Academic Success, Sleepwalking and Healthy Snacks – PediaCast 205
Join Dr Mike for this weeks edition of PediaCast as we cover news parents can use and answer more of your questions. Topics include the effect of artificial womb sounds on pre-term babies, stair-related injuries, academic success, labial adhesions, sleep walking, meningitis, and healthy snacks. Don’t forget: if you have a question or topic idea, it’s easy to participate in the show by visiting our Contact Page!
Womb Sounds and Preemies
Academic Success and Fear of Failure
Father’s Role in Academic Success
High Dose ADHD Meds
Sounds From Mother Improve Health of Pre-Term Babies
Stair-Related Injuries: Common and Preventable
Reducing Academic Pressure and the Fear of Failure
Academic Success Linked to How Parents Play with Toddlers
Higher Doses of ADHD Drug May Cause Academic Problems
Kawasaki Disease – PediaCast 203
Night Terrors – PediaCast 188
SnackWise – Nutrition Rating System
Child Nutrition and Reauthorization Act – Local Wellness Policy
Announcer 1: This is PediaCast.
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!
Dr. Mike Patrick: Hello, everyone and welcome to PediaCast, a pediatric podcast for moms and dads. And we're coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio. It is episode 205 for March 28th, 2012 and we’re calling this one Academic Success, Sleepwalking and Healthy Snacks.
Now, most of you who are familiar with the show know we cover lots more than just the three topics other than the title and we're going to get to exactly what we're going to talk about in detail here in just a minute.
First and I know it's kind of superficial when you talk about the weather, like if you strike up a conversation with a stranger, you're on public transportation or you're waiting in a doctor's office, you're in an elevator, it's easy enough to say, hey, what's going on with the weather.
And so I try not to talk about superficial things on the show, but this spring has been so crazy that I can't help but mention it. And most of you also know we lived in Florida for a while and this March has been like March in Florida. I mean, you didn't have to go to Florida for spring break; you could just have your spring break right here on Ohio. So temperatures in the mid 80s on some days, rock 'n' rollin' with the thunderstorms.
It's been pretty crazy. And I've one in the past that kind of roll my eyes at the whole global warming climate change kind of thing. And of course I understand that weather varies, but it's been pretty warm and makes me a little nervous about the summer that's coming up. So we'll see, maybe all things will average out and we'll have a cool summer. But I don't know, I'm not going to count on it.
All right. Also I want to mention to you, we have lots of opportunities for community involvement here on PediaCast. Of course we do have some social media outlets that we are a part of. So we're on Facebook, we're on Twitter, also take part in Google+, so if you are in all of those things as well, make sure you add us in your circle of friends.
You can like us on Facebook, add us to your Twitter feed and join our circle in Google+. So we have all those things available to you. And another way that you can become involved in the program is to go to the Show Notes and make a comment. So if there's a topic in a particular show that is interesting to you, you can just head on over to the Show Notes at pediacast.org and if you have a comment or a question or want some advice from other listeners, you can comment in the Show Notes so we can kind of have a community there at pediacast.org as well.
And of course, the biggest way to get involved is to ask a question on the show. If you go to our Contact Page at pediacast.org you can as a question and we answer those on the program or if you have a topic idea or you want to point us in the direction of a new story, you can use the Contact Page for those things as well.
And then this is something that I typically mention at the end of the show, but, you know, once a quarter, so I like to put it up front so everybody gets a chance to hear it. We don't have a big marketing budget here at PediaCast and we're still trying to get the word out to moms and dads out there across the country and around the world who may be haven't heard about the program. And then there are some things that you the listener can do to help us out. Of course we don't charge anything for the program. It's important to us that we keep it free and accessible for everyone, but one thing that you can do to help us out is just help spread the word.
iTunes reviews are very helpful. If you found us through iTunes and used those reviews to help make your decision to listen to PediaCast, you know how important iTunes reviews are. And we are in need of new ones, so if you head over to iTunes and just want to take a couple of minutes out of your time to write a review for us, we'd really appreciate that.
You can help us out is to tell your doctor. So the next time you take your child in for a well checkup or a sick visit, either one, just mention the program. Let them know that it's evidence-based and that we cover lots of topics and answer questions in detail. But we don't hand out medical advice for specific people. It's all about education. Just kind of point them in the direction of pediacast.org.
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And of course telling your Facebook friends and Twitter followers and Google+ peeps about the show, that's always helpful too.
By the way, on the Show Notes pages, we also have a convenient way for you to share each individual show on Facebook or Twitter or Google+. So if there's a particular show you want to tell your friends about, you can just go to the Show Notes page for that particular show and share us that way as well.
We also need some likes on the landing page of pediacast.org, also the Contact Page and the Listen Now Page, which is where the PediaCast player exists. Again we're just trying to drum up more, you know, get it in front of more eyes so that more moms and dads know about the program.
So those are just some little ways that you can help us spread the word through the Internet and social media and your own community.
For those of you who are listening for the first time, I know that we don't usually self-promote in this much detail at the beginning of every episode. But it'd been a while since we did that and I just wanted to remind everyone that we really count on you to help introduce the show to new folks.
All right. So what are talking about today? I kind of a little bit of a hint in the introduction with Academic Success, Sleepwalking and Healthy Snacks. We're also going to look at a research article that looked at womb sounds, actually artificial womb sounds, piped into the incubators of preterm babies to see if that could help them progress and do well and get out of the NICU a little bit faster. So what's the effect of piped in womb sounds for preterm babies, we're going to talk about that.
Also a study that came out in Nationwide Children's Hospital here regarding stair-related injuries. We're going to talk about the numbers and also some practical tips on how you can prevent stair-related injuries in your own home.
As I mentioned, we're going to focus a little bit on academic success. One of the things that we found through one research study that can have a determining role on how well your child does is how much do they fear failure. So you might be surprised about this, when parents really put a stress on their kids to really succeed academically, their kids can develop a fear of failure and is this helpful for their academic studies or can this actually make things worse. So we'll talk about that.
Also, what is the father's role in academic success? Can dad make a difference that perhaps mom can't? And what about single moms? And what's the role of the father in academic success?
Also, a higher dose ADHD medicines, you know, when they don't seem to be working anymore and as kids are getting bigger and growing, sometimes we increase the doses of ADHD medicines, is that helpful or could it actually cause some harm? So high dose ADHD medicine and their role in academic success is also coming up on the program in just a little while.
