is your baby frequently fuzzy? Do they have vomiting, a distended belly? Are they growing well?
All important things, so the bottom line is a baby having hard formed stool everyday, there's no red in it, they're not fuzzy, they're not vomiting, they don't have a distended belly, they're growing well, they're happy – I 'm good with that; as long as the baby is healthy and happy and growing well, there's no blood in the stool. Fine, have a hard bowel movement everyday that's a little balls, I don't care.
If a baby on the other hand is not happy, they're not healthy, they're not growing well; then I would take a closer look and consider helping that baby out.
What would I do? That depends on the constellation of things that I'm seeing or that you're telling me. And it might range from a simple rectal exam and a prescription to give some apple juice as a medicine, not for nutrition – to help loosen up the stool or I might do some more invasive testing; anal manometry, barium enemas – looking for Hirschsprung's Disease, upper GI with or without a small bowel follow through especially if there's blood or vomiting, stool culture especially if there's blood and I might prescribe a stronger stool softener, things like; Lactulose, Miralax, Mineral Oil, might try Glycerin suppositories. Lots of options here and again, this is where the art of medicine and experience come into play.
So I would definitely talk to your doctor about all this, Mary. But I do appreciate you writing in so we could discuss the issue as a group.
It's a tough call and you know in an interactive show would allow me to answer your questions a little bit better. You know if I was on a radio show right now and had call-ins like a Dr.Dean Edell or what's the money guy's name , I'm failing to think of his name on the top of my head. If my wife were here, she'd let me know. You know, the money guy, it talks about money all the time. It's going to come to me at some point here, probably while I'm in the middle of talking about fifth disease. I know, how many of you right now are screaming the name at your radio because you want to tell me what the name is. So, if anyone out there is a radio producer that would like me to do a radio show, give me a buzz.
All right. Let's go ahead and move on to our final question. It's still going to bug me. What's that guy's name?
OK. Fifth's Disease. This is Kim in Denver Colorado. Kim says, "Dr. Mike, thank you so much for you podcast. It has been a terrific resource. My son just moved to the four year old room at his day care and they have a sign posted saying, 'There have been a couple of confirmed cases of Fifth Disease' in that room. What is this and is it dangerous? The information on the web seems to indicate it's not that big of a deal, but I would like to hear your opinion. Thanks again, Kim."
All right, Kim. So let's talk about Fifth Disease.
It is also known as Erythema Infectiosum but we don't use that term very often because parents just kind of crinkle up their brow and say, "Huh? What are you saying?"
Erythema Infectiosum also known as Fifth Disease. Why is it called Fifth Disease?
The childhood exanthems or common rashes during childhood particularly when it was not known what caused them but they followed very specific descriptions, so you could tell that these two kids have the same thing because their rashes looked alike. And the first rash was called First Disease, and that turned out to be Measles. Second Disease was Scarlet Fever, so a rash caused by Streph. Third Disease was Rubella also known as German Measles which we vaccinated kids for these days. Fourth Disease, it's a little controversial what Fourth Disease was, it's also been called Duke's Disease, some say it was actually Scarlet Fever that was a little atypical and so it was misdiagnosed, some would say it was a Staph-rash, some would say it was another viral rash perhaps caused by Enteroviruses or Coxsackie Virus, so it's a little shaky what Fourth Disease really was.
I think if a person had a rash and the doctor didn't really know what it was, they'd call it Fourth Disease back way back when.
Fifth Disease was Erythema Infectiosum. That's what we're going to to talk about. And Sixth Disease was Roseola we'll talk about that some other time.
So what is Fifth Diseases or Erythema Infectiosum?
It's caused by a virus; it's caused by Parvovirus B19. Now this Parvovirus is a human virus, it's not the Parvo that dogs get. You cannot get Fifth Disease from your dog, this is a human virus called Parvovirus B19 and kids get it from other kids.
