Syncope, Rabies, Controlling Toddlers – PediaCast 252

Join Dr Mike in the PediaCast Studio for more answers to listener questions! This week’s topics include Metro Parks, syncope, discharging newborns from the hospital, rabies & breastfeeding, sacrococcygeal teratomas, controlling toddlers, chronic diarrhea, ground rules for sharing, and planned home births.

Topics

  • Columbus Metro Parks

  • Syncope (Passing Out)

  • Newborns Going Home

  • Rabies & Breastfeeding

  • Sacrococcygeal Teratoma

  • Controlling Toddlers

  • Chronic Diarrhea

  • Ground Rules for Sharing

  • Planned Home Births

Links

Transcription

Announcer: This is PediaCast.

[Intro Music]

Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.

It is Episode 252 for May 8th, 2013. We're calling this one syncope, rabies and controlling toddlers.

So I want to welcome everyone to the program. We have another big Listener show lined up for you this week. And we'll get to the complete line up in a moment.

0:01:00

First, I got to tell. My wife and I have had some great experiences here recently hiking through the Columbus Metro Parks. And of course, we've lived in the Columbus area for quite some time.

Yeah, we moved to Florida for a few years and then we came back to Columbus. But in all of our years here, we knew the Metro Parks existed and we've been to them occasionally. But I never really took advantage of the hiking. And so, really, we were eager to get outside once the weather warmed up.

And most of you know, I'm not a big fan of that prolonged period between winter and spring. So we get into mid 60s weather and the sun outside. We're just itching to get out and do something.

So we checked out the Sharon Woods Metro Park in Westerville and we've also checked out the Highbanks Metro Park up in Lewis Center, area of Columbus.

And the cool thing there is, there's actually eagles like, Bald Eagles nesting… yes, in Ohio along the Olentangy river.

0:02:04

And there's an Observation Deck that you can hike to and actually see these Bald Eagles, so that was pretty cool. And then we have one a little closer to home, the Battelle Darby Creek Metro Park has some great hiking trails as does the Glacier Ridge.

So you know all about getting outside, less green time with your kids, getting them away from the video games and the television for a little bit and so this is one opportunity. Really something if you're in Central Ohio, get outside with your kids, take them to a Metro Park, lots of play equipment.

There's fishing, hiking. Have a cook out. So I'd really encourage you to check those out and I'm embarrassed to say it took us how many years to really get on board with the Metro Park System.

Now, OK, you're not in Central Ohio. If you're in a big metro area, you probably have Metro Parks of your own or state parks nearby, or community parks.

0:02:59

So my point is really just get outside with your kids, do something fun. Your local parks are one place to think about doing that you should think about it like "Hey, I drove by them every day." But it's not where those things that you're really actively thinking "Hey, let's really do it." It's one thing to drive by in another place to turn in and check it out.

So I'd encourage you to do that with your kids.

All right. So what are talking about today? Oh, by the way, if you to know more about the Columbus Metro Parks, I'll put a link in the Show Notes Episode 252 over in pediacast.org. So you can look them up, see where their locations are and what amenities each of them has on your own.

OK. So what are talking about today? We have a listener with a six-year-old who has "passing out" episodes. We call these events "syncope" and we'll discuss them in detail.

We also have an experienced mother about to have another baby. She's a little upset because her pediatrician expects the baby to stay in the hospital nursery at least 24 hours. But she wants to go home as soon as possible, a few hours after delivering.

0:04:02

Is this a good idea? Should she push leaving early against her doctor's wishes? We'll talk about that.

Then we have rabies and breast feeding. Yes, you heard me right. That is the combination we're going to talk about.

You've all heard of rabies. But what exactly causes rabies? What does it do to your body? And why are rabies shots so important?

And if you've potentially been exposed to rabies and you're getting rabies shots, should you breast feed? It's a good question. We'll consider it.

And then we have another mother whose baby has a sacrococcygeal teratoma. Now what in the world is that? I know it's a "big" words.

We're going to break down the words. It's actually easier to… once you break down the words, it's easier to understand. It's like "OK. That makes sense sacrococcygeal teratoma."

I know doctors use these Latin words to sound impressive but once you break down the meaning, it's not such a big deal. So we'll break it down and clue you in.

Finally we have a series of quick questions from a mom concerning toddler control, diarrhea and sharing.

0:05:03

Now these are three separate subjects. It's not controlling the sharing of the diarrhea, [Laughter] just to be clear.

And then we're going to wrap things up with the final word on "Planned Home Births". So the American Academy of Pediatrics has a new Policy Statement on delivering your baby at home. I'll sum it up and add my own two cents. So that's coming your way.

Don't forget if there's a topic you'd like us to talk about or you have a question for me or want to point me in the direction of a new story, it's really to get in touch. Just head over to pediacast.org and click on the Contact link. Easy to do. And I read every one of them that come through.

Also I'll remind you the information presented in PediaCast is for educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

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

0:06:00

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

[Short Break Music]

All right. We are back with our Listener Questions. And first up is Heather in Peoria, Illinois.