And then we're going to get to some of your questions. This week they deal with a labial adhesions, as with little girls whose labia is adherent. We'll talk about that. Also sleepwalking and infant meningitis and then we'll round up the show with a topic on snacks, healthy snacks. How can you figure out which snacks are healthy for your kids and which ones aren't? I mean, I understand it's easy to say hey, grab an apple, grab a banana and have some fruit or a little bowl of nuts.
But what about actual snack foods in vending machines? That's what we're going to focus on, like the Doritos and Chili Cheese Fritos and all those kind of potato chips are just the things that you find in vending machines and also at school during the school lunch program, they always have a display with some snacks there that you can choose from. And of course in your pantry at home, what are healthy snacks, which ones should you have more often, less often and almost never. We're going to talk about those things, coming up.
Again, if you have a topic idea or a question for us on PediaCast just head on over to pediacast.org and you can click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
All right, with all that in mind, we're going to take a quick break and we will be back with the News Parents Can Use right after this.
Our News Parents Can Use is brought to you in conjunction with the news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at medicalnewstoday.com.
We start today's news segment in the newborn nursery when babies are born prematurely they are thrust into a hospital environment that will highly successful at saving live is not exactly the same as the mother's womb. And while Neonatal Intensive Care Unit is equipped with highly-skilled caregivers and incubators that regulate temperature and humidity, Dr. Arnir Lahav, Director of the Neonatal Research Lab at Brigham and Women's Hospital, says, "Something is missing – the sounds that a baby would hear inside the womb."
New research conducted by Dr. Lahav and his colleagues links exposure to an audio recording of mom's heartbeat along with her voice to lower incidence of cardiorespiratory events in preterm infants. This research is published online in the Journal of Maternal Fetal and Neonatal Medicine.
Dr. Lahav says, "Our finding show there may be a window of opportunity to improve the physiological health of these babies born prematurely using non-pharmacological treatments, such as auditory stimulation. Because they are underdeveloped, preterm infants experience high rates of adverse lung and heart events including apnea, which is a pause in breathing that last longer than 20 seconds, and bradycardia, the medical term for periods of significantly slow heart rate."
Researchers sought to determine whether an auditory intervention could affect the rates of these unwanted cardiorespiratory events. To conduct the study, Lahav enrolled 14 extremely premature infants, born between 26 and 32 weeks gestation who were admitted to the Neonatal Intensive Care Unit at Brigham and Women's Hospital.
The infants were assigned to receive an auditory intervention of maternal sound stimulation four times per day throughout their NICU hospitalization. Each infant received a personalized maternal sound stimulation, in other words, a soundtrack consisted of the voice and heartbeat of each baby's mother. The recordings were played inside each infant's incubator through a specialized micro-audio system developed in Dr. Lahav's lab.
Overall, researchers found cardiorespiratory events occurred at a much lower frequency when the infants were exposed to maternal sound stimulation compared in neonates exposed to routine hospital noise. And this difference was statistically significant for infants who are 33 weeks of gestation or older. Our findings are promising and showing that exposure to maternal sounds stimulation could help preterm infants in the short term by reducing cardiorespiratory events.
It also suggest there was a period of time, at 33 weeks gestation and beyond, when the infant's auditory development is most intact and maternal sound stimulation intervention could be most impactful. Dr. Lahav concludes by pointing out a study, had a small sample size of just 14 infants and says further research is needed to verify if this intervention could have an impact on the care and health of preterm babies.
And from the newborn nursery to the top of the stairs, nearly 1 million children under the age of five were taken to hospital emergency departments from 1999 to the end of 2008 in the United States, that's according to research from the Center for Injury Research and Policy, right here at Nationwide Children's Hospital. This is a study recently published in the journal, Pediatrics.
There is good news to report from these numbers, over the study period, the total yearly number of stair-related injuries to those under the age of five dropped by 11.6%. Still, a child under five years currently presents to an American emergency department every six minutes for a stair-related injury. The research team gathered their data from the National Electronic Injury Surveillance System of the U.S. Consumer Product Safety Commission.
Senior author, Dr. Garry Smith, said, "While we are pleased to see a declining trend in the number of stair-related injuries, stairs continue to be a common source of injury among young children. Through a combination of educating parents, use of stair gates and modifying building codes to make stairs safer, we can prevent these types of injuries. One quarter of the injuries experienced by children 12 months or younger occurred while somebody was carrying them and those injured while being carried were three times more likely to be hospitalized to those injured while not being carried."
And it sort of makes sense when you think about it, you sustain a bigger fall when you're being carried as opposed to a series of little falls when a baby goes down the stairs on their own. Not to minimize a baby tumbling down the stairs on their own, of course, but when they're being carried not only is it a farther drop to the ground but you also have the likelihood of the carrier falling on top of the baby, which is not good.
In addition to the nearly 1 million stair-related injuries sustained by children under the age five and seen in U.S. emergency departments from 1999-2008, the team reported a few more interesting statistics – 2.7% of the children required hospitalization; 35% had soft tissue injuries; 26% had punctured wounds or lacerations associated with their fall; 76% had head or neck injuries; and 11% had upper extremity injuries.
The research team has some recommendations parents can follow to keep your child safe around the stairs. Be sure to keep stairs in good order and clutter free. Stair gates should be fitted to the bottom and top of the stairs and although gates are effective in reducing injury risk, adult supervision is still vital. When possible, do not carry a child up or down the stairs and if you must carry a child, don't carry other things including laundry baskets, and be sure to hold on to the hand rail. Don't use strollers or carriages underneath of the stairs. Avoid mobile baby walkers. Teach your child to hold on to the hand rail at all times and if your small child wishes to carry something on the stairs, teach them to ask an adult for help. Teach your child to always walk up and down the stairs, never run. And teach your kids to respect the stairs; they aren't a place for jumping or playing on.
Looking back at these recommendations, our family, I think we did a pretty good job of following these rules when our kids were young. There might have been some exceptions, you know, for slinkies, which never seem to work quite as well as you want them to, and rolling super bouncy balls down the stairs. But it was always accompanied by plenty of supervision and only when the kids were little older.
All right. We're going to move on up front to a new few stories on academic success and how you the parent can promote it. Children may perform better in school and feel more confident about themselves if they are told that failure is a normal part of learning rather than being pressured to succeed at all costs. This is according to new research published by the American Psychological Association. Dr. Frederick Otten, a post doctoral researcher at the University of Poitiers in France, says his team focused on the widespread cultural belief that equates academic success with a high level of competence and equates failure with intellectual inferiority.
By being obsessed with success, students are afraid to fail so they are reluctant to take difficult steps to master new material. Acknowledging difficulty is a crucial part of learning could stop the vicious cycle in which difficulty creates feelings of incompetence that in turn disrupts learning. The study published online in the American Psychological Association's Journal of Experimental Psychology could have important implications for teachers, parents and students.
