Baby Problems – PediaCast 323

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Show Notes

DESCRIPTION
Join Dr Mike in the PediaCast Studio as he answers listener questions on a variety of common (and not-so-common) baby problems. Topics include craniosynostosis, duodenal atresia, malrotation with midgut volvulus, pyloric stenosis, intussusception, undescended and retractile testicles, fluoride supplementation, and the relationship between SIDS and residential altitude. Be sure to tune in!

TOPICS
Craniosynostosis
Duodenal Atresia
Duodenal Stenosis
Malrotation
Midgut Volvulus
Pyloric Stenosis
Intussusception 
Retractile Testicle
Undescended Testicle
Fluoride Supplementation
SIDS & Residential Altitude

LINKS
Gut Bacteria – PediaCast 243
Colic – Pediacast 038
Constipation – PediaCast 292
Gastroesophageal Reflux – PediaCast 176
Lactose Intolerance – PediaCast 009
Milk Protein Allergy – PediaCast 259
Parenting 101: Baby Basics – PediaCast 241
Guideline on Fluoride Therapy (AAPD)
Guideline on Infant Oral Health (AAPD)

Transcription

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.

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

It is Episode 323 for July 15th, 2015. We're calling this one "Baby Problems". I want to welcome everyone to the show.

We have another Listener Edition of the program lined up for you this week, which means that this is a show that you designed. So if you don't like the topics, don't blame me, just answering the questions you asked. I also want to be upfront with you right from the beginning. We're pretty much exclusively covering topics that relate to babies today. Most of the time, I try to select a variety of topics that apply to a wide range of ages. But not so today, because the most recent batch of questions have been baby all the way, so that's what you're going to get this time around.

For those of you without babies at home, or those who don't take care of babies — maybe you don't even know a baby at this point in your life, I don't know — if that describes you, you might want to go ahead and hit stop and find another episode of PediaCast to listen to. Not trying to be rude, I just don't want to waste your time.

Now, if you want to copy the link and send it to someone you know who has a baby or someone who takes care of babies in some capacity, that'd be fine, and of course, very much appreciated.

OK, for those of you who are left, we really do have some great topics for you today. We're going to cover some common things, and some uncommon things, definitely information every informed parent with a baby should know. We could even have life-saving information for you today, especially when we get to our question on digestive issues. So be sure to stick around for that.

0:02:19

Before we get to the line-up — I should not have shooed away the parents with babies so quickly, maybe you're still around — I wanted to mention another movie this week. And no, we're not becoming a movie review podcast. In fact, our family does not really take in a lot of movies at the theater, really, compared to probably others, but there have been a couple we've tried with the summer blockbuster movie season and all. And I mentioned one of those a few weeks ago, Jurassic World, and how we incorporated that movie into some quality, family fun and stimulating conversation.

Since then, we also saw Inside Out. I have to tell you, if you have the opportunity to take your kids to that one, you should — or wait until it come to the Dollar Theater or the Redbox or one of the streaming services. But you should definitely see it at some points with your kids if you can, especially if your child is frequently dealing with his or her emotions, and particularly, when sadness and anxiety and anger come into play. Because from a psychological perspective, the movie is really well researched and advised. In addition to great entertainment, which our family at least has come to expect that from Disney Pixar , there's a lot of educational and insightful information in this film, not just for little kids but teenagers and adult as well.

I have to say I really caught a glimpse of myself in the movie, which is always reassuring because it's like "Hey, maybe, after all, I'm normal." And I think that's something that many kids need to hear, that they're normal, as they deal with emotions other than happiness and joy.

You and I both know kids who battle with sadness and depression and anxiety and anger and disinterest and disgust. Inside Out isn't a cure-all by any means, but it really does shed some accurate light on what's going on in the human head, at least in my mind, literally, and maybe that's why I identified with it so well.

OK, there aren't little characters really running around in your head, but at the same time, it really does translate well, I think, to what is going on.

0:04:25.9

Anyway, consider taking your family to that one. Good stuff, definitely a catalyst for thoughtful family conversation afterward.

All right, what exactly are we talking about today in this program? Craniosynostosis, it's a big word and relates to problems of skull growth in young babies. Your pediatric providers are on the lookout for it in those well baby visits, but parents should be aware of this condition as well, so we'll fill you in on that one.