She says, "My now six-year-old son has started passing out. So far we have miraculously avoided any concussion from these, mostly due to a very nimble school secretary who earns some roses from our family."

0:07:02

"I myself have had six documented concussions, at least two before fourth grade due to accidents and the rest since high school because I started passing out, usually when I'm doing something normal, sometimes when I'm already setting but never when I'm highly active."

"I was diagnosed with a vasovagal syncope by a tilt table test. We always figured that mine was caused by a nerve misfire that was damaged by the original concussions. And I have a diagnosis of idiopathic neuropathy."

"Could this be genetic? Should I worry? Should I take him in for a tilt table test? Or just deprived him of roller coasters and becoming an airborne ranger? Or should I just wait and see like the pediatrician that saved his life says. Sincerely, Heather."

Thanks for the question, Heather. So a six-year-old who passes out, that's quite worrisome. And when any child passes out, it definitely deserves an emergent check at your doctor's office or an emergency department.

Now, I assume you've done this because if your doctor says "let's wait and see where this goes" and I'm assuming it's a doctor you trust, which is always important because this is a pediatrician that apparently saved your son's life at some point in the past.

0:08:06

So it sounds like you consider yourself in good hands that you feel comfortable with the workup that's been done and you're happy with the plans set forth by your doctor "to wait and see". All good things.

Of course, I can't really comment on the appropriateness of the past workup and plan because I don't know much about the exact nature of your child's "passing out" episodes. And I didn't examine your child.

And as I often repeat on this program, it's important we all understand; we don't practice medicine here or give advice for specific children.

But this we can do. We can talk about passing out in school-aged kids, in general, and discuss the potential causes, how you differentiate between these causes and what treatment might look like once you have established the correct cause.

OK. So with the ground rules established, let's talk about passing out or "fainting "which is also known as "syncope". That's the medical term for it. So there's a pretty wide range of possible causes.

0:09:00

Some of which are no more than a nuisance, but others that are life threatening. And in determining between these causes, the history surrounding the "passing out" event is extremely important.

What was your child doing when they passed out? Were they sitting, standing, engaged in physical activity, had they been sitting and suddenly got up?

Had they been standing in a warm room with a buttoned up collar for a long period of time? Did they fallen and hit their head? If so, did they passed out and then fallen and hit their head? Or did they fall, hit their head and then passed out? So the order of these events is important, but not always clear.

What are symptoms were present before or after they passed out? Do they have any chest pain? Do they have feelings like their heart was skipping beats or pounding hard and fast? Do they feel dizzy or lightheaded beforehand? How long were they out?

Did they regain consciousness on their own or did they need help? Did they have stiffening or shaking while they were out? And what was their mental status when they woke up? Were they immediately alert? Were they groggy for a few minutes and then alert? Or were they very sleepy and difficult to keep awake for a prolonged period afterward?

0:10:04

What does your child remember of the event? What did other people witness and how reliable are those witnesses? Have there been any recent fevers or illnesses? Has this ever happened before?

So my point here is, the history is always important in a medical evaluation. But for syncope, it's particularly important. And the direction of the workup really hinges upon it.

Ok. So we've obtained the detailed history and we performed a physical examination which, the bulk of the time in these cases is going to be normal. Most often when kids present with "passing out" they recovered. And they look great when the doctor sees them.

However, full recovery does not mean we should ignore the problem. There may still be a serious underlying condition and now we have this "window" to figure out what that underlying condition is, because depending on the condition, the next time they might not be so lucky, or the condition might not be serious at all.

Also, we'd like to avoid "passing out" episodes in the future even if the condition is not serious because the situation can always become serious if your child passes out at an inopportune time, like when they're swimming or riding a bike.

0:11:11

OK. So what are the possibilities? You can probably infer some of them by the questions I proposed in the history taking portion of our discussion, especially you medical types out there. You know where my questions were leading.

Now, vasovagal episodes, as Heather points out, is a common problem. It's a common cause of syncope. And we'll talk more specifically about vasovagal episodes in a minute. But the differential diagnosis for "passing out" is really quite large and in addition to vasovagal episodes it includes things like seizures, head injuries, heart rhythm problems, heart structure problems, low blood sugar, breath-holding spells, migraines, brain tumors, brain bleeds, other central nervous abnormalities like Arnold-Chiari malformation; anxiety, hyperventilation, drug abuse, toxin exposures, dehydration, orthostatic hypotension, so lots of possibilities, some life threatening, others not.

0:12:06

And the workup we'd want to do really depend on the exact nature of the event, while also considering past medical history, family history and the findings of our physical examination.

And depending on these variables, our workup could include things like, orthostatic vital signs. We measure heart and blood pressure with the patient lying, sitting and standing. If we're worried about the heart or other circulation problems, we'll often start with an EKG, possibly a chest x-ray.

The child might need a referral to a cardiologist and the cardiologist might perform an echocardiogram, looking at the structure of the heart with sound waves, or an event monitor, something that you wear over a prolonged period of time so you can see what the heart is doing at some future time, when they have an episode.