Most children do get this during childhood and then form immunity to it and never get it again in their life. However, it is possible to get through childhood and not be exposed to it, so adults can become infected and it's also possible to get a milder version of the disease and so you don't develop a hundred precent immunity to it and that can cause you to get it as an adult.
OK. Why am I stuttering and stumbling over everything? 'Cause I thought of the guy's name. It's Dave Ramsey – I know some of you are like, "Whew." I was hoping you are sending it to me telepathically. Dave Ramsey, that's who I was thinking of, the money guy. See I could do a Dave Ramsey kind of show pretty easily. I just need a producer to find me. So if you know someone, please.
So anyway where were we?
Most children get Fifth's Disease and then don't get in adulthood or they get a milder form of it and they can get it in adulthood or they don't get it at all and adults can get it.
Incubation period – highly variable, so from the time you're exposed to the time that you can pass it on to others, and I'll explain why I'm not saying till the time you get sick because some people don't get sick with Fifth Disease but can still be contagious and pass it on. So from the time you're exposed to the time you're contagious is variable and can range anywhere from four days to three weeks. So it's not very helpful there.
20% of those infected who can still spread the disease have no symptoms, none. But if you look at 80%, what will end up happening is that they will have a mild viral prodrome prior to the rash. So four days to three weeks after they're exposed, they will have a little bit of a stuffy nose, a little bit of congestion, might have a mild sore throat, could have a fever – that fever usually is a low-grade fever but it can be a high fever. So you have a viral prodrome before you have a rash, basically you have a mild cold and then you get the rash. When you get the rash, you're no longer contagious, maybe the first day you have the rash – may be you're mildly contagious then. But for the most part, once the rash appears, you're not contagious anymore. You are contagious during that mild cold phase.
The problem is you can't diagnose it during the mild cold phase, you could with blood work but usually you don't get blood work from mild cold and so it's not something we test for. So once you have the rash, then we can say, "Hey, you have Fifth Disease." But you can go back to school 'cause you're not contagious anymore.
What does the rash look like?
You get red rosy cheeks and sometimes it's called Slapped Cheek Disease. If you had a fever during that viral prodrome, you might call it Slapped Cheek Fever although you would not have the fever at the same time as you have the slapped looking cheeks, so you have the fever then you have the rash.
Basically, you get these red rosy cheeks it looks like you've been eating really well, you know how some kids will get the red rosy cheeks when they ate a big meal or if you have a fever you get the red rosy cheeks. Although in this case, you have them even without the fever.
And then you get a lacy reticulated, so think of what a giraffe; a reticulated giraffe looks like, that sort of pattern although much smaller. So a lacy reticulated rash to the trunk and extremities and it's most noticeable on the upper arms and the thighs. The rash waxes and wanes sometimes it's very visible and sometimes it's hardly noticeable at all and it tends to be more noticeable when the skin is warm. So first thing in the morning, kid's all cuddled up under their covers, their skin's warm; you're going to see the rash more. After a warm bath you're going to see it more. If they've been playing outside, working up a little bit of a sweat, you're going to see it more.
The rash has no symptoms other than a possible very mild itch associated with it, but most cases there's no symptom at all to the rash. The rash usually lasts just a few days, but it can come and go for several weeks. And it's not the virus that's causing this rash; it's your immune system. So your body makes antibodies which kill the virus and those same antibodies then are what's causing this rash and that's why it can come and go for so long afterward.
Again, in most kids it only last a few days but, in some cases it can wax and wane, come and go over several weeks but you're not contagious with it during that time.
Adults who get this, who either skipped it all together when they were a child or who had a mild case of it and didn't form complete immunity, basically it's the same sort of thing. Usually have a mild viral prodrome, basically a cold, might have a low grade fever, a little bit of a sore throat, but adults often times don't get the rash, they just have it as a cold. What adults sometimes get is some joint pain.
Joint pain is very common with Fifth Disease in adult, particularly in the hands and wrist or the hips or the knees and it can be one joint infected, it can be multiple joints that are infected. And it usually last a week or two, but it can last several months. So it's sort of like the rash in kids, the joint pain can come and go and last for several months. And in my experience, I've seen several adults who have had one hip that hurt after they were exposed to Fifth's Disease and on hip that just hurt on and off for a few months afterward.