Infant digestion, this is one of those topics that we could do several shows on — and in fact we have — because there's so much to cover. Some of the more common stuff, as I mentioned, we've covered previously and in depth. And in many cases, multiple times — things like gastroesophageal reflux disease, colic, constipation. So for the things that we've covered pretty well, I'm going to point in the right direction with links to show where you can listen and learn more.

One of the things that we have not covered so well on past episodes of PediaCast are the plumbing issues, anatomical problems that babies can have with the digestive tract. They're important because they can be life-threatening in a hurry, conditions like duodenal atresia, pyloric stenosis, malrotation and midgut volvulus, intussusception. They're big words. That's why I simply called this episode "Baby Problems". I'll explain what they mean, and more importantly, what signs and symptoms that you should watch for and what to do if those signs and symptoms occur.

And then, retractile testicles — some babies have testicles that aren't always living in the scrotum. Instead, they're hiding up inside the body. How do you tell the difference between an undescended testicle and a retractile testicle, one that moves up and down on a whim? What do you do for those? When do you do it? So I'll explain that in more detail.

0:06:17

And then, we have a question on fluoride supplementation. When do you start? How much do you use? What if you're breastfeeding? What if your child doesn't get enough fluoride? What if they get too much fluoride. So that's coming your way.

For my final word this week, SIDS and residential altitude, could the elevation at which you live — particularly if you're in one of the mountainous states and in particular, Colorado for this particular study — could the elevation in which you live affect your baby's risk of sudden infant death? And if so, above what elevation results in the greatest danger?

This one may be of so much interest for the hometown crowd. Ohio's pretty flat, for those of you who have never been. But listeners in the Appalachians, in Rockies, and Cascades, this would definitely be of interest to you. So stay tune for that.

Also, I want to remind you if there's a topic that you like us to talk about, if you have a question for me for a future episode of PediaCast, it's easy to get in touch. Just head over to PediaCast.org, click on the Contact link and ask away.

You can also call the voice line, 347-404-KIDS, 347-404-K-I-D-S. I do read each and every one, and listen to each and every one of those that come through. Again, we'll try to get your questions on the show in a future episode.

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. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

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

Before we take our first break, I do want to make one other plea with you. Most of you probably know by now that we're doing another podcast for providers called PediaCast CME. CME stands for Continuing Medical Education, and all doctors have to have a CME Credit to stay up to date. Being a doctor involves life-long learning, and so, we wanted to provided a podcast for physicians in the crowd, particularly pediatricians, family practice doctors, nurse practitioners, anyone who takes care of kids in a primary care setting.

0:08:35

We really wanted to be able to get some CME Credit out and PediaCast CME does offer free Category 1 CME. But one of the ways that we advertise or let people know about a new program is through iTunes. In fact, many of you listening right now may have discovered PediaCast by doing an iTunes search. One of the things that clues you in that a podcast is beneficial is by looking at the reviews.

Since we started PediaCast CME back in April, we don't have any reviews yet in iTunes. I think it will be helpful to have some reviews in there. It might catch the eyes of pediatricians who are going through iTunes, and they say "Hey, this is a well-reviewed podcast, one that I might want to take time to look at and to listen to and get something out of."

So, if you have a moment — again, I'm certainly not asking everyone to do this, but if you happen to be sitting in your computer right now — it's pretty easy to go into iTunes, just do a search for PediaCast CME, that particular podcast will come up. And if you feel so inclined to leave a review, that will be helpful in terms of helping us get PediaCast CME a little bit more visual aid for people coming around looking at it. It will put it in front of more eyes, and I really would appreciate that.

So we don't ask for much of the PediaCast audience, but if you do have a moment, please head over to PediaCast CME in iTunes and leave a little review there, so that we can tell more people about it.

0:10:09

All right, let's go ahead and take our first break, and I'll come back and answer a question about craniosynostosis and explain exactly what that is. That's coming up right after this.

[Music]

Dr. Mike Patrick: I have a question today from Theresa in Lawrenceville, Georgia. She says, "Can you do an episode focusing on craniosynostosis. My eight-week-old son was just referred to a neurosurgeon because his pediatrician suspects this condition based on a small narrow interior fontanelle and ridges on his coronal and sagittal sutures. He has a prominent forehead but otherwise, his skull growth seems normal so far. Thanks — Theresa."

Well, thanks for the question, Theresa. It's a great kickoff for a show dedicated to baby problems. Craniosynostosis is one of those conditions that it's not exactly common, but it's not rare either. It's one of those things that's important to recognize and do something about because timely diagnosis and appropriate treatment really can change a child's life.