And as Heather mentioned, they might do a tilt table test where they lie down flat, swing you quickly to an upright position and see what your heart rate and blood pressure do, and see if that makes you pass out.

0:13:06

If we're worried about seizures, the brain or other central nervous system issues, then we might check an EEG, looking at brain electrical activity. CAT scans or an MRI of the brain is also a possibility.

And you might need a referral to a neurologist or a neurosurgeon depending on what we find there. Blood work and urine studies may be helpful in other situations.

So the important point here is that there's lots of things to consider, lots of things that we could do but every child with syncope does not need all of these things done. They're merely possibilities, depending on which direction the history and physical exam is taking us.

So Heather, you mentioned vasovagal syncope. What is that? Well, it's a common problem, as I mentioned. What it is… is stimulation of the tenth cranial nerve, which is also called the vagus nerve.

Stimulation of that nerve leads to a temporary drop in heart rate and blood pressure, which results in a brief episode of fainting or "passing out" or syncope.

0:14:06

So it's vaso which refers to the circulatory system, and vagal which refers to the vagal nerve or the vagus nerve, and that's why it's called vasovagal syncope. So the vagal nerve gets stimulated, you get a decrease in heart and blood pressure and you pass out, vasovagal syncope.

So what causes the stimulation of the tenth cranial nerve? That depends on the person and specific triggers. For some, it might be the sight of blood. For others, it may be standing in a warm room with a tight shirt collar around your neck, straining hard to have a bowel movement, iced cold water in the face, these are other common triggers.

And sudden changes in body position can be a trigger for others, which is why a tilt table test maybe helpful. Incidentally, another disorder that may be diagnosed by the tilt table test is postural orthostatic tachycardia or POTS, which is different from vasovagal syncope.

0:15:01

And if you would like to know more about that condition, be sure to check out Episode 228 over at pediacast.org because we covered it in considerable detail a few episodes back. And I'll put a link to that episode in the Show Notes, for this Episode, 252.

So hope that helps, Heather. I know I didn't really answer your question. Does your son need more of a workup for his syncope?

Maybe, I mean, it really depends on the exact nature these episodes, his past medical history, more details on your family history and the results of any tests that have already been done and your doctor's findings on physical exam, so a lot to consider, which is why we can't really provide specific medical advice in the form of a podcast.

But I do appreciate the question, Heather. Thanks for writing in.

All right. Let's move on to our next listener. This question comes from Elizabeth in Round Mountain, Nevada. She says, "Dr. Mike, I'm 36 weeks pregnant with my second baby. I would like to limit my hospital stay as much as possible. And while my OB does not have a problem with this, assuming an uncomplicated delivery, he has told me the pediatrician will not discharge our baby for at least 24 hours."

0:16:02

"Does the pediatrician have the right to hold our baby in the hospital? Or can my husband and I discharge the baby? I don't want to be confrontational but if the baby is doing great and there are no complications and we're not first-time parents, why does he need to stay in the hospital?"

"In free-standing birthing centers, babies and moms are frequently allowed to go home within a few hours. Now I understand if there was a traumatic birth or other complications. The best place for the baby would be the hospital and I would absolutely follow the advice and care of the pediatrician."

"But if there are no problems, why can't we just go home? I would appreciate your thoughts on this. Thank you, Elizabeth. P.S.: I finally got off my lazy bum and we're going to review in iTunes. I should have done this much sooner since this is one of the best podcasts I've listened to. And I tell everyone about it. Thanks for the service you provide."

Thank you for the kind words, Elizabeth. And thanks for your iTunes review. Those are always appreciated. Most of all, though, thanks for your question. It's a good one. But you might not like my answer.

0:16:58

I would definitely recommend staying as long as your pediatrician advises you to stay. And I think a minimum of 24 hours is absolutely reasonable. And to be honest, I'd push for two days if possible. But that's me.

Ok, why? I've just seen too many babies who look fine at birth, crash and burn 12 hours later in the newborn nursery. Unfortunately, it does happen and it can be very difficult to predict.

So what kind of life-threatening conditions resulted in a baby who looks fine at birth and continues to look fine for a few hours who then crashes and ends up in a newborn intensive care unit?

Babies with certain congenital heart disorders are one example. There's a little blood vessel called the ductus arteriosus, which bypasses the lungs in the fetal circulation. Babies inside moms aren't using their lungs for respiration, right? They're using the placenta for that.

So we don't need much blood in the lungs. It's OK to bypass the lungs. But then, shortly after birth, sometimes a few hours after birth, the ductus arteriosus normally closes, because now we don't want blood to bypass the lungs anymore.

0:18:05

We want the blood going through the lungs. OK, that's fine, right?

Well, it's not fine. If your baby happens to have an undiagnosed heart condition, such as pulmonary stenosis, pulmonary atresia, coarctation of the aorta, transposition of the great vessels, tetralogy of Fallot, interrupted aortic arch, these heart conditions depend on the ductus arteriosus being opened in order to get oxygenated blood to the heart and the brain.

