Whooping Cough, Handwriting, Self-Esteem – PediaCast 197

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Join Dr Mike as he covers news parents can use and answers listener questions from the PediaCast Studio. Topics this week include: vaccines for parents – should mom and dads get shots at the pediatrician’s office? Plus “pseudo-outbreaks” of whooping cough, handwriting and academic success, the relationship between asthma and infant growth, discrepancies in child-abuse suspicion based on race and parent earnings, donated human breast milk, baby cereal, pain tolerance, and self-esteem.

Topics

• Vaccines for Parents
• Pertussis Outbreak — For Real?
• Handwriting and Academic Success
• Asthma and Infant Growth
• Unfair Child Abuse Suspicions
• Donated Breast Milk
• Baby Cereal
• Pain Tolerance
• Sugar Cereal Solution
• Self-Esteem

Transcript

Announcer 1: This is PediaCast.

[Music]

Announcer 2: Welcome to PediaCast, a pediatric PodCast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!

Mike Patrick: Hello everyone and welcome once again to PediaCast. A pediatric PodCast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in beautiful downtown Columbus. You have to excuse my voice a little bit this week, just you know, just kind of nagging little cold, nothing big.

But enough to make me a bit hoarse and I might be reaching for the water bottle a little bit more often in this episode compared to others. It is 197 -PediaCast 197 for February 1st, 2012. Welcome to February folks.

01:06
Whopping cough, hand writing, and self esteem. Of course we have a lot more coming your way, and we'll get to all of the topics here in just a moment. So, tomorrow is Groundhog's Day, right. So we got to find out if we have six more weeks of winter. And I'm hoping that we don't because I'm ready for spring.

It's really been kind of a miserable winter so far here in Ohio, I mean we'd had very little snow, lots of rain, and just kind of cold and gray. And I don't know, I'm ready for the sunshine again. I need my vitamin D, and I'd rather get it from the sun, than from supplements. But you know, you get it whatever way you can. We do have some exciting news for you.

We are doing something new over at pediacast.org on the show notes page. You'll find that we are starting to add transcripts to each of our shows.

02:04
And so, this is going to be helpful in a few ways. Number one; it will make it easier to search, so you can find the individual topics that aren't necessarily listed in the show notes themselves in the topic index or there aren't tag on the post. So, basically anything that we talked about on the show, it's going to make it searchable at the website by adding the transcript.

And then also if you have a busy day and you don't have time to listen, and you just want to glance through it, we have a written copy of our content for you as well. We're going back and doing some of our more popular and interesting shows. And then moving forward most of the new shows should have transcripts for you. So, if you head on over again to pediacast.org click on show notes, and you'll be able to access the written transcript of each of our shows that way. All right. So what are we talking about today? Vaccines for parents. Should moms and dads also get their shots?

03:03
Now, you know kids out there who are listening to this right now, if your mom or dad and you're in the car, you got kids in the backseat, they are jumping -or they shouldn't be jumping, they should be restrained, but I'm sure that they're very excited at this point saying, "Yeah."

Shots for moms and dads you bet, we're all for it, so we're going to talk about that. Also, Pertussis speaking of shots for moms and dads. Pertussis outbreaks, are all of them real or could there be false outbreaks or pseudo outbreaks as the CDC calls them. We're going to talk about that.

Also hand writing is it linked to academic success? Doctors have poor hand writing, right? Doctors are kind of known for that. So, does poor hand writing mean greater academic success or is it the other way around? Does good hand writing have positive indicator for future academic success, we'll discuss that also.

04:00
Asthma and infant growth, unfair child abuse reporting practices, and then we're going to get to your questions. What about donated breast milk? Another on baby cereal, pain tolerance, and self esteem. So, these are all things coming your way very shortly.

I want to remind you if there's a topic that you would like us to talk about or if you have a question for the show, it's easy to get a hold of me, just go to pediacast.org, and you can click on the contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S.

And I also want to remind you if you get a hold of us in some way other than the contact link, make sure you put in your first name and where you're from. Everyone is always interested in knowing those things. You have to do it on the contact page, but if you email or call the voice line, we don't always get that information. So, please provide that for us and we'll get your question and answer on the show.

Also, I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.

05:07
So, if you have a concern about your child's health, make sure you call your doctor and arrange a face to face interview and hands on physical examination. Also your use of this audio program is subject to the PediaCast terms of use agreement, which you can find at pediacast.org. And with all that in mind we will be back to cover news parents can use right after this short break.

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So, children aren't the only one's who benefit from vaccines. Moms and dads need them too, not only for their own health, but also to prevent t he spread of potentially deadly germs to their kids.

06:07
Many adults are behind on their Pertussis vaccines and may not have been vaccinated against diseases such as Hepatitis A, certain forms of Meningitis, and Pneumonia, and even the flu. So, it gives, you know ,as long as children get these shots they're fine, right? They're protected.

Well, not necessarily. Vaccines aren't a 100% effective in every person. So kids not only rely on vaccines stimulated antibodies to fight off illness, they also rely on those around them being vaccinated to minimize exposure in case your child is one of the few who didn't make adequate antibodies against their vaccines.

And since parents are around their children a great deal, it's important that moms and dads don't harbor deadly germs to pass on to their kids. Of course we also want parents to be healthy so they can continue to parent and have healthy relationships with their children and grandchildren down the road.