So let's start with what is it? And we'll start with a name, craniosynostosis. Cranio lets you know that we're talking about the skull. Syn, S-Y-N, is a prefix rooted in the idea of joining or fusing together, and ostosis refers to bone. So craniosynostosis means the fusing together of bones in the skull.

0:12:04

Now, for many of you out there, the idea that the skull is made up of different bones that fuse together, this may be a new concept for you because the skull you're used to seeing on skeletons, let's say at Halloween, it looks like one big bone. But it doesn't start out that way.

The infant skull is actually composed of several distinct bone including two frontal bones in the front (one on each side), the temporal bones on the side. Of course, those are in the areas of the temple. The parietal bones, they're also on the side, but they're above and behind the temporal bones. And then the occipital bone which is in the back of the skull. And there are others, most of which make up the face.

Now, these bones are connected by flexible connective tissue, and the areas where they connect are called sutures. So when Theresa mentions the coronal suture, that's where the frontal and parietal bones meet up. So it's a line that travels from one side of the skull to the other.

The sagittal suture is where the two parietal bones come together at the top of the skull. So it's a line that travels from the front of the skull just behind the frontal bones to the back of the skull and ending where it hits the occipital bone.

There's also an important suture in the back of the skull, connecting the two parietal bones with the occipital bone. So it's a line that also runs side to side, kind of like the coronal suture which is more in the front of the skull, but it's in the back of the skull and this one's called the lambdoid suture.

To be semi-complete, there's also two sutures connecting each temporal bone with each parietal bone, which again lies above and behind the temporal bone. This is called the squamosal suture. And there's a suture running down in the center of the forehead connecting the two frontal bones called the frontal or metopic suture.

0:14:01

Another term you've probably heard of before is fontanelle. These are also known as soft spots and these are areas where two or more sutures come together, forming larger areas of connective tissue rather than solid bone. There's the anterior fontanelle, which is the soft spot on top of the head in the front. This is where the coronal suture (again, traveling from side to side) — just think of it like traveling from ear to ear, side to side across the front portion of the scalp — it's where the coronal suture meets the frontal suture (which runs down the center of the forehead between the two frontal bones) and the sagittal suture (which runs along the top of the skull between the two parietal bones).

So where those sutures all come together — the coronal sutures, the frontal suture and the sagittal suture — that's called the anterior fontanelle. The anterior fontanelle is large and diamond shaped, and if you have a baby at home, or you've ever had a baby at home, which is probably most of you, then you know exactly what I'm talking about.

If you start the anterior fontanelle and run your fingers back along the sagittal suture — so along the top of the head — then, you run into the posterior fontanelle, which is a smaller soft spot in the back of the skull where the sagittal suture meets the lambdoid suture.

All right, enough of the anatomy lesson. And by the way, that's just a tiny preview of medical school for you. Why is all this important? Well, it's important for understanding what craniosynostosis is all about. But it's also important for the baby because the skull needs to flex during childbirth to get through mom's pelvis. The head wouldn't fit through there if it weren't one big solid bone.

Also, the skull needs to grow very rapidly during the very few months of life in order to accommodate a rapidly growing brain. It accomplishes this feat by each bone growing out into the connective tissue that exists in those sutures. Once the individual bones connect and fuse, then the skull can't grow rapidly anymore.

0:16:11

So let's head back to our word, craniosynostosis , skull bones fusing together. We'll add one more qualification, craniosynostosis is the premature fusing of skull bones. Because we all know the skull bones do eventually fuse. The skulls stop growing at some point and the end result is the familiar, what you see on the Halloween skeleton. But if you look closely, you can still see the sutures' jagged lines, but the bones on each sides of those lines do meet and are fused together.

So this sets up a few logical questions. Number one, when are those sutures supposed to close? Two, what happens if they close too early? And three, if they do close too early, how can you tell and what can you do about it?

So let's answer question number one, when are those sutures supposed to close? Well, it depends on what suture you're talking about. When you consider each suture, there's a range of time that's normal. The sutures in the back of the skull begin to close first with the posterior fontanelle, sort of disappearing by about two months of age, sometimes even sooner than that.

The sutures in the front of the skull however stay open longer, so it's really the front portion of the skull that's growing most rapidly. And those stay open until about 12 to 18 months of age. Although again, sometimes, sooner, but not before nine months of age. So you should feel a nice open anterior fontanelle, a nice soft spot, at least through 