And if the ductus begins to close, your seemingly well baby may begin to have certain symptoms, such as rapid breathing, poor feeding, turning blue, and dying… serious stuff. And this is how many of these heart conditions end up getting diagnosed, after the ductus arteriosus begins to close.

And a well baby is suddenly very sick, critically sick, but there was no sign of anything being wrong until several hours after the birth. These kids need medication to keep the ductus arteriosus open and delay in getting them the medication or delay in respiratory support may kill them on their way home or once you get snuggled inside the house.

0:19:07

So that's one very real concern.

Another is neonatal sepsis. So septic babies… once we get blood infections right before they're born or during the birthing process… they aren't born with a fever. They may be fine for a few hours. And then fever pops up, along with other concerning symptoms.

And without timely identification of the problem, obtaining blood culture, starting antibiotics, overwhelming infection can result, and your baby crashes and burns.

Another issue is hypoglycemia or low blood sugar. Some babies have normal blood sugar at birth, but a few hours later they drop. They aren't feeding well and without quick intervention with glucose containing IV fluids could they cease and die.

So these are three very real and not at all uncommon conditions which turn normal healthy newborns into very sick babies in the intensive care unit within a matter of hours.

Now having said all that, let's look at this through a risk versus benefit lens.

0:20:03

What's the chance of your baby having any of these problems? Pretty low, but when you consider they happen every day in large birthing centers, they aren't exactly rare either. So a very real possibility is out there that a normal baby could crash and burn a few hours later, after they've looked well, 12 hours out, boom, problem.

And if your baby has one of these conditions and you go home before it declares itself, what's the risk? It could very well be death or a poor neurological outcome due to the brain not getting enough oxygen, if they're not resuscitated appropriately.

Now what's the benefit of staying? Well, rapid identification and life-saving treatment of potential problems.

What's the risk of staying? So we know the benefit? What's the risk? There really isn't much of one. Hospital-acquired infections in the newborn nursery are certainly more rare than the conditions I've mentioned.

0:20:59

I suppose there might be a financial concern for some, or fear you won't bond quite as well with your baby, or not get the support you want. It might burst the bubble of your perfect delivery plan.

But that's a bit being selfish, isn't? When you consider missing one of these conditions and going home too soon, that could burst the bubble of your baby's future life.

So for me, when I boil it down, the benefit of staying one or two days outweighs the risk of leaving early. That's how I see it, anyway. And I hope that helps, Elizabeth. Again, thanks for the question, really do appreciate it.

Next stop, Leslie in Peetz, Colorado. "I was recently exposed to rabies through an infected horse. Yikes! I was not bitten but touched his saliva." So we're talking horse pet, people.

I started treatment immediately with a rabies vaccine and immunoglobulin. I'm also breastfeeding my nine-month-old son. I was concerned that I could pass this to my son through breast milk.

Several doctors have said it would be safe but did not explain the reasons why. Can you explain how the rabies virus works and its spread and the incubation process and your thoughts on the safety of nursing.

0:22:03

Thanks for the question. It's a tall order but I'll give them a try. First let's tackle rabies in general and then we'll focus specifically on the breast feeding issue.

Rabies is the Latin word for "madness" and it's an apt description, the image of a foaming at the mouth, out of control dog probably comes to mind. Fortunately responsible pet owners and vaccine programs have greatly reduced the incidence of rabies in American dogs.

But in other parts of the world, 55,000 people die each year from rabid dog bites. Raccoons, skunks and foxes are still common carriers of rabies in the United States. Horses aren't common but any mammal can be a possible carrier.

The most common of all is the bat and the bats are sneaky. They swoop down. They can inflict tiny bites and scratches that you actually might not notice till it's too late.

So let's get a bit more specific and drill down to the virus itself.

0:22:59

Rabies is caused by the Lyssavirus, Lyssa being the great goddess of madness, rage and frenzy.

The virus enters your body from the saliva-filled bite or scratch of an infected animal. And from there, begins a multi-week journey of a peripheral to your brain.

So the incubation period is a long one, to the tune of weeks, not days. Now don't let this initial lack of symptoms fool you.

Once the Lyssavirus arrives at its final destination, the brain, it begins to wreck havoc. And once symptoms start, at that point, there's really no stopping them. So what are these symptoms that we want to prevent the onset of this, so the cascade doesn't occur?

Rabies begins with flu-like symptoms. So you can feel you can have a fever, runny nose and congestion is possible, aches and pains, just flu-like symptoms.

But these rapidly progress to anxiety, confusion, agitation, aggression, insomnia, hallucinations, terror and delirium.

0:24:02

Then you become weak and paralysis sets in. You have trouble swallowing. You drool. You foam at the mouth. You go mad. And death is nearly universal. So preventing the onset of symptoms is critical and that's where the rabies shot comes in.

Now back in 1885, Louis Pasteur and two assistants obtain the virus from the jaws of a rabid dog. Really, I mean they put their lives on the line. [Laughter] They opened up the jaws of a rabid dog and obtain the virus.

They cultured the virus in rabbits. I don't think there's a single scientist out there today who would put their life on line like that. Hah!