Dr. Jean Claude Croizet, a psychology professor at the University of Poitiers, says, "People usually believe that academic achievement simply reflects a student's inherent academic ability, which can be difficult to change. But teachers and parents may be able to help students succeed just by changing the way in which the material is presented."
In their first experiment with 111 French sixth graders, students were given very difficult anagram problems that were virtually unsolvable. Then a researcher talked to the students about the difficulty of the problems, one group was told that learning is difficult and failure is common but practice helps just like learning how to ride a bicycle.
Children in the second group also had a discussion with researchers but they focused on how the children tried to solve the problems rather than talking about how difficult learning can be. All students then took a test that measures working memory capacity, a key cognitive ability for storing and processing incoming information. Working memory capacity is a good predictor of many aspects of academic achievement, including reading comprehension, problem solving and IQ.
The students who were told learning is difficult performed significantly better on the working memory test, especially on more difficult problems, compared to the second group. They also had a third control group who took the working memory test without doing the anagrams or having discussions with the researchers.
A second experiment with 131 sixth graders followed a similar procedure with difficult anagrams and discussions and it showed similar results. The second study included an additional group of students who took a simpler anagram test that could be solved but this group was not told that learning is difficult. All the students in the second study completed a reading comprehension test and the children who were told learning is difficult scored higher than the other groups, including the students who had just succeeded on the simple test.
The author's point out how students think about failure may be more important than their own success when learning challenging skills.
A third experiment with 68 sixth graders measured reading comprehension and asked questions that measured students' feelings about their own academic competence. The group that was told learning is difficult performed better in reading comprehension and reported fewer feelings of incompetence. The study noted the students' improvement on the test were most likely temporary but the result showed that working memory capacity may be improved simply by boosting students' confidence and reducing their fear of failure.
The study team concludes by saying our research suggests students will benefit from education that gives them room to struggle with difficulty. Teachers and parents should emphasized children's progress rather than focusing solely on grades and test scores. Learning takes time and each step in the process should be rewarded, especially early stages when students will most likely experience failure.
And here's another way parents can promote academic success, the ways in which parents engaged with their children at the age two predicts their children's future academic outcomes, according to results of a 15-year study. This project began in 1996 by researchers from Utah State University's Department of Family Consumer and Human Development.
In order to find out the extent of influence, early parent-child engagement has on a child's future academic success, the team examined families participating in the U.S. Early Head Start Research and Evaluation Project. Results from the study we published in an upcoming special issue on Fathers in the Family Science Journal. According to the researchers, parent-child activities demonstrated to have a positive impact on children's future academic outcomes include elaborating on the words, actions and pictures in a book were on unique attributes of objects relating book, text or play activities to the child's experience and encouraging and engaging in pretend play.
Also presenting activities in an organized sequence of steps seems to help. Investigators say there has been extensive research done on the importance of early parent-child interactions on future educational experiences but most have focused on the relationship between the child and the mother. This study looked at the combined long-term impact of both maternal and paternal interactions in these critical stages of early development and discovered that children not only benefit from the interactions they have with their mothers but also with their fathers.
In 229 low-income families, the researchers examined mother-toddler and father-toddler interactions at age two, these observations were then analyzed in relationship to child outcomes at three years of age and in the fifth grade. The team examined families with resident biological parents, as well as single mom homes. Results from the study showed that in both of these family types, toddlers who were taught more during play with their mothers performed better academically, in addition to mother's play, the child's gender and participation in the early head start program seem to help.
Resident biological fathers who teach during play with their toddlers also positively impacted the child's fifth grade reading and math performance. The study suggests that in homes with both biological parents, toddlers receive higher levels of cognitive stimulation from the mother, when compared to single mothers and in families with both biological parents, fathers contributed to later academic outcome significantly more than the mothers.
Investigators say it's interesting that when a biological father is living with the biological mother and his child, the mother tends to provide more cognitive stimulation to their toddlers and when the biological father is engaged with the toddler, it really adds something more to later academic performance.
Researchers conclude it's important for parents to engage with their children during the vital early stages of brain development because early exposure to cognitive stimulation with both mothers and fathers can have a long lasting and positive influence on the educational success of at risk children.
And finally, high doses of ADHD drugs may cause more academic problems than they solve.
New research with monkeys sheds light on how the drug, methylfenidate, may affect learning and memory in children with Attention Deficit Hyperactivity Disorder. The results parallel a 1977 finding that low dose of the drug boosted cognitive performance of children with ADHD but a higher dose, while further reducing hyperactivity, impaired performance on a memory test. Many people were intrigued by that result but their attempts to repeat the study did not yield clear-cut results, so it says Dr. Lewis Populin, PhD, an associate professor of Neuroscience at the University of Wisconsin-Madison, School of Medicine and Public Health.
Dr. Populin is senior author of the new study exploring the same topic and recently published in the Journal of Cognitive Neuroscience. In the study, three monkeys were taught to focus on a central dot on a screen while a target dot flashed nearby. The monkeys were taught that they could earn a sip of water by waiting until the central dot switched off and then looking at the location of the now vanished target dot.
The system tests working short-term memory, impulsiveness and willingness to stick with the task as the monkeys could quit working at any time. The study is different doses of methylfenidate, which is the active drug in Ritalin, Concerta, Metadate and Methylin and it use doses comparable to the range of clinical prescriptions for ADHD in humans.
The study is important because according to the Centers for Disease Control, almost 5% of American children are taking medications for Attention Deficit Hyperactivity Disorder. So what did they find? Well, a degree of dosing had a major and unexpected impact. At low dose, the performance scores improved because the monkeys could control their impulses and wait long enough to focus their eyes on the target. All three were calmer and could complete a significantly larger number of the trials. But at the higher doses, performance on the task was impaired.
Dr. Populin says, "At the higher doses the monkeys didn't seem to care. All three continued making the same errors over and over. They stayed on task more than twice as long at the higher dose but they had much more trouble performing the task. Although ADHD are commonly thought to improve memory, if we take the accuracy of their eye movements as a gauge of working memory, memory was not helped by either dose," says Dr. Populin. It did not get better at the lower dose and there was a negative effect on memory at the higher dose.
"Memory is the root of many intellectual abilities, but it can be affected by many factors," says Dr. Bradley Postle, a professor of Psychology at the University of Wisconsin-Madison. Dr. Postle, an expert on working memory, was not involved in the study but he says methylfenidate affects the brain executive function, which can create in the internal environment that depending on the dose is either more or less amenable to memory formation and/or attention.