And now in that case, blood work could give you an idea of what's going on. 'Cause if you have an adult patient who had chronic hip pain over a six-week period, you might want to do a titer to see if they were exposed to Parvovirus B19 recently by getting an IgM level for Parvovirus B19. It's an expensive test but if you have chronic hip pain, you don't want to call a rheumatoid arthritis so you want to make sure they don't have arthritis or hip issue, that's something to think about. But I'm not an adult doctor, ask the adult podcast about that.
Treatment. What do you do?
It's really just supportive and you're not going to do really much of anything during the rash phase. If the rash is extremely itchy, you have to rethink the diagnosis. So the rash usually bothers moms and dads looking at it a lot more than it bothers the kids who have it.
During the viral prodrome phase though, you may want to treat fever, do supportive things for the upper respiratory infection symptoms, you know a humidifier in the bedroom, having blow their nose a lot, consider nasal decongestant-type medications if the child's old enough and you're pediatrician approves or whatever your thinking is on that because that's another controversial issue now.
Parvovirus B19 infection can be very dangerous to the first trimester fetus. So a woman who is early on in her pregnancy, you would rather not be exposed to this virus because infection with it can lead to spontaneous abortion. However, most women, so fetal demise and you have the abortion or it can also cause very bad birth defects if the fetus lives. Now most women have immunity from their own childhood and this is not an issue. Also and this is probably the most important thing; is remember, by the time this disease is diagnosed, it's no longer contagious. So if you're a pregnant woman, it's a little hard to avoid Parvovirus B19 infection without wrapping yourself in a plastic bubble and never going outside because kids are infectious with this before the rash breaks out – before a diagnosis is made. So by the time you know a kid as Fifth's Disease, it didn't matter whether you're around them or not at that point. So it's a little disconcerting and a lot of times people will come across this on the Internet and they'll have heard, "Hey, you know I'm pregnant, I shouldn't be around Fifth's Disease. It can be dangerous."
You've hear that like diagnosed a kid with Fifth Disease and, "Oh, I'm pregnant. What do I do?" Well, the mom don't have to do anything now, if you're going to get it, you're going to get it. So that's sort of I guess sad and frustrating, but not much you can do about it.
And other complications, folks with Sickle Cell Disease or any form of Chronic Hemolytic Anemia, Parvovirus B19 infection may precipitate and aplastic crisis. What that means is that the red blood cells haemolyze basically bust apart and this can cause extreme anemia which can be life threatening and require blood transfusions, supportive treatment in an Intensive Care Unit. So people with Sickle Cell Disease and other forms of Chronic Hemolytic Anemia also infection with Parvovirus B19 can be very serious for them. Likewise, it's very difficult to avoid because when people are contagious with it, you generally don't know they have it.
I guess one exception to that would be if one kid in the house or a class is diagnosed with it and then four days to three weeks later you child has a mild cold, low grade fever, maybe a little bit of a scratchy throat but not like streph throat where it really hurts a lot. In that case, maybe that is the beginning of Parvovirus B19 infection or Fifth's Disease and so you would want to avoid being around someone who's pregnant.
Again, if your child with Fifth's Disease is around someone who's pregnant, it's not necessarily panic time because again, most expectant mothers will have had Parvovirus B19 in their childhood and have very good immunity against it and the fetus is going to be just fine. So it's not a universal thing that any pregnant woman that gets around it is going to have a problem. So, all things to keep in mind.
All right, that wraps up our Listener Segment for this week and we will be back to wrap up the show right after this.
OK. Half a million downloads in 2008; I don't know that just boggles my mind. So I know that there's a real need out there for a program like this because parents just have so many questions and you want a good source that you can go to. Books about parenting and child health, they're just words on a page, you know this is more lively, more interactive, although it could be a lot more interactive if it were a call-in program, I do realize. But there's definitely a need for this and I enjoy doing it, I really do. So let's try to shoot for more than half a million people in 2009.