07:00
So, how does this relate to pediatric medicine? Well, lots of parents are healthy and don't see their own doctors very often if it all. The age range that most parents, it's typically a healthy period of your life. But moms and dads do spend lots of time in the pediatrician's office. So, this pegs the question, should pediatricians offer shots for moms and dads?

Well, that's the recommendation from Dr. Herschel Lessin and Dr. Kathryn Edwards of the Committee on Practice and Ambulatory Medicine, and the Committee on Infectious Diseases from the American Academy of Pediatrics. In a recent article in the Journal of Pediatrics, researcher say, "Ideally, adults should receive immunizations at their own physician, but to provide greater protection to these adults and reduce the exposure of children to pathogens, immunizing parents or other adult family contacts in the pediatric office setting could increase immunization coverage for this population to protect themselves as well as children to whom they provide care."

Of course more questions comes to my mind. Questions like who pays pediatrician's to purchase, store, and administer the vaccines?

08:07
Do parents have to pay out of their pocket? Do their insurance companies pay for this? And the fact that it's not their regular doctor giving the shots to them would that be an issue? Also would this constitute and to what degree will this constitute? because I think it will.

A doctor-patient relationship between the pediatrician and the parent. And there are charting issues, liability issues to deal with here. So, I'm not trying to be 'Debbie Downer', I'm not saying it's not possible or that it's a bad idea, but they're certainly are logistical issued to consider before this idea sees the light of day.

In the meantime though it is important for parents to be as up to date on their vaccines as your children are. So, be sure to ask your doctor what you need. First go to your doctor, even if you're healthy and get your shots done for your kids and for you. Speaking of vaccine preventable illness, Pertussis also known as whopping cough, is a bacterial infection that results in severe difficult to control coughing.

09:04
The infection can interfere with breathing and result in death. In fact around 300,000 people die from whopping cough or Pertussis each year. But most of these deaths occur in children living in under developed countries. Still with many kids going without proper immunizations in America, the disease is on the rise here at home.

According to the CDC there are more than 27,000 cases reported each year in the US with 27 deaths in 2010, nearly all of which were infants younger than one year of age. Pertussis often shows up in communities as clusters of outbreaks has occurred in California a couple of years ago when 9,000 people tested positive and 10 infants died. But sometimes what appears to be an outbreak isn't.

For example what appeared to be a Colorado outbreak of Pertussis in the summer of 2009 wasn't really an outbreak at all. The CDC has determined that the laboratory which tested the positive samples had Pertussis DNA on laptop computers, counters, club containers, and medical equipment, and the Pertussis identified in the test samples likely came from these contamination rather than from the patients.

10:08
The CDC became suspicious because when they went back and talked to those supposedly infected with Pertussis, their symptoms didn't matched up with classic Pertussis symptoms. And as it turned out the amount of Pertussis DNA in their samples was much less that what would be expected with a real infection.

This isn't the first time the CDC has encountered a pseudo outbreak of Pertussis, that's the word they use for an outbreak that appears to be real on the surface, but turns out to have another explanation. Other pseudo outbreaks occurred in New Hampshire, Massachusetts, and Tennessee between 2004 and 2006.

The CDC has published some best practices guidelines for laboratories and medical offices to help prevent pseudo outbreaks in the future. Recommendation includes setting up different areas for Pertussis vaccine preparation and laboratory work. So, you know don't put the shots together and drum up in the same place that you're going to test for Pertussis because DNA from the shot might show up in the sample in the lab sample.

11:07
Health workers should also put on new gloves when handling Pertussis vaccine and when collecting Pertussis swabs, and they should dispose off these gloves immediately after finishing the job at hand. The CDC stresses that other outbreaks of Pertussis have been real and deadly. So, despite this findings it's still important that kids and parents are up to date with their Pertussis vaccines

I commend the CDC for announcing this, be to just keep it quiet, OK you have the report, let's not make a big deal about it. And some would say, the CDC and other government agencies are in the business of scaring parents so that they feel that they have to get their shots, and make money for the drug companies who are lobbying the government.

I mean, there's some sort of conspiracy theory I think that's out there. But I think it's nice when the CDC says, "Hey, you know, OK this is something that we identified as an outbreak, and you know what, it really wasn't an outbreak. We found XY and Z out."

12:05
So, I think that's good to have that transparency in the government and I think that just again goes against those who say there's this big vaccine conspiracy out there. All right. Let's move on to off of the topic of immunizations and on to the topic of hand writing.

The art of hand writing is in a fight for its life as students migrate to keyboard. But researchers at Florida International University say not so fast. The investigators want to see if there is academic value associated with good penmanship. So, they studied the hand writing skills of a thousand second grade students, and found out that those who wrote well and legibly tended to get better grades.

They're carrying the researches step further and they plan to work with struggling pre-case students to see if writing intervention will lead to better results in Reading and Math. So, my question with this and maybe you were thinking it too. Why is doctor handwriting so bad?

13:04
I mean, if you look at doctors, you'd think that bad handwriting is associated with academic success, like I mentioned in the intro to the show. Well, I can tell you from experience that my handwriting before becoming a doctor was fabulous, OK. I don't mean to brag, I don't want the pride to bubble up, but I had good handwriting.