So anyway they get the rabies virus. And this is interesting. They cultured the virus in rabbits. And then they weaken the virus by drying out the infected nerve tissue. Now this did not actually kill the virus.

0:25:00

OK, this just caused the virus to be mildly attenuated so it lessened its potency. And back in those days, the shots, so of this weakened virus, 21 shots were given under the skin of the abdomen over a three-week period. And pain, redness and swelling associated with these shots were intense.

And remember, this was not a killed virus or even an attenuated virus as we defined attenuated viruses today. This was just mildly weakened. And serious neurological damage from the vaccine was actually common because they were causing a milder form of rabies.

But it was still better than the alternative of fall out natural rabies infection which was universally deadly.

Now today's rabies shots are safe. They are made up of killed rabies virus and injected deep in the muscle of the upper arm with just four injections over a two-week period.

0:26:02

And these injections of these killed rabies virus stimulate your immune system to make antibodies against the rabies virus so your body attacks the live virus that's in your system when it gets there more efficiently.

And as in Leslie's case, doctors can also give rabies immunoglobulins which are already made antibodies, which can immediately start killing the virus. So that's rabies in a nutshell and I think we've answered most of your questions, Leslie, all of them, but one. And that's the breast feeding issue.

And this is a difficult question and really it's one you have to answer for yourself after being armed with the facts. So what are the potential concerns with breast feeding when you have potentially been infected with the rabies virus yourself?

The first question along those lines would be, does the actual rabies virus get into the breast milk? And if it does, could it infect your baby? Followed by, does the rabies vaccine and rabies immunoglobulin… do those things cross into the breast milk?

0:27:02

And if so, what effect would they have on your baby? Those are the concerns, right?

And unfortunately, we don't have concrete answers to these questions. We don't know for sure if rabies virus passes into breast milk. We don't know for sure if breast milk could transmit rabies to your baby, if the virus is present.

We don't know for sure if rabies vaccine crosses into breast milk. We don't know for sure, if rabies immunoglobulin passes into breast milk. And if they do, we don't know for sure what the effect would be on your baby.

We don't know these things for sure because these things have never been studied or tested. We don't have evidence-based sources to go to for answers. So the doctors who were telling you breast feeding is OK, they are relying on what they do know and making a judgment based on… you guessed it… risk versus benefit.

So here are the facts I suspect your doctor are considering. Now I can't say for sure because I'm not in their heads. But this is what I suspect.

0:28:01

First, the risk of rabies transmission to you from the horse saliva, in the first place, that's pretty low. It's not impossible but it's low.

Why? Because the horse did not bite you. Bites and scratches allow the virus easy access to a nerve so that they can then make that transit up to the brain. But the skin is a great barrier.

Still there are case reports of transmission from infected saliva through mucous membranes. So if the horse's spit touched your eye, your nose or your mouth, then transmission is possible, but again not likely.

However, because rabies is so deadly, we have to pay attention to even tiny, tiny risks which is why they decided to give you the rabies vaccine and the immunoglobulin. But at the end of the day, if rabies virus does cross into the breast milk which, again, we don't know for sure if it does or not.

But let's say it does. Then the risk of you having any rabies virus in your body to get into the breast milk is very, very low.

0:29:01

Why? Because again the chance you actually caught rabies from the horse is low and because you were immediately started on rabies immunoglobulin and rabies vaccine, so any virus that did get into you, hopefully those things have killed fairly quickly.

Now your doctors are likely considering a few more things. There has never been a verified case of rabies transmitted through breast milk. So if it happened, you'd be the first and you'd probably be a case report on the CDC's website.

But notice I said "verified". There have been anecdotal reports of rabies transmitted from mother to baby by milk. Another words, mother had rabies, was breastfeeding or nursing her baby and then baby got rabies.

But we aren't sure if the disease was actually transmitted by the breast milk or if mom and baby both got the infection from the same source. So these cases weren't thoroughly studied.

0:30:01

So we just don't know. And as it turns out, there've only been two such cases, one involving a mother and baby lamb. OK, they were talking sheep here, folks. And the other did involve a baby or a mother and baby human.

So there's that. Now if it were a real serious concern, you'd think it would have more case reports. Still, these reports perhaps make transmission to breast milk plausible.

Another point to consider and this one involving the rabies shot. If rabies vaccine crosses into breast milk, again, we don't know if it does or not, but if it does, it is killed virus and would not be expected to harm your baby.

Rabies immunoglobulin probably does cross into breast milk since we know other antibodies cross through. But again we wouldn't expect this to be harmful either.

So while we don't know for sure that breast feeding is 100% in this situation, your doctors are telling you that the risk of transmission to your baby through breast milk is exceedingly low.

0:31:03

We also know that breast feeding has lots of very real benefits for baby. So in their mind, in your doctor's mind, the benefit of you breast feeding outweighs the risk of you passing rabies on to your baby, even though the risk is not an absolute zero.

But you know we may call sorts of decisions every day where benefit outweighs risk, but the risk is not zero. We drive cars. We ride in airplanes. We go outside. We ride bikes and swim. We stay indoors where a fire might start in our sleep. So there's risk everywhere, including breast feeding after being exposed to horse saliva-containing rabies virus and while getting rabies shots and rabies immunoglobulin.