If you can concentrate and are able to process information without being interrupted by distracting thoughts or distractions in your environment, you will perform much better on a memory test. Apparently, the lower dose of methylfenidate helped create the conditions for success without actually improving memory itself. Of course monkeys are not people, but the monkeys in the studies still reminded the researchers of school children. Dr. Populin says, "They made premature movements, could not wait to look at the target before they could be rewarded for doing so. It's kind of like a kid with a teacher says when you complete the task raise your hand, but he can't wait even if he knows that by responding prematurely, he will not get rewarded. The study results had another parallel with daily life. Drug dose induced are often set high enough to reduce the characteristic hyperactivity of ADHD, but some children said that makes them feel less creative and spontaneous, more like a robot. If learning drops off as it did in our study, that dose may not be best for them. Our monkeys actually did act like robots at the higher doses, keeping at it for seven hours even though their performance was bad."
Researchers say, "The logical way forward would it be to involve a similar study with people diagnosed with ADHD, not monkeys. With millions of children and an increasing number of adults taking these medicines for the condition, we have to be very careful about finding the right spot on the dose curve or we may get changes in behavior that we don't want. People think these drugs improve memory but our data said no. Your memory's not getting better. And at the higher doses, while you get more behavioral improvements, that improvement comes at a price and that price is cognitive ability."
All right. So something to think about, especially for those of us with kids who take medication for ADHD. We are going to take a quick break and we'll be back with some of your comments and your questions right after this.
All right. We are back and appreciate you sticking with us. We are going to turn our attention to our listeners segment now and we're going to start with something that we haven't done for a little while, and that's to get to some of your comments. So not just your questions but some other things you have to say about the show.
And the first stop is Wheezy in Austin, Texas and Wheezy says, "I just wanted to express my gratitude to you and Nationwide Children's for providing this podcast. Recently my son was sick and I had a febrile seizure. Fortunately due to this podcast, I knew what it was and why it happened, so I didn't flip out as much as I would have otherwise, especially if I had no knowledge at all. I still got slightly panicked when he began to turn blue from not breathing since I didn't know how long the seizure would last. He is of course doing great now. Thank you so much for arming me with great and helpful information."
Thanks to you Wheezy for writing in, you are welcome. Next stop, Melissa in Westerville, Ohio says, "Thanks for all your information with the 15-year old who suffered from Kawasaki at 18 months. It was good to hear the progress that has been made. I also appreciated the information on the long-term care, especially as an adult, I will encourage my daughter to continue seeing a cardiologist after leaving home." And thank you for your thank you, Melissa, we always appreciate hearing how we helped. That's why we're here and why we do this.
And I do want to mention for those of you who may not have tuned in to the Kawasaki program because you think well I don't know what Kawasaki disease is, it doesn't affect me, I really don't care. Actually it is something you want to know about because it's important. Kawasaki disease can cause quite a bit of heart damage and it's important to recognize in its early stages and so it's something that all parents should be aware of, so that they can be on a lookout for in their own kids. It can get diagnosed as quickly as possible. So you may want to tune in to one of our recent episodes that dealt with Kawasaki disease.
All right. We also have some feedback from you. Heather in Milwaukee, Wisconsin said, "Listened to a recent podcast, you asked for some feedback on the show. I'll admit I like the old format because you hit on listener questions and news more often. Now it seems to be more interviews, which are fine, if you have kids with these diseases or you're in the medical field. But I don't connect so much with those types of shows and find myself waiting longer between episodes that spark my interest, as just my two cents, but overall, I love the show and look forward to each one coming out. Thanks, Heather."
And I would love your two cents, Heather, thanks for sharing. And we are trying to strike that perfect balance between the interview shows and the news and listeners shows because we do have listeners out there who like both. But we are trying to find that balance and we'll continue to search for just the sweet spot with that.
And next up we have Michelle in Columbus, Indiana. She says, "I really enjoy the listener questions in your episodes. You did ask for feedback. I wanted to let you know I enjoy the interviews and definitely the regularity and frequency of the shows. I would prefer interviews about once a month and three episodes of research roundups or listener questions each month. Thanks for asking for feedback and thanks for a fantastic podcast. It's in my top three and has been since the beginning." And thank you, Michelle, for letting us know what you think as well.
For the rest of you, comments, suggestions and feedback are always welcome and you can do that at pediacast.org.
All right. Let's get to some of your questions now. First stop with that is Jane in Alexandria, Virginia. Jane says, "I am a happy listener of the show, while this won't help you determine format, I enjoy the long shows, short shows and everything in between. Not only are the topics interesting, but you've taught me medical information in a more analytical way. My question for you is about labial adhesions. I recently noticed that my 10-month old daughter's vagina was closed which was a bit shocking as I've never heard of such a thing. But we're visiting our doctor about this but I was curious what you have to say on the subject and think others may benefit from the information too."
OK. So labial adhesions, what's this all about? It's a common condition that pediatricians see quite often and basically if you think about a little girl anatomy, they have the labia majora, which are the skin folds down there around the vagina, and then you have the labia minora, which are the smaller folds that are sort of tucked in beneath the labia majora. So these are the smaller folds that kind of close up over the vagina. And this is a connective tissue and what will happen with the labial adhesions is the labia minora on each side kind of fused together. And it's usually when this happens, the uppermost portion is spared and the reason for that is just the active peeing keeps it open. So when your child urinates it has to get out and the urethra is located on top of the vagina, sort of more superiorly. And so that top part of the labial minora when this happens typically doesn't fuse all the way to the top, because the active urinating several times a day helps to keep that open.
So what do you do for this? Well, the biggest thing here is that like many things in pediatrics, if it's not causing a problem you don't necessarily have to fix it. And something to consider here is that the tissue of the labia minora in little kids tends to be sticky and what happens is when the kid goes to puberty, the epithelium or the outside layers of the labia minora kind of change to a more slippery and less sticky component.
And so what'll happen is that those adhesions typically will just go away on their own as a child progresses through puberty. So it's not something that you necessarily have to do anything about, as long as it's not causing a problem.
Now, what are some potential problems that you can have this? Well, one would be if because of what your child does, it has a tendency to sort of self-reduce, in other words it kind of rips apart on its own. So let's say you have a kid who does gymnastics or they ride horses or they're going up and down rough terrain on bicycles so things are getting charred. You have this possibility that what's adhered could kind of rip open and then that can cause pain and bleeding. And if this is a recurrent thing, then you may want to do something about this problem, because now it's not something that isn't causing issues, it's actually causing pain and bleeding in an intermittent fashion and so you want to do something about it.