In fact as a young doctor I was often told that my handwriting didn't match my profession. And I was always sort of proud that people could read my writing, few pharmacy's would call me to ask about my prescriptions because it was very legible exactly what I wanted. But thousands of prescriptions and medical charts, and school notes later, my handwriting began to look and of a lot like the typical scribblings of a doctor.

So, my point here is that doctors don't necessarily start out with bad handwriting, it just deteriorates. Which is a different thing all together. Of course I migrated to keyboards myself and don't have a ton of opportunity to write by hand, but when I do it's not quite so bad anymore.

14:03
So, handwriting it's important and might be important for academic success. We don't want to just rely on keyboards. All right. Moving on, what about infant growth and asthma? We talked about that we're going to discuss that topic in the intro. Is there a relationship between the two? Well, researchers in the Netherlands say there is a relationship.

Now, when I first heard this I thought, OK, they're going to say that infants with asthma don't grow as well as infants without asthma. But actually that's not it at all, that's not what they were going after. The authors of this study which was recently published in the American Journal of Respiratory and Critical Care Medicine.

They see that rapid growth during the first three months of life is associated with an increase risk of asthma symptoms. Previous research has shown a link between low birth weight and asthma. But this is the first to look at a specific growth pattern after birth and its relationship to the occurrence of asthma symptoms.

15:00
The team says, the mechanisms underlying this relationship were unclear, but they think accelerated weight gain in early life might adversely affect lung growth and might be associated with adverse changes in the immune system. They say, for the research is needed to replicate their findings and explore the mechanisms that contribute to the effects of rapid infant growth on respiratory health.

They would also like to examine infant growth patterns beyond the three month window to see if these relationship with asthma persist. You know, I'm also wondering if they looked at infant feeding or diet. And as we begin to understand the immune system's role in the asthma development, I'm left wondering if perhaps feeding differences could account for more rapid growth.

For instance the kids were getting more calories, and then the asthma could be because if they're getting more food or a particular diet, that perhaps they're getting more anogen exposure and that's then causing an immune response. So, could it be that feeding differences could account for this.

16:03
So that again, in some kids they get more food or different food. And they get more calories and more anogen exposure which results in weight gain. And more of a chance to have asthma problems. So, I wonder if our Dutch investigators have a suggestion box somewhere. If I find it, I'll be sure to tell them to control for feeding differences. I think that should be an important component as they continue their investigation.

Our final story in our news, parents can use segment of the program. It's a little bit disturbing; researchers at Indiana University School of Medicine in Indianapolis surveyed more than 2,000 Pediatricians and in the survey, they presented a case study of an 18 month old with an ambiguous leg fracture.

So, let me explain this, as doctors we get stuff in the mail all the time. And one of the things that we get are surveys that are from folks doing research to say, "Hey, as a Pediatrician, how do you handle this? How do you handle that? What do you tell parents to do."

17:03
As investigators try to get information about the practice habits of Pediatricians. So, in this particular case the investigators looked up 2,000 Pediatricians sent them a survey, and basically gave them a case scenario. And they said, "OK, you've got this 18 month old, they have a leg fracture, it's a leg fracture that the parent does not have a good story for how this leg fracture occurred."

And so, it is one that abuse or neglect have to enter into the doctor's mind because there's not a good story for this. I mean obviously it was an 18 month old, they fell down some stairs, they broke their leg, OK the story matches up the fracture. But in this case it's a leg fracture and the story doesn't quite match up.

Now, all of the 2,000 Pediatricians that were surveyed got the same story. OK, the same fracture, the same 18 month old, the same ambiguous story from the parents. But what they did change or make different from person to person that they sent this out too, is for some of the Pediatricians the family was described as African American, and for others they were describes as Caucasian.

18:11
In addition to varying the cases by the family's race, they also varied the families socioeconomic status. And they did this by mentioning what the parents employment was. So, if it was a high socioeconomic status case, they mentioned that the parent was an accountant or a bank manager.

And if it was a low socioeconomic case, then they mentioned that the parent was a grocery clerk or a factory worker. And then they took the the pediatrician's responses and just they wanted to see if there was a difference in the suspicions for abuse if you took a race or socioeconomic status as your indicator.

So, is there difference between the number of times that the doctor would say they suspected abuse based on race or socioeconomics.

19:00
As it turns out, race did not seem to make a difference in doctors analysis of the situations. So, when the family was portrayed as black, 45% of doctors believed abuse was almost certain or possible, 32% wasn't sure, and 23% didn't suspect abuse at all.

When the family was portrayed as white, 46% suspected abuse, 28% were unsure, 26% didn't suspect it at all. So, again the difference there if they're black about 45% abuse was possible, and if it was white 46%, so only a difference of 1% there. However there was a discrepancy when you compares socioeconomic status of the families.

When the family was portrayed with a high socioeconomic status 43% still suspected abuse, but when the family was portrayed with a low socioeconomic status, that went up to 48%. So, from 43% up to 48%, so an increase in 5% of those who suspected abuse. Now, it's not a big number, but it is statistically significant.