The risk is low but it's there. You asked your doctor's opinion and they say the benefit outweighs the risk. It sounds like you agree with them. You're still breast feeding and if you're comfortable with the situation, as I've described it, it fits into your risk comfort zone. And I'm happy for you.

Now, what would I do in a similar situation, if it were my wife and my baby?

0:32:03

You know, honestly, with those two case reports in mind, even though they're unverified, I'd probably say "You know what. Why don't you pump and discard the milk a couple of weeks. We'll switch to formula or use up our supply of frozen breast milk and resume breast feeding when the rabies shot and immunoglobulin are finished in a couple of weeks."

That's what I would do because there's just this little voice in my head making me nervous about it. Now I don't fault your doctors or you one bit for your decision to continue nursing. You're taking a risk. It's a tiny, tiny, tiny one.

Driving your car even with the baby properly restrained in the middle of the back seat is likely a much bigger risk. Driving is more dangerous for me, too. So why would I have my wife stop breast feeding in this situation but continue driving? It makes no sense, right?

I don't always have to make sense and it comes down to perception and risk tolerance. That's all. And I'm just being honest and transparent with you. I suspect most doctors would say "keep breast feeding" in this situation, unless it wasn't their kid. Hmm.

0:33:04

See folks, medicine is not always black and white. There's plenty of shades of gray.

Thanks for the question, Leslie and as always, much appreciated.

Next stop, we have Tasheena in Tulare, California. "Hi, Dr. Mike. I'm a big fan of your show. I listen every week and I tell everyone I know to check it out. My question is in regards to recurrence of sacrococcygeal teratoma in children. My daughter was diagnosed with this after the nurse noticed a lump on her bottom during her first bath."

"None of the doctors, nurses or her pediatrician had seen anything like it. We were referred to a great pediatric surgeon who works at the Central Valley Children's Hospital here in California."

"After diagnosis, he removed the tumor along with the coccyx when she was 2-1/2 months old. The surgery went well, little longer than expected. But there were no complications and we were home within two days, after the pathology came back negative for cancer."

"I'm just a little concerned however because her surgeon said, after her follow-up appointment, that she would never need to see another doctor regarding this condition."

0:34:03

"Since the entire coccyx was removed, there is no chance of recurrence."

"Well, I've done my own research in the mean time and have found evidence-based peer-reviewed articles which say there is a small chance of recurrence, even if it's benign and even if the coccyx is removed."

"I'm not one to believe everything I read on their Internet but when it comes to even the slightest possibility of my child getting another tumor that may grow cancerous, if left unchecked, we'll that terrifies me."

"After all there was only 1 in 40,000 chance of her having a sacrococcygeal teratoma in the first place. Do you know anything about recurrence of this disorder? And do you think she should be checked yearly for the next three years as suggested in some of the articles I read? Thanks for your help, Tasheena."

Thanks for the question, Tasheena. First, let me congratulate you on your research. Nice job. And to catch everyone else up on the topic, let's define sacrococcygeal teratoma.

Sacrococcygeal, that's let you know the location. So we're talking about the spine.

0:35:00

The sacrum is the bone just above the tail bone, and the coccyx is the tail bone. So sacrococcygeal simply means in the vicinity of the tail bone and a little bit above it.

Teratoma as you probably gathered is a type of tumor, and it's a tumor made of germ cells. And in this case "germ" does not mean germs as in bacteria or viruses, but rather a tumor with all three germ layers.

And for you science types out there, that would be mesoderm, endoderm and ectoderm. So instead of one cell type, this is actually a tumor made up of layers of different cell types. So instead of a ball of identical cancer cells, it's actually tissue.

And as it turns out, teratomas may contain well-differentiated tissue such as hair, teeth and bone. Now I know you're saying "What!" How can this be?" We'll think of it this way and admittedly, I'm simplifying this a bit.

0:35:58

Early during development, a few cells destined to become specific tissue. So these are cells that are destined to become hair or in any case, destined to become the cells that make hair, or destined to become teeth, or destined to become bone.

And a few of these cells migrate to the wrong spot and the tissue starts growing in this wrong spot. But then the body is like "Hey! That's not right. Stop what you're doing and walls the whole thing off," but what's done is done. It's there. And a common place there is, is the sacrococcygeal region. So we have a sacrococcygeal teratoma.

Now most of these are completely benign. But a few do have malignant components. And if this is the case, or even when no malignancy is found as in Tasheena's case, out of an abundance of caution, the entire tail bone may be removed in an effort to prevent recurrence. So that's the background.

Now recurrence is uncommon with these tumors but it is possible, especially if there is a malignant component.

0:37:01

But even in the case of benign teratomas, it's always possible, although not likely that the pathologist did not find the malignant component, but a tiny one really was there. They just didn't see it and it got left behind and then the tumor may recur.

Now there's a low risk of this. It's very low risk. But it's possible. Now having said that, the chance of a tiny unseen malignant component being left behind is even less likely when the entire coccyx is removed.