Another potential problem with this is that you could have a partial blockage of urine and so it's not necessarily that you're completely closed but it does obstruct the urethra a little bit and some of the urine may then actually flow behind the labia minora and actually go up into the vagina and it can stay in the vagina and then can harbor bacteria in there so that you can get a vaginitis or an infection in the vagina because of residue urine that's entering that space. It's not supposed to be there.
Or you can also get incomplete emptying of the bladder and that can actually cause urinary tract infections as well because the urethra, which is the little tube that connects the bladder to the outside world, is kind of short in girls and so it's easy for skin bacteria to go up the urethra and enter the bladder. But the active urinating or peeing frequently kind of rinses him out so that they can't set up shop in the bladder and actually cause an infection. But if you have a partial obstruction of flow out because of the labial adhesions, then you could potentially have the residual of urine that's staying in the bladder and that kind of set you up to get urinary tract infections.
So if you have a kid who gets urinary tract infections and they have labial adhesions, the labial adhesions could be playing a role in that and so now, you do have an issue that you would want to do something about the adhesions.
And then finally, a total blockage, so in other words if the labia minora is adhere together all the way up and it's causing total blockage, then you can get bladder distension, pain, you can get some kidney dysfunction, but this is rare. This is something that very, very seldom seen. Don't quote me on numbers here but if you took a thousand kids who all had labial adhesions, probably one would have a significant issue where you really have bladder distension and pain and backing up of urine up to the kidney. It may not even one, it's really, really rare.
But again, something that you need to think about with this. So if you have a kid with labial adhesions and it's not causing any problem, again when they go through puberty it's probably going to fix itself and not really be something that you have to worry about. You just want to let your pediatrician know it's there, watch it with yearly visits, kind of follow it along. And again, as long as your kid's peeing OK, they have good urine output, they aren't getting frequent urinary tract infections, it's not a problem where it keeps pulling apart and bleeding and painful and then goes back together, then you don't need to do anything.
But if you do need to do something, typically, what we'd do is a cream called, Premarin Cream, and this is a topical estrogen and the way you're basically doing is just tricking those cells of the labia minora into thinking that puberty has hit. So you're providing an estrogen topically and that causes the epithelium to change, as I mentioned from that sticky epithelium to more of a slippery epithelium, so it goes from sticky to slippery and that helps by using that every day and just kind of providing some genal attraction that can help the adhesions to separate and not come back.
And once it's separated, some daily Vaseline just helps to keep that area slippery and helps it to not stick back together. Something to keep in mind when you stop using Premarin Cream or the estrogen creams, when you stop using them, typically the epithelium, it's kind of hard to fill the body on a permanent basis and so that surgeon's gone and they'll say, hey we need stickiness instead of slipperiness again; and then it's possible for the problem to come back when you're not using the estrogen cream anymore.
And then that's when it's going to be important to use the Vaseline and really try to keep things slathered down so that it doesn't stick back together. Or you need to just kind of wait till it happens, see how long it is, did your child start to have problems again and then use the estrogen cream again when you need it.
More aggressive maneuver's where you really pull that apart and cause pain and bleeding, really is not necessary, unless the kid really does have obstruction of urine outflow that's causing kidney issues. But that's a very rare and of course it'll only be done by your doctor and under their supervision.
Again, if it's not broken, don't fix it. That's a very important point in the world of pediatric medicine. Otherwise, you're on the risk of causing problems.
All right. Next stop we have Kate in Chicago and Kate says, "Dr. Mike, love your show and appreciate your straightforward approach to medicine and helping parents deal with behavior. On to my question, my almost 6-year old son had these tonsils and adenoids out last summer due to obstructive sleep apnea. His tonsils were huge, he snored constantly and he would stop breathing for up to 20 seconds at a time. He was a restless sleeper before the surgery and we thought that would calm down once his breathing and sleeping were better. Tonight, about an hour after putting him to bed, he came downstairs crying. My husband and I tried to ask him what was wrong but got no response. I asked him if he had an accident and touched the front of his jammies to feel if they were wet and he started to go pee right there. We got him into the bathroom and we started to undress him and he began laughing. He still did not seem fully awake and aware of the situation. By the way, we have also heard the same laugh coming from his room in the middle of the night. After getting him cleaned up and changed, he was fully awake and had no recollection of how he having come downstairs. Is he sleepwalking? I also found him some mornings asleep with his feet on the floor and his body bent over his bed like he was climbing in or out of the bed. I did a search and did not find any subject covered in any of your podcasts. Is this something I should bring to the attention of our pediatrician or wait and see if it continues more? I would love to hear your thoughts on this subject. Thanks again for your wonderful show, Kate."
Well, thanks for your question, Kate. My simple answer is yes, you should definitely bring this up with your pediatrician and I'm inclined to do it sooner rather than later. And just so you folks know, when I get questions like this where I have a concern and think something should be looked into quickly, I don't really wait to do it on the show here. I did email Kate back and let her know my thoughts on this.
Now, we don't provide personalized responses for everybody. In fact, we don't do it very often at all because we aren't here to give medical advice. But when it's more of a significant situation, just rest assured we do get back to folks and say yeah, this is something you should get checked out. We can't comment on exactly what this is but there are some concerning things here that you probably ought to have your doctor look at, we let you know.
Another example of that is when we talked about mercury from CFL light bulbs not too long ago. Again, when there are urgent things, we do get in touch with people so you don't have to wait until the show comes out where we talk about it. And in this situation though, we certainly did do that for Kate.
OK. So let's talk about some of the possibilities here and keep in mind as we discuss this. And again, this is not new news for my regular listeners, but as always we can't make a diagnosis on a podcast, over the Internet or by email and interactive discussion and physical examination by your doctor are absolutely required. But having said that we can look into some of the possibilities.
Sleepwalking is a definite possibility. So you can have a kid who is sleeping but they still have enough of their brain, even though they're in a sleep mode, they still have motor and sensory input that allows them to get up and walk around without necessarily being aware of what they're doing. And so this would be sort of the classic sleepwalking where your cognition isn't there but your body works and it does do some automated things and does able to go up and downstairs and laugh and do some other things.
Sleepwalking is definitely a possibility. And if it is sleepwalking, unfortunately there's not a lot you can do other than it does seem that better sleep hygiene tends to help with sleepwalking. So if you have a regular bedtime routine, kids are getting a good night sleep, they are necessarily taking mood-altering medications before bedtime, if they do have obstructive sleep apnea that you've gotten that taken care of, and so just good sleep hygiene kind of stuff can help.