20:02
Study investigators point out that child abuse and neglect is not limited to those in lower socioeconomic classes, it happens in all income levels. And doctors needed to look at objective data, not race or socioeconomic status to determine their level of suspicion. So, you know that 5% OK, you know that's a shame.

But what I find even more disturbing with this study, there's something even more disturbing than the results that the investigators display for us. I think what's most disturbing for me is the high numbers who weren't sure if they suspected it or didn't suspected at all.

In almost half of the cases regardless of race, and regardless of socioeconomic status, in about half of the cases the doctors indicated that this 18 month old with a leg fracture without a good story for how it happened, 50% of the doctors weren't really all that concerned about abuse as being a problem.

21:03
Now, we've talked about this before, we've talked about child abuse. And it is a doctor's responsibility to report if they're suspicious. It's not an accusation. It doesn't mean of you report it that it's a concern. Now, I understand in this study they didn't ask how many would you report this as abuse. They didn't asked that specifically.

But the fact that so many weren't even suspicious or they weren't really sure, they should have been suspicious. I mean, a 100% of doctors should have said,"I have a suspicion. Doesn't mean I'm saying 100% that's right. I'm not accusing, but I have a suspicion in my mind because there's not a good story for this leg fracture in an 18 month old."

So, that should be way closer to 100% not 50%. So, I really think that's pathetic. And it saddens me, really, if we're suspicious we need to be more assertive in our suspicions and not just, "Oh, I'm not really sure about it."

22:06
Now, the good news here is they mentioned that they were just pediatricians they sent it too, and I suspected the bulk of them were General Pediatricians. And they don't see a lot of leg fractures in their primary care offices.

My hope is that if the same survey went out to a group of emergency medicine doctors who are the ones seeing most of these injuries would have a higher percentage of those who suspected abuse. Again without regard for race or socioeconomic status, but that they are at least suspect, at least have a notion of this is something that ought to be reported so that someone can look into the family.

Because when we fail to suspect it, then we fail to report our suspicions and we're doing family this service by returning children to dangerous situations or rather potentially dangerous situations, rather than giving the families the social hope that they need.

23:00
So, I get off my soapbox now, but you know just one of those things I feel a little passionate about because, I mean you don't want a kid just because they're in a high socioeconomic status, they can still be abused and neglected. And we don't want to miss that, we shouldn't miss it. And we really needed to be advocates for the kids that we see.

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

[Music]

All right. Welcome back to the program. First stop in our listener's segment is Tara in Irvington, New York.

24:02
And Tara says, "I have an eight months old son, who I have adopted. A friend who just had a baby has donated breast milk to my son. We have since found that breast milk must be age appropriate. Her daughter is five months older than my baby. Is her breast milk useful to my son? Thanks. Tara."

All right. Thanks for the question, Tara. First let me say, there's really two parts to this answer. The first is there is evidence you're right that the nutritional components of breast milk do change over time. But the changes are subtle, and as a whole human breast milk is preferred over formula. And really regardless of the baby's age, especially in the first 12 months of life, and regardless of how far out post partum the mother is.

So, a mismatch between your baby's age and the age of the nursing mother's baby isn't really that big of a deal. And just to kind of give you an example that there are, and we talked about this in episode 195, just very recently we had our breastfeeding extravaganza show.

25:04
And we talked about human breast milk banks where lactating moms can donate breast milk and then that breast milk is used for kids who needed primarily for premature babies who aren't able to get breast milk from their moms for one reason or another. Either their biological mom is not in the picture or the mom is not able to produce breast milk, or she's on medication, or she was on drugs.

So, the baby in the neonatal intensive care unit has a need especially in premise for human breast milk, but they're not able to get it, and so they use donor milk. That donor milk is not necessarily from moms who just had a premature baby.

So, human breast milk can be used even for premature babies even if the mom is way further out post partum than that baby is. So, it is used, it's still better than formula, but and this is as they say a big 'but', I wouldn't do it.

26:05
Now, I don't think that it's a good idea. And the reason for that is, when I answer this question you know, I kind of put myself into the position of the parent. And so, what will I do? If this is my situation and my kid. And there are things about your friends that you don't know.

Does your friend, do they have Hepatitis B? Do they have other diseases that they could transfer? How well was the milk stored? You know was it definitely at a constant temperature in the freezer?

There's all kinds of safety questions that would make me kind of step back from this a little bit. And so, using basically a biological human product, for your baby from another person, even if it's your best friend makes me very leery about that.

27:02
And probably not a good practice. Now if your friend, she was lactating, if it's the milk storage issue, we really don't again know for sure how it's stored. Did the temperature stay right? How old is it? And personally, I would think that a milk bank is not going to take that. I think that they are more after fresh milk and they are also going to test it.

And there are some quality assurance practices that go into place. But if she's lactating and wants to pump, and wants to provide milk for that kind of situation, I think that's great. But in terms of her having some old stored milk in her freezer that she wants to give to your baby, if I were in that situation, I would say no thank you.

And again, when we're looking at risk versus benefit ratio, I think if you personally don't have enough breast milk, so that you have to supplement with some formula or let's say that you've already because you didn't mention that.

28:03
But let's say you've already stopped breast feeding and switched to formula, and now there's human milk that's available, I think if you're looking at a risk versus benefit, then in that case formula might better than breast milk from even though you're best friend. Best friends don't always share everything or think of the things that are important.