So, given the negative pathology report and given the fact that the entire coccyx was removed, your child has a very low risk of recurrence. So low, your surgeon is comfortable with saying "Look, we're done".

But it's not an absolute zero risk and even your surgeon would admit that. So from a mother's point of view, you're still worried because you've researched it and you've seen the risk is not an absolute zero.

So you have a different risk tolerance than your surgeon.

0:38:00

There's nothing wrong with that. Do you guys sense a theme emerging with this episode?

I do understand your concern, Tasheena. And like you, I have come across recommendations for long-term follow up of sacrococcygeal teratoma. But I also understand the surgeon not wanting to be the one to do the follow up.

Surgeons cut things out. That's their calling. Long-term follow up of an extremely unlikely recurrence, not so much. So here's what I would do.

I would just ask your primary care doctor to refer you to a pediatric oncologist. If the oncologist tells your doctor "We don't need to see a child with a benign sacrococcygeal teratoma who had the entire coccyx removed." Have your Doc say "Look, it's for mom's peace of mind."

Because that's important, too. And in the end, I think the pediatric oncologist will be happy to see every six months to a year for a few years and then everyone wins, my two cents, anyway, which after all is what she asked for.

Now some of you out there may be saying to yourself "Why does he give concrete advice to some listeners and not to others?" Look, it's risk management, folks, plain and simple.

0:39:03

Some recommendations are appropriate; others aren't.

All right, we have time for one more listener today. This one a very close to home, Christina in Columbus, Ohio, says, "Love the show. Here is some parenting questions I have. I know you won't be able to answer them all.

Actually, Christina, I will answer them all because they are all short easy questions with sure easy answers.

Number one, my three-year-old suddenly must pick out her own clothes. I'm OK with it, weather permitting. But what is this about? We'll it's about control, Christina. Three-year olds don't get a lot of say, and so when they start to find the areas of their life that they can control, they start exerting their independence and they want to pick and choose and have some control.

And I think your response to her attempts of control, I think, your response is perfect. You're OK with it as long as the outfit is appropriate for the weather or the circumstances. Now let's say the outfit she chooses isn't appropriate. Then what?

0:40:00

Oh, I'd say pick out a few outfits that would be appropriate and let her choose from among them.

Number two, we had a stomach virus that went through the family. My nine-month-old has not been able to get rid of the diarrhea. She's hydrated and still breast feeding. Is probiotic yogurt OK to give?

So yogurt is fine for healthy nine-month-old babies. I do want to point out… it may or may not help in this situation. Sometimes these prolonged diarrheas just have to fix themselves or it could be a sign of a continuing problem.

So even if your child has seen a doctor and then you said this diarrhea is just caused from a virus, I would say, if the watery diarrhea is lasting longer than you expect, lasting for more than a week, let's say, or if it's accompanied by blood in the stool, fever, vomiting, poor feeding, decreased urine output, really any other new and concerning symptoms, then you definitely want to check in with your regular doctor, even if your doctor already saw and said "Yeah, this is a virus and just give it some time."

0:41:02

So if it's not getting away or if it's not getting better, when you would expect it to be getting better, make sure you call your doctor again.

OK, number three. Now that the nine-month-old is scooting around, he wants his sister's toys. Any ideas on ground rules for sharing and fighting?

So another good question, Christina. First from the perspective of your nine-month-old, he's not going to understand "sharing" at all. And if you really want something your daughter is playing with, he's going to grab it, every time. And you can preach sharing till your blue in the face. He's not going to get it.

But you should be able to re-direct your nine-month-old and entice him with something else, pretty easily. OK, it's easy to get their attention from one thing to another when they're nine months old.

Now in the other hand, your three-year-old daughter, she does need to learn about sharing. So if the baby is playing with something that belongs to her and he had it first, she should wait. But I wouldn't make her give up something she is playing with first to the baby. Just re-direct the baby and let her be, at this age.

0:42:00

Now things will be different by Christmas. So in a few months, you will need to set ground rules. And for our family it was this. Simply, "first come, first serve". Whoever is playing with it first gets it for a while, even if it belongs to the other child, as long as they're not damaging it or using it inappropriately.

In our house, most toys were community toys. Now there were some exceptions for special items but not many. If there's an argument, once both kids clearly understand the concept of sharing, if there's an argument at that point, you may want to set a five-minute kitchen timer, when the timer goes off, the toy transfers, but only for another five minutes if the first child wasn't done.

And it's back and forth with the toy for five minutes at a time, usually does not last long because they soon realize that cooperative play is much better than a few minutes with the toy by themselves.

So thanks for the questions, Christina. As always, very much appreciated.

Don't forget if you have a question for me, or you want to suggest a show topic for one of our interview shows with pediatric experts, or want to direct me in the direction of a new story, simply go to pediacast.org and click on the Contact Us.

0:43:09

OK, it's the Contact link.

And I read every one of those that come through so if you submit something under the Contact link at pediacast.org, rest assured I will see it.

All right, that wraps up our Answers to Listener Questions this week. But stick around. I'll be back with a final word on "Planned Home Births". That's coming up, right after this.