Although if there's a strong family history of sleepwalking even though those things may not help and then the best thing is just making sure that your child is in a protected environment. In this kind of situation, it may not be a bad idea to have doors closed, to have your door open, so the door closed or try to make a barrier so that it's less likely they'll get out into the hallway and fall down some stairs, but still possible.
If you have a first floor bedroom, kind of move in their bedroom to the first floor against they're not at the top of the stairs, especially if they're venturing out frequently. Just having baby monitors, even though it's an older kid, so that you can be aware and hear and kind of guide him back into their room.
So for a safety conscious standpoint, it kind of depends on what their typical sleepwalking behavior is like and then just trying to make sure that the environment that they're going to be sleepwalking in is as safe as possible. But that's not too common, those kinds of sleepwalking things.
Another possibility is night terrors. Now, usually with the night terror and this doesn't happen during the dream part of sleep. It happens during more of a deep sleep where the emotion centers of the brain suddenly start firing and in most kids this kind of shows up as a kid who starts crying and is upset and is screaming in their room and you rush into their room and they're in bed and they don't really seem to be with it and then they slowly wake up out of it and don't remember having it.
And we talked about night terrors in lots of detail back in PediaCast #188, so I'm not going to go into those in too much detail here again. But if you are interested in hearing more about night terrors, again, PediaCast 188 and just to make it even easier for you to find; actually, if you do a Google search and just put in PediaCast 188, that show should come up for you. But in the Show Notes to this episode 205, it did put a link for you so you can find it easily if you want to go that route.
So, night terrors, if you want to know more PediaCast 188. So that's a possibility, although, usually with night terrors you don't get up and walk around. Laughing, so when you hear him laughing in his room in the middle of the night, if he really is not awake and laughing consciously, and he's laughing and you walk in and he's doing his laughing thing and then you kind of wake him up and he doesn't remember laughing, then it's possible that that's a night terror kind of thing.
Usually, it's more of an emotional response where you're upset and crying, but laughing, you could see that. It's a little more rare but you could. Although walking down the stairs and that whole business doesn't sound as much like night terrors as it does sleepwalking, but maybe of a combination of things going on.
But, the reason that I would see your doctor about this is because I'd also be worried about something called complex partial seizures. Now what's that?
Well, a classic seizure that we think about where your whole body goes stiff and you're shaking and you lose consciousness, those are called tonic-clonic seizures. And it does involve basically the entire brain sending out signals at the same time. So you have all your muscles kind of working together, then you get stiff or you can shake and you lose cognition or consciousness so you're not going to be able to be up and walking around.
But other seizures can only involve a specific part of the brain. And if that part happens to be a motor area, you can have an increased tone or shaking of one part of the body, the part that's controlled by the part of the brain that's affected. And this is what we call a focal seizure. So if you have a brain abnormality that only involves the part of the brain that controls the right arm, you can have a seizure that only involves the right arm and again, we call this a focal seizure instead of a generalized tonic-clonic seizure.
But what if the problem is part of the brain that controls emotion or thinking or complex movements, like chewing or picking or fumbling? Well depending on the area affected, you could see something like what Kate has described. So you could see a kid who isn't really aware of and responsive to their surroundings but who could still manage to get around, even up and downstairs. They can lose control of their bladder during a complex partial seizure and they could exhibit strange behaviors like laughing for no apparent reason, particularly if that laughing is happening when they're not otherwise normally responsive
So complex partial seizure is also possible explanation.
So there are lots of different things that could be doing this and that's why I recommended to Kate that she definitely let her doctor know about this as soon as possible. A child with this kind of symptoms might need some head imaging and EEG and may need to visit a pediatric neurologist to get to the bottom of it.
In the end, it may be sleepwalking. But again, I wouldn't assume that from the get-go. Sleepwalking is what we'd call a diagnosis of exclusion in this sort of case where you want to make sure it's not something more serious before you settle on sleepwalking as the reason.
And you'll notice again I'm using lots of non-committal words like might and maybe and likely and again, that's because you cannot practice medicine on a podcast or over the Internet, so make sure you see your pediatrician, Kate, and do it soon.
All right. Let's move on to our final listener question of the day. This one comes from Tanya in Quito, Ecuador and Tanya says, "Dear Dr. Mike, I am a new but very happy fan of your show. I started listening this year and have been catching up on many of your past shows. All the topics are very interesting to me. We have two kids, a 4-year old and a 1-year old. I would like to ask you two different questions and hope so much you can help me. One year ago, when my baby was only 21 days old, she got meningitis. I took her to the hospital at a very early stage of the illness. The doctors put her on antibiotics as they did not want to lose any time. They found she had staphylococcus aureus and she spent two weeks in the Neonatal Intensive Care Unit and then one week in a regular hospital room. In November 2011, we did several medical exams at the Miami Children's Hospital and all the results came out great. She's doing well and her development is completely normal. I have a couple of questions, can we be sure the diagnosis of staphylococcus aureus was 100% sure or are there false positives? How can a newborn contract staphylococcus aureus? Even if the latest medical exams came out completely normal, is there a chance she might have some meningitis-related problems in the future and what problems might we see? Would you recommend future medical exams to confirm she is over this? Thank you so much for all your information and for sharing your knowledge. Warmest regards from the middle of the world, Quito, Ecuador. Hasta pronto (meaning see you soon), Tanya."
Well, thanks for writing in, Tanya. So let's answer your questions about meningitis during the newborn period. First, I want to say that staphylococcus aureus is a bacteria and it's ubiquitous, meaning it's everywhere. So it's on our skin, it's in our noses, it can be in your mouth, it's all over the place. But as long as it stays in those places, it's not a big deal. But if the staphylococcus, the staph bacteria, if it invades your skin or it gets into your urinary tract or gets into your bloodstream, then they can cause a problem.
So, we understand it's everywhere. You're not going to be able to get rid of it. If you throw in antibiotics all over the place and then cleaning solutions and try to get it off of your skin and out of your nostrils, what you're going to do is just the bacteria is going to find a way to live in the presence of those chemicals and that can create resistance and then it's harder to fight the bacteria off when there really is a problem.
The other thing, there are chemicals that will kill all bacteria but they tend to be toxic to yourselves, as well and so they're not going to be as helpful either. So we just live knowing that the staphylococcus is on us and as long as it's on our skin and not invading, then it's not a problem. If it does invade your skin or it gets into your urinary tract or it gets into the bloodstream, well then it can cause a problem, unless your immune system is quick to kill it. But if your brand new baby and you don't have that great of an immune system, then it can become a problem.