So anyway, that's just my opinion. If your friend is interested in donating to a human milk bank, back again on PediaCast 195, we kind of touched on that. And in the show notes for PediaCast 195 over at pediacast.org, we do have some links to you, there are some resources with regard to human breast milk banking.

All right. Let's move on to Carmen from Saskatoon, Saskatchewan in Canada. Hope I'm saying that right, Saskatchewan, I think that's how you say it. Anyway, Saskatoon in Canada pretty cool sounding place anyway.

29:01
Carmen says,"Hi, Dr. Mike. First of I just want to tell you how much I appreciate the effort you put into the show. You had answered a question for me back in show 148 about temperature control, and my son who has epilepsy. You were the first doctor who actually answered my question in detail and explained to me the reason why. Thank you.

I have two questions today, my nephew still gets baby cereal every morning for breakfast. He is six years old. I think he still gets it because he is picky and likes the same thing day in and say out. Plus he just seems to love it. In my mind this can't be that great for him as the GI index of this food must be very high. To me it's like feeding him a bowl of sugar. Can you weigh in on this. Is it bad for him?"

So, I'm going to pause here and just answer that question right off there for you Carmen. Yeah, baby cereal is going to be pretty dense in calories, but then again so are a lot of the alternatives that parents use at these age, like sugar sweetened cereal. I think and my practical is it really sort of depends on his own growth and his growth chart.

30:01
I mean if I was seeing a kid like that in my office and they really love baby cereals still, but on their growth chart they look good, although six years old, OK, that's a little old for baby cereal I understand that. But at the same time you got a kid, they're six years old, they look great on their growth chart, their weight and height are proportional, acceptable where they are on the chart, and their BMI looks good.

You know, they're growing great. And they love eating some of that baby cereal in the morning, probably not going to make a big deal out of it. And as the aunt , you probably shouldn't either. This is between the mom and the kid, and their doctor.

Having said that, if you know that the kid is obese and the kid has a high BMI, is large for his age, and obesity is a concern, then absolutely I would say that is a lot of calories and they probably ought to switch to something different.

31:01
So again, it really depends on the scenario, and the kid's specific growth chart. Again, this is another reason why you have to actually have a thinking head as a pediatrician and not a vending machine or something that use in flow charts to make decisions because there's a lot of factors that you have to take in into account.

OK. Carmen goes on and says, "Here are some background information for my second question. My son was born at 28 weeks gestation, and was in the NICU for eight weeks. At four months of age, one month corrected age, he had a simple hernia operation which causes him to have a stroke and he almost died. This is why he has epilepsy and he is developmentally delayed.

After all of these trauma, the poor guy had several lung infections and spent the next three years in and out of the hospital. I think he was admitted about four times. He also has to have blood drawn routinely for his epilepsy meds. Needless to say, he is one tough nut. My question is about pain threshold for him.

After the Christmas holidays we were sitting down the dinner and I noticed a huge water blister and burn on his finger. It looked very fresh and was quite large. We asked him how it happened and he pointed to the kitchen. We think he must have touched the stove.

32:09
The thing is, he never cried or screamed when it happened or indicated that it hurt. He did have trouble falling asleep that night, so I suspected it did hurt him, but he never complained ones. Do you think that his pain threshold is really high because he was poked and prodded so much since birth. Could a burn of this nature really not hurt?

Has there been any studies on this and premise are sickly children. I'm really curious about it and a bit worried. What if something is wrong and he doesn't feel the pain associated with it. Thanks." That's a great question, Carmen. And of course I'm not going to be able to give you an exactly absolutely right answer for your particular child, but I can offer you some insight. And I think two things are at play here.

Chronic kids, they are used to a degree of discomfort. And so if you have a kid who is getting lots of blood draws, you have a kid say a diabetic kid and they are poking themselves for their insulin everyday, I mean there are kids who go through challenges, and they're painful challenges.

33:08
And so, in the scheme of things they get hurt, and they do have something to relate that to. I mean if they're also getting hurt on a fairly regular basis because of their medical condition then when they get hurt accidentally out in the real world, they have something to compare that to.

And it may or may not be worst than what they are used to experiencing, and so they may make class of it. And we've seen this a lot in the emergency department urgent care setting because we do ask kids, "Hey on a scale of one to ten, one being it not bothering you at all, 10 being like the worst pain you've ever felt. Where do you put your pain?"

And we see kids who say,'oh this is a 10." and they're sitting there and they're fine, they can jump up and down, they're playful, but they say that their pain is a 10. And you know, to them that's a 10, but now take a kid who has a ruptured appendix, or who has head injury with a broken skull, and their 10 means something a little bit different.

34:06
And so, our pain -sort of where we put pain is relative to our other experiences. and for kids with chronic illnesses, that experience and relatively maybe a little bit different. So, I do think that there are some degree with that. Now, your child in particular though may have some other reasons for having a little bit of a different in pain processing as compared to other kids.

I mean, the fact that he had a stroke and has epilepsy, that tells you that his brain took a hit and he may very well have some issues in processing pain. And so, in a kid like that, not only is it a relative issue, but there may be an absolute issue as well. And that their brain isn't quite as good at processing that pain and interpreting that pain, and reacting to that pain, as it is in another kid because they have some deficit in their brain because of the stroke which the epilepsy also doesn't cause that problem in pain processing.