[Short Break Music]

0:44:08

All right. We are back. Although they're still uncommon, the rate of planned home births has increased during the past several years in the United States. And in a new Policy Statement entitled "Planned Home Birth" and published in the May 2013 edition of the journal Pediatrics, "The American Academy of Pediatrics makes recommendations for the care of infants born in a home setting." They say, "Regardless of the circumstances of the birth, including location, every new born infant deserves health care that adheres to academy standards."

The American Academy of Pediatrics concurs with the recent statement from the American College of Obstetricians and Gynecologists that the safest setting for a child's birth is a hospital or birthing center but recognizes that women and their families may desire a home birth for a variety of reasons.

With this in mind, pediatricians should advise parents who are planning a home birth that the American Academy of Pediatrics and American College of Obstetricians and Gynecologists only recommends midwives who are certified by the American Midwifery Certification Board.

0:45:11

In addition, there should be at least one person present at the delivery whose primary responsibility is the care of the newborn infant and who has the appropriate training, skills and equipment to perform a full resuscitation of the baby.

All medical equipment including the telephone should be tested before the delivery, and the weather should be monitored. Plus a previous arrangement needs to be made with a medical facility to ensure a safe and timely transport in the event of an emergency.

The American Academy of Pediatrics guidelines include warming the baby, a detailed physical exam, monitoring of temperature, heart rate and respiratory rate, eye prophylaxis, vitamin K administration, hepatitis B immunization, feeding assessment, jaundice screening, and other newborn screening tests.

Infants may also require a monitoring for group B streptococcal disease and glucose assessment, comprehensive documentation and follow up with the child's primary health care provider is essential."

0:46:08

So if you'd like to see the "Planned Home Birth" Policy Statement in its entirety, I'll put a link for you in the Show Notes for Episode 252, this episode, over at pediacast.org.

So my take on this really goes along with our discussion on the importance of keeping your newborn in the hospital nursery for a day or two.

Look, folks, in many cases, emergencies don't announce themselves. Now sure, there are high-risk situations in which the need for life-saving interventions can be anticipated. But normal routine, run-of-the-mill term babies born by vaginal delivery, every single day in the United States, many of these go south and quickly become emergencies requiring life-saving interventions by a team of highly trained and seasoned medical professionals.

So the first sound decision you can make as a parent is this, plan on delivering your baby in a place where his or her life can be saved in the unlikely but absolutely possible event of a medical emergency.

0:47:09

Pull out our good friend, the benefit risk meter, and you'll find the benefit of delivering your baby in a medical facility and staying in that facility for a day or two far outweighs any risk, cost or personal inconvenience.

And that's my final word.

All right. I want to thank all of you for taking time out of your day to be a part of the audience, really appreciate that.

As I always mentioned, iTunes reviews are helpful so if you have not spent the five minutes that it takes to go to iTunes, look at PediaCast and write a quick review. Please do so. It really helps spread the word about the program.

Put some more confidence in the program for parents who are looking into it and thinking "hey do I really want to spend an hour of my time listening to a podcast on pediatric material?" So when they see that it's a highly rated podcast and see what some of you folks, moms and dads, out there in the trenches what you have to say about the program, then they say "Hiya, I will take and listen to this."

0:48:07

So truly how we help share what we have with others by letting them know what's available and iTunes reviews are a great way to do that.

Another way or links, mentions, shares, retweets, repins, all those things on social media sites. We are on Facebook, Twitter, Google Plus and Pinterest.

Also I want to remind you on Pinterest, we have a News Parents Can Use Board with news stories that we don't cover in the podcast so you'll find exclusive information on our Pinterest board.

Also be sure to tell family, friends, neighbors, co-workers, and your child's doctor about the program. And posters are available under the Resources tab at pediacast.org.

The telling your child's doctor is really important. We just want all the pediatricians across America to know about this show so they can share it with their patients. And how are they going to find out? Really the best place is personal recommendation from you.

0:49:00

So please let them know the next time you're in for a well checkup or a sick office visit.

One more time, it's easy to get in touch with me. Just head to pediacast.org and click on the Contact link.

And if you want to connect with any of the pediatric specialists here at Nationwide Children's Hospital, if you want an appointment with one of them or you want a referral, or you want a second opinion… any of these things… just go to the Show Notes and click the link that says "Connect Now with a Pediatric Specialist" and that will take you to an exclusive form, just for listeners of this program that you can write in and let us know what the issue is, what your concern is, what it is you want.

And let us know how to get back in touch with you and that can be by telephone. It can be by email. It could be snail-mail, however you like… and we will get back in touch with you.

So connect now with a pediatric specialist. It's exclusive to Nationwide Children's Hospital. You don't have to be in Central Ohio. You can be anywhere. You can be anywhere in the entire world and we'll get back to you, because we care.

0:50:02

We really honestly do.

All right, that wraps up our program this week and until next time, this is Dr. Mike saying, stay safe, stay healthy and stay involved with your kids.

So long everybody!

[End Music]

Announcer: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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