I don't have much of an advertising budget, and why? Because I don't have much of an income from the show. We do have some sponsorships, Saturn was a sponsor for a while, Audiblekids.com has been very generous to us and of course, Nationwide Children's Hospital has helped us out a great deal, but it doesn't really pay the bills and it really doesn't totally cover the cost of doing the show, it doesn't even begin to.
So what we need is a bigger audience, so that we can get bigger sponsors and people will take us more seriously, but to do that, I'm going to need your help. Because the word of mouth is the best way to increase the audience. So I really need moms and dads out there, tell your friends, tell your family, tell your pediatricians about PediaCast. You can download posters at the website if you go to Pediacast.org, we have a Poster page. If you like to design a poster for PediaCast and send it to me. Hey, I'm game. Let me know.
I would like to thank Nationwide Children's Hospital for helping us out as I said before. Also, Vlad at Vlad Studio. He's a Russian artist that does all of our artwork and he is fabulous. He has a website at Vladstudio.com, please visit him. You can order posters and prints of his work and it would make an amazing nursery or child's bedroom. So if you like the artwork that's on the website at Pediacast.org, you definitely want to give Vlad at Vladstudio.com a visit on the Internet.
Pediascribe, that's my wife's blog. She's going to talk about the aftermath of when hurricane Ike hit Central Ohio. Yes, hurricanes hit Ohio. We had a massive wind storm right before we left and it never really got blogged about because we're right in the middle of packing and moving and things were crazy. So, Karen takes a step back in the Pediascribe blog and talks about hurricane Ike hitting Central Ohio because it was an amazing wind storm and she's got some pictures on the blog and of course we'll have a link to that in the show notes at Pediacast.org.
And then Bagga Chips is my daughter Katie's blog and she has a post called The Amazing Dancing Sheep. And what good is a teenager's blog if you can't embarrass your mom? So if you want to see Karen dancing with a sheep, you want to check out Bagga Chips. That sounds terrible doesn't it? You want to check out Baggachips.com; of course we'll have a link to it in the show notes at Pediacast.org as well.
There's a listener survey, if you haven't done that, it takes like 30 seconds but it does help us with demographics and it's in the sidebar at Pediacast.org.
Also, iTunes reviews, they're helpful. You know we have over 300 reviews in iTunes and we currently have a 4 1/2 star rating. We are featured above the Radio Disney podcast and we're right up there with the Sesame Street Podcast and Storynory and Manic Mommies. And we're really proud of that but it's not my doing, it's your doing. 'Cause if you listened to a couple of shows and then left, we wouldn't have much of an audience then we wouldn't be so prominently featured. [Claps] So, kudos yay, seriously to all of you because you're the reason that I keep doing this even when I do take a month off.
So iTunes reviews, if you've not written one of those, giving us a four or five star review, [Laughs] if you don't like the show, just quietly turn around and leave you don't have to write a bad review. But if you take the time to do a review in iTunes, that is helpful. Because the more reviews we have, then the higher our rating, the more likely we'll stay where we are and people will find the show. And how many of you, as I've said before saw these reviews and then that's why you came to PediaCast.
Ultimately, I'd like to give this podcast free for parents, and so sponsorships I think are the way to go. I have toyed with the idea of doing of a PediaCast Premium which would be a subscription service but I just hate doing that. It may come to that, we'll see depending on how the sponsorship thing goes, but with the economy the w ay it is, it's difficult to get sponsor money.
And as I said before if anyone wants to hire me to do a radio show, hey, I'm game. Any executives from Clear Channel out there, man just give me a buzz. [Laughs] All right.
I'm only partially kidding.
Until next time, this is Dr. Mike saying, "Stay safe, stay healthy, stay involved with your kids." And we'll see you next week OK, we're back to the weekly shows. Don't worry about that. So, so long everybody.