So if the staph bacteria invade your skin or gets into urinary tract or into your bloodstream, it can be a problem, especially if your immune system is not up to the task of protecting you. So, how did it get into your baby? There's lots of ways that it can happen and the issue here is not that it did. It's that your baby's immune system didn't take care of it. That's the issue.
But it's not a surprising issue, but it's the issue, it happens. And it happens fairly often, which is why all 21-day olds with fever get a whole septic work-up. They get blood work, they get urine, they get a spinal tap, they get admitted to the hospital, they get placed on IV antibiotics because it does happen. And the body's immune system just isn't able to take care of it. So how?
Let me just give you an example. Let's say your baby has a diaper rash and they've got staph aureus in the diaper area, they've got skin that's kind of broken down because of the rash, it's easy then for the bacteria to invade the skin and end up in the bloodstream. Or it could go up the urinary tract and into the bladder, we already talked about baby girls having a really short urethra earlier in this show, and so it is easy for skin bacteria to get up there. And then if got the bacteria grow in the urine, it can get up to the kidney, it can get into the bloodstream, so that's another way.
If your child has eczema, they have dry skin and flaky, scaly skin, that's another area where bacteria can possibly invade. Or the bacteria could just be in the nasal cavity and just get in burled into the mucus membranes and get into the bloodstream that way. And that sort of thing is happening to all of us all the time, but again if you have an intact immune system, it takes care of it before you ever get a fever and know that you even have a problem.
That's what our immune system is designed to do. But in little babies, the immune system isn't up to the task quite yet and so it's a little bit easier for the infection to get inside of them, into the bloodstream. So the staph bacteria gets into your baby into the bloodstream and then what had to get meningitis, what happens at this point is that the bacteria crosses what we call the blood-brain barrier and it gets into the cerebral spinal fluid and causes what we call meningitis.
Now that blood-brain barrier in older kids and adults is pretty resilient and it's difficult for bacteria to cross it. But again, in little babies, who are less than a month old, it's much easier for the bacteria to cross that blood-brain barrier and get into the cerebral spinal fluid which is the fluid that covers the brain and the spinal cord. And the way we diagnose that is with a lumbar puncture or a spinal tap where we put in needle in the lower back into the cerebral spinal fluid space and collect that fluid off and send it for a chemical analysis and culture to see if anything is growing in there.
And in your case, Tanya or in your baby's case that staph bacteria did cross, got into the blood, crossed the blood-brain barrier and caused meningitis. And the meningitis is just a fancy way of saying that the organism got into the cerebral spinal fluid, that fluid surrounding the brain and the spinal cord. And again it got there from the blood and how it got into the blood, I don't know exactly how but it happened and it happens.
All right. So let's tackle your questions. Can we be sure the diagnosis of staphylococcus aureus is 100% or are there false positives? Well, labs are pretty good in identifying this organism. The question doesn't become so much of was the staphylococcus aureus really there or not. If it came up with the positive, I would suspect that it means that they grew a culture, they found that organism growing, they identified that organism and labs around the world, including in Ecuador, going to be pretty good at saying this is staphylococcus aureus. So false positives of identification are probably not going to be an issue.
Now with some of the rapid tests, there can be problems. We talked in the show, not too long ago, about dogs being false positives for strep, human group A strep, and really that's because they did a test that wasn't really designed for dogs and so the test was sort of tricked into thinking that it was human group A strep when it was really a type of dog strep and so that was a false positive.
But in this case, we're not really talking about a rapid kind of test. We're really looking and this is a culture and so identifying that organism is a pretty straightforward thing. And it's unlikely that this was a false positive that your baby probably did have as staph aureus growing.
But, there is a question that comes into play here and that's the possibility of contamination. So, sure we've identified staphylococcus aureus but it's a possible, so we did a lumbar puncture, we got the cerebral spinal fluid or blood culture, we grew staph aureus, did it really come from the CSF or the blood or did it come from the hands of someone handling the specimen? So the person who drew the blood or the person who did the lumbar puncture, is that possible that they contaminated the specimen and that the staph aureus that we're finding really came from them and not from inside your baby. That's a possibility. But, that's not something that you want to assume.
So if you have a baby with the fever, who's 21 days old and they grow a staphylococcus aureus, you're going to assume that that's correct and you're going to treat it. You're not even going to entertain the possibility that this was contamination, even though it's possible. So the doctors who started on the antibiotics right away did the right thing in that situation.
You asked how can a baby, a newborn, contract staphylococcus aureus, I think we've covered that one pretty well already. You know it happens. And then your next question, even if the latest medical exams came out completely normal, is there a chance she might have some meningitis-related problems in the future and what problems might we see?
So you can have long-term consequences from meningitis during the newborn period. Meningitis causes severe inflammation as the body tries to kill the organism and that inflammation that's killing the organism can also damage the brain; so you can see developmental delay; you can see seizure disorders develop because you've damaged part of the brain; you can have vision problems; hearing problems; all of these things are possible.
You can also sometimes see toxic effects caused by certain antibiotics used to treat the organism. So there's definitely the potential for brain injury and long-term effects from having meningitis and from fighting meningitis with antibiotics, which you have to do because the risk of having a toxic side effect from the antibiotic still outweighs the risk of what would happen if you didn't use an antibiotic.
But there are certain antibiotics we can choose to use that are safer than others and we can measure blood levels to make sure we don't get toxic effects outside of a certain range. In particular, I'm talking about Genomycin when that particular antibiotic is used to treat meningitis. But the good news for you, Tanya, is that you usually see evidence of these kinds of problems fairly soon. So the fact that you're a year out and your child is developing normally, that is great and that's really good news.
Could she still develop an issue at this point? It's possible that she can have some developmental issues in the future and that the only thing that you can figure that caused them was this bout of meningitis that she had. But it's not probable. In fact, I'd say the chances are pretty slim of that happening.
Is there anything that you could do at this point right now to prevent that from happening if it's going to happen? There really isn't. So your best bet is just to be on the alert and if any problems arise with your child's development or hearing or vision or your child starts to have seizures, any of those kinds of things, you want to see your doctor and deal with them right away when they appear.
But the fact that you've gone a year and your child's doing well and developmentally appropriate and everything seems to be great, that's a really good sign. But you do want to know to identify problems and address them as soon as possible if they happen down the road in order to intervene and maximize future developmental potential by figuring out what's going on and dealing with it right away.
So how do you watch for these things? And that sort of leads us in to your next question. You ask, would you recommend future medical exams to confirm she is over this and the answer to that is yes, I would recommend future medical exams, not necessarily to confirm she's over this. These examinations your child should have anyway. So you want to see your pediatrician on a regular basis, 12 months, 15 months, 18 months, 24 months. In your case, 2 1/2 years is not a bad idea and then at three, maybe 3 1/2 and then yearly at that point.