But the fact that they have epilepsy following the stroke, let's you know the brain took enough of a hit that they could have other issues with that as well and disturbances and pain processing might be one of those problems.

35:14
So, I do think it is a concern for future injuries. I mean, he is going to be a kiddo, I think you have to watch closely to keep him safe and intervene when he hurts himself. Of course, we want to do that for all of our kids, really at the end of the day, I mean all of our kids will be safe and we want to intervene as soon as possible when they get hurt.

And we have to sort of moderate that by not over protecting them too, and that's part of the art of parenting, right? But in a kiddo who had a stroke, and has epilepsy, and who doesn't get too excited about a burnt hand, I agree with you that's a kid you probably want to keep a pretty close tabs on him.

Is there something that you can do about that? Is there a way to make their pain processing normal again? Or to make their relative sensitivity to the pain increased, probably not. But certainly talk to your doctor and see what they have to say as well.

36:03
All right. Next stop is Beth from Virginia Beach, Virginia. And Beth says, "Dr. Mike I've been listening for years and really enjoy when PediaCast shows up in my feed. In our house the kids have fallen victim to the love sugar cereal. I use to never get it, but there are times they just beg for it. I had a friend tell me their sugar cereal solution and I loved it."

Sugar cereal solution, try to say that five times fast. OK. So, what is the sugar cereal solution that you love Beth? Well, she says, "Each of my kids pick one box of sugar cereal to have in our pantry, on Saturday morning only they are allowed to enjoy a bowl. It's sugar cereal Saturday, and it's a treat for them and they let the lazy parents sleep in one morning a week.

A few weeks ago they forgot it was Saturday and they had regular breakfast cereal. Later when they realized they had missed their ones a week treat they were bummed, but they knew that wait till the next week to enjoy it. OK. Come on, Beth. You didn't let them.

37:00
OK. So, they have their regular cereal on Saturday, you couldn't give in and let them have the sugar cereal the next day, OK. That's OK again the Art of Parenting. I like that it's a special thing for them and we don't battle it any other day of the week. We too like the steel-cut oatmeal like you've mentioned.

But I found that most mornings it was tough to get it cooked, so I started cooking it in the crock pot overnight a few weeks ago. Turns out great and the kids loved the warm breakfast. And I love the breakfast is ready when we wake up. Any ways, thanks again for the amazing PodCast, I feel so much informed on my parenting because I understand some of these childhood illnesses, Beth.

And P.S. Thanks to your PodCast, I'm friends with your wife on Facebook, and just love her. Well, thanks for the nice comments, Beth. Yeah, my wife Karen had incredible Mommy Blog going once upon a time, and especially if you get sarcasm which I'm always surprise with just how many people don't get sarcasm and they are offended by it. And of course now that we're affiliated with Nationwide Children's Hospital, we have to be a little more cognisant of certain sarcasms.

38:06
So, I'm not sure that Karen will be showing up on the blog anytime again soon. But hey, you know message her on Facebook and you know, you can put the idea in her head. Maybe she would just come up with an independent one again at some point. She has talked about it, I think she enjoyed writing the blog when she did.

So anyway, who knows what the future holds. We do all appreciate you sharing your sugar cereal solution with us. And I have to agree with you, steel-cut oatmeal cooked a few hours before you wake up in the crock pot. I'm in agreement. That is some good tasty stuff. All right. Finally up in our listeners segment this week is Tammy in Indiana.

Tammy says, "Hi, Dr. Mike, love the show. My daughter just turned five and is in kindergarten. She did start kindergarten early three months past the cutoff, but she's reading at a second grade level, and we didn't want her to get bored. We put her in with the intention of having here repeat kindergarten if she had social issues.

39:03
We are noticing that she refuses to try to do things that she notices she isn't doing as well as other kids or things that she just thinks that she cannot do. She has always been a bit reluctant to participate in activities that she think she's not good at. But lately it has gotten extreme. For example at gymnastics,she does extremely well in the bars and the balance beam and is very proud of her abilities.

On the flip side, she cannot do a cart wheel, and now she just refuses to try. She'll tell her teacher that she is sick, she has an injury, anything to get out of that part of the class. What I can't seem to get across to her is that no one else in her class can do cart wheels either. They are all just learning and everyone else in their gym class is a year or two older than she is.

I'm worried about her self esteem. We were teaching her checkers today and she ended up in a bit of a breakdown because she is "just a loser", that's what she calls herself "just a loser' because she isn't good at anything, but painting and singing. Although she is not good at those things either, I'm not sure where they came from. And she also says, "there has to be more to life than this."

[Laughter]

40:07
She's a little dramatic too. Bailey, has always been put into groups at school Montessori before public kindergarten, gymnastics, swimming, etcetera because she is physically the size of kids a year or so older than her, and academically a year or two above her age group. The problem is that maturity wise, she is not that advanced. She has the emotions of a kid who just turns five spending her days with kids who are turning six.

Now, for the questions; can you recommend any books about how I can help foster her self esteem? I do a lot of the love and logic type stuff already. In your opinion, should kids be entered in the kindergarten early like we did with Bailey? Is her behavior a common occurrence around this age or are we being a bit sensitive because of her situation?

What can we do to help her through this phase? And if we continue to struggle with this issue, should we hold her back even though her teacher assures us that she should go on with the rest of the class. I've been listening to your show since the beginning, and I love it. Thank you for your work."

41:02
Well, thanks for the question, Tammy. And thanks for being a loyal listener over the years. So, we're really back at the Art of Parenting here aren't we? That's exactly what this is, and I can't answer these as a pediatrician because they don't teach us this kind of stuff. But I can answer as a father who's been there. And I can relate to pretty much everything that you're saying.

In fact that story I was kind of -laugh, I was really through that because there are some of that I can seriously relate to. My own daughter who now is 17 years old and won't appreciate that I'm going to share some of the stuff with you, but she was very similar to this. And I can remember a time, I don't know if you guys all remember the game Hi-Ho Cherry-O, where you have the cherry trees, and you spin the spinner, and you have to take the cherries.

I don't know, I think you're taking the cherries off and put them in little bucket, and whoever gets the cherries of their tree first wins. There were times when she would lose that, I mean she literally would flip out.

42:00
And the game would go flying the little cherries go everywhere and she goes storming up to her room that she's a loser and very upset about this. And I can laugh about it now, but at that time it was distressing like, 'Come on, you know what the fun is playing the game all right. Get over the fact that you just lost."

I mean the fun is that we're sitting down together as dad and daughter and doing this thing and spending some quality time. So for me that was the goal, I don't care if I win or lose, it's kind of hard to cheat, when it's a spinner because you got a smart kid who knows what the number is and how many cherries come off the tree. It's a little hard to cheat and let your kid win, when you're playing Hi-Ho Cherry-O.

Now, because of her disposition there were other times that I have to admit that I would let her win, now my wouldn't. See, my wife is very competitive. And so, she had to win. So, I'd take a step back and I didn't care. Again, I didn't care if I won or not. And so, we play air hockey for instance and I'd let her win.

43:02
And quite often I'd let her win. And you know, that kind of build up her self esteem a little bit, although I would say it backfired on me because as she recently learned that I let her win and she got seriously upset about that. Like, "How could you just let me win? You mean every time that I felt good about myself that I had won it was a lie?"

He can't win sometimes. And again I think this is where the Art of Parenting is really comes into play here. And I also think that a parents gut feeling on some of these stuff is really what you have to go with. I mean, I can't say, "Is it right to go ahead and put a kid in kindergarten or not?"

And you as a parent, you have to make that decision based on all of the factors, looking at your kid's academic success, how they react with their peers, what are the teachers saying. You have to synthesize all of that. But then ultimately you have to go with your gut. And once you go wit your gut, you just have to go with and you don't look back.

44:03
You say, whatever comes, comes, and we'll deal with it. And you can always say, what would have been like if we'd kept our back? Or what it would be like if we put – well, you didn't do those things, you didn't hold her back, you didn't keep her in it, you know whatever.

And so, you just deal with where you are and you go with your gut. And I think that's the biggest part of advice that can share with you. Ten years from now, it's not going to matter whether you kept her back a year or whether you went ahead and let her go with it.

It's not really going to matter, and so don't get too stressed out about it, whatever you decide to do, go for it with gusto, stick with it, and deal with it, and deal with the outcome, and go from there to make your next decision.

And I don't say this to lighten your situation at all. Did this kind of help me through some of that? You know when you're a parent and you're struggling over -for us it was home schooling, do we home school or not. We lived in a school district that we didn't particularly trust at that time, and we wanted to home school.

45:05
But of course you can agonize over that, do we really -what's this going to do when my kids wants to go to college? Are they going to be social; with other kids? Are they going to grow OK and be OK? So, we had to make the decision, yeah we're going to home school.

And just go for it. And provide other social opportunities, and we did that, and you know, my kids get along with other kids just fine, they have best friends, they have sleep overs, they are socialized as society would call being socialize today, because we sought opportunities for that to happen. And my daughter is going to college next year.

She has a great merit scholarship, she did fine on her standardized testing, it all worked out. And I think in many cases it does all work out regardless if she'd been in public school, I think in the end of the day she'd have friends, she should have done well, she'd get in to college. I don't think personally that I would have a strong of a father-daughter relationship with her as I do today.

46:03
But, you just go with it. You go with your gut, you go with life, and that's where you are. So, I hope that helps. I know Tammy if you're wanting me to say, "Yes you should hold her back. And this is what you needed to do to boost up her self esteem." I think to some degree I will offer this too.

With kids if they are reluctant to do something they're not good at, you got a couple of choices. As a parent, again this is the Art of Parenting, do they have the potential or are they just not going to get it. If they have the potential and it sounds like your daughter does, I mean she can do the balance beam and the bars, she probably can do cart wheel. It's just a matter of getting over the fact that she's not as good as the other kids.

She just got to get over the fact she's loss the Hi-Ho Cherry-O, you know what I'm saying? And so, practice, encouraging her to do it at home, coming up with the good old fashion positive reinforcement program.

47:01
OK, you're going to practice your cart wheels at home, none of the other kids were looking. You're going to practice the cart wheels and here's the cool thing, when you practice the cart wheels for 10 minutes, you just try them over and over and over again. They don't have to be perfect, they don't have to look good, just the fact that you're trying them for 10 minutes, we're going to put a star on your sticker chart.