Your doctor's going to check growth, he's going to check developmental milestones, he's going to check language development, hearing and vision, all things we normally checked in all kids. And to deal with problems as they arise.
So those routine, well checkups are going to be really important. And then you just want to be on the lookout, know what next developmental stage that you're looking for. Is your child progressing through development and your pediatrician can help you with that. And then if your child's not meeting those milestones then you want to bring that to your doctor's attention sooner rather than later, or if you notice any problems with vision or hearing.
Again, it's unlikely you're going to see problems as far out, but it is possible. Oh and by the way, if some problem does occur, maybe difficult to say for sure that it was the meningitis that caused it. I mean, certainly, kids are going to go on to develop autism; subset of them had meningitis when they were babies, and it doesn't necessarily mean that the meningitis caused their autism. Even if they happen to have that episode of meningitis, they may have developed autism at a certain point in the future anyway.
So if something does go wrong with development or does start to be a problem, we can say well maybe that episode of meningitis caused it but it's also possible that it's not related at all. Now, here's one thing that I would not worry about. And my gut is kind of telling me that this is something that you, Tanya, might be still worried about. And that is I wouldn't worry that the staph is somehow still in there causing damage.
The antibiotic that your child had killed the staph, the fever went away, she got better, she's well now, you're a year out, she's developing normally, the staph is gone. Staph does not go dormant in the brain and then reactivate it some later time. I've never seen that, never heard of that happening. Could she get staph again in her bloodstream and then have a go to her cerebral spinal fluid again and causing a new bout of meningitis? That's possible but it's also possible for that to happen to you and it's also possible for that to happen to me.
As I said before, staph is everywhere, it can and does invade our bodies but most of the time our immune system takes care of it quickly, just as our immune system was designed to do. And since your child is now a year old and healthy and growing and developing well, is every reason to believe that now, unlike when she was 21 days old, that her immune system is up to the task.
So, I hope that helps, Tanya, and thanks for writing in and contributing to the show, from Quito, Ecuador.
Don't forget if you'd like to participate in PediaCast, it's an easy thing to do. Just head over to pediacast.org, click on the Contact link, you can get a hold of me that way. Also email firstname.lastname@example.org or you can call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
All right. We're going to take a quick break and then we're going to come back to wrap up the show and also talk about healthy snacks. That's coming up, right after this.
All right. We are back and I've kind of hung this out in front of you. I feel a little bad about it, when you're watching TV and then the news folks come on to give you a little teaser about what they're going to have in their broadcast. And then there's something you're really interested in and they save it for the very last part of the show. And I kind of did that here and now I'm feeling a little guilty about it.
But I do want to get to healthy snacks. This is a service that's offered here at Nationwide Children's. It's called Snackwise and it's a snack nutrition rating system that's free to use. If you head over to snackwise.org, that's how you find it. It basically helps you choose healthy snacks for your family. It has a nutrition calculator for snacks and you can find that at a lot of different websites. But Snackwise goes a step further and has a unique snack rating system. So not only will it calculate the nutritional value of a specific snack, it also looks at the ingredients and the nutritional information for that snack and then puts it into one of three categories – either Best Choice, something that you should Choose Occasionally or something that you should Choose Rarely.
And it's not just for families. They also have a service for schools where it helps schools meet the Child Nutrition and Reauthorization Act's Local Wellness Policy and so this is a tool that you can use if you're a school administrator or involved with school lunch program or you do lunches for preschools and daycare facilities. You can use this site to make sure that you are in compliance with the Child Nutrition and Reauthorization Act.
But it's also there for families so that you can make good choices when you're thinking about snacks. And it does include basically every snack you could think of that would be in a vending machine. So we'll put links on the Show Notes to get in to snackwise.org and the Show Notes for this episode 205 will have a link for you.
There's also a link to the Child Nutrition and Reauthorization Act's Local Wellness Policy if you're interested in what the government has to say about healthy snacks. You can find that in the Show Notes as well.
In the meantime, I want to share with you the top 10 Healthy Vending Machine Snacks as outlined at the snackwise.org website. And again, we'll go to the top 10 here in terms of the most healthy snacks, but if you're interested in your snack that you like to eat and if it's something that's the best choice, something you should choose occasionally or something you choose rarely, you can go to snackwise.org and look it up.
By the way, my favorite snacks and the Chili Cheese Fritos and Classic Doritos are among them, they didn't fare so well. They're on the Choose Rarely side of things. And fortunately, I do choose them rarely, although they're my favorites.
OK. So what are the top 10?
Number 10 is the South Beach Living Snack Bar Delights, Chocolate Raspberry. Number 9 is the South Beach Living Cereal Bars, Peanut Butter, Cinnamon Raisin, Cranberry Almond, Maple Nut and Chocolate. They all tied for number nine. Number eight is the Solo Nutrition Bar, Chocolate Charger and Mint Mania (that, I might have to check that one out). Number seven is the itaMuffin VitaTops (all flavors). Number six is the Power Bar Pria Complete Nutrition Bar, Chocolate Peanut Butter Crisp. Number five is the Herbalife Protein Bar, Chocolate Fudge. Number four is NutriPals Snack Bars, Peanut Butter Chocolate. Number three, Quaker Oatmeal To Go for Kids, Apple Cinnamon. Number two, CLIF Kid Organic Z Bar, Peanut Butter; and drumroll please. The number one, Nutri, the number one, I almost gave it away. The number one, top 10 healthy vending machine snacks is NutriPals Fruit Bars, Strawberry.
And again, unfortunately for me, Chili Cheese Fritos and Classic Doritos didn't do so well. You can see how your favorite snack fared, again, at snackwise.org. So check that out.
All right. I want to thank all of you for taking part in the program. We went a little long today with our news and listeners show, we sometimes do, apologize for that. But we have lots to pack in. Also, I want to remind you, as I mentioned at the beginning of the program, iTunes reviews are most helpful as are mentioned in your blogs, on Facebook and in your tweets.
And don't forget about our different options for community participation through our Facebook feed and Twitter and Google+. You can also share Show Note pages through those social media outlets and of course, spreading the word by telling your family and friends about the show.
We also have PediaCast fliers available on the Resource tab at pediacast.org. And most of all, let your primary care doctor know about PediaCast the next time that you go in for a well checkup or sick office visits, so they can check us out and spread the news with the rest of their families.
I want to remind you, too, if there's a topic you'd like us to talk about, just head on over to pediacast.org, click on the Contact link or you can email email@example.com or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.
And as always, until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody.
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.