You got five stars we're going to Dairy Queen. Some, OK, if they have an obesity problem, maybe Dairy Queen is not the right one to do, but you know you can go ride the horse at WalMart, whatever it is. Whatever your kid's currency is, that's what you want to go for, make that positive reinforcement routine, and they're going to get better because they're practicing, and they're going to get more self esteem and feel better about doing it at the gym in front of other kids. And so, I think that's going to help you out. Now, if you have a kid that you know what, this is not their gift. OK, you see people every week on American Idol singing is not their gift. And some parent, push them and push them and said, "Oh you've got a great singing voice." And you know, the kid makes a fool of themselves on national TV because they can't sing.

48:08
So, I mean when they don't have that gift, not everybody has every gift, and so you do have kind of figure out what your kids gifts are and direct them in that way. And again, it doesn't sound like it's the case for your child in terms of gymnastics, but there are some kids that gymnastics is not their gift, and so if you push them, and push them, and push them, it's not going to have a pretty ending.

It's going to have the ending of some of these people singing on American Idol on national TV, right. I mean, it's not going to work out. And so we can't all be good at everything. For my kids they are not very coordinated, they are not good at organized sports, they are good at music. So, you kind of pick and choose and what are they good at, don't just throw them to the wolves in every single situation.

So, I think that helps with self esteem is figuring out what they're good at and nurturing those things, and helping them to get beyond their failures.

49:02
And to try as best as you can to stress that it's having the fun, it's not when you're loosing, it really is having the fun. And I think too you can model that through playing games at home. And that's one of the reasons that board games are such a passion of mine.

And why when we have interview shows we kind of talk about them a little bit because I think it's a great opportunity to show that, 'Hey, it's not always about winning and losing, it's about having fun'. And my 17 year old daughter who used to pass out when she lost a Hi-Ho Cherry-O, she does a little bit better with losing games now.

She's still competitive like her mother, and she sometimes does throw a hand of cards down, and I have still seen her stump here and there, but 17 years,, it's better. Sometimes it's all we could ask for.

All right. Well, thank you so much Tammy. Not sure that's exactly the answer you bargain for, but it's the answer you get. So, there you have it.

50:00
I want to remind all all of you if there's a topic that you'd like us to talk about, it's easy to get a hold of me, just go to pediacast.org, click on the contact link, I'll answer your question as best as I can without providing actual medical advice.

I want to always point that out of you're really concern about your child talk to your doctor. It's important your doctor not me. You can also email pediacast@gmail.com, or call the voice line 347-404-KIDS, 347-404-K-I-D-S. OK, we're going to take a very quick break and we'll be back to warp up the show right after this.

[Music]

51:12
All right. we have lots of resources for you at the website. So, pediacast.org is kind of the landing place for our program, kind of the home of the show. So, I do encourage you to go there, we're going to start to have transcripts of the show, written transcripts. OK. So, let's say you think, "Oh this is great. I'm going to go with the transcripts now." Keep us in your feed, OK.

We appreciate the downloads, really we do. And so, keep us subscribed, but if now and then it's easier for you to read it rather than listen to it, we'll have the transcript of the show available for you starting now over at pediacast.org so you can check that out.

We also have a few of our old ones and we're going to be adding more of our old ones as time goes on. And we have the time and energy and resources to do that.

52:00
I want to thank all of you for taking time out of your day to listen to PediaCast we really appreciate it. And we also appreciate it when you share PediaCast with your friends and in particular tell your doctor whether it's a pediatrician, or a family doctor, the next time you go in for a sick visit or a well child check, tell your doctor about PediaCast.

We really want to spread the news through the America's and around the world network of child care provider. So, let them know that there is an 'evidence based', use that term 'evidence based PodCast' looking at pediatric issues. And we'd really appreciate it if they listen because I think that they'll get a lot out of the show. And also can spread the word to their own patients about PediaCast.

Also, we do have a flyer that's available on the website, if you go to the resources tab at pediacast.org. It's a pdf file that you can download and print out, and hang out wherever you want, bulletin boards, in gyms, in nurseries, in churches, and schools, wherever you're aloud to hang out flyers. Exam rooms too for pediatricians.

53:02
We just really appreciate you spreading the word about PediaCast that way. We don't have a big marketing budget, we don't have billboards in the major U.S. metropolitan area telling folks about PediaCast. So, just through word of mouth. Also, if you could mention us in your blogs, on Facebook, in your tweets, all those kinds of things, and iTune reviews are also very helpful as well.

But most of all I just want to thank you for being a part of the show. I mean, we credit several listeners today who's like I've been listening since the beginning, I've been listening since the beginning. And to me that kind of loyalty, you can't pay for that. And I just really from the bottom of my heart appreciate those of you who take the time out of your day to listen to the show, and who get something out of it. I really appreciate that.

And for those of you who understand my own sense of humor and sarcasm, I appreciate that too. All right. Once again pediacast.org, contact link you can email pediacast@gmail.com, or call the voice line 347-404-KIDS. If you have a comment or suggestion, topic idea, any of the above, just give us a holler.

54:03
And until next time. This is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long everybody.

[Music]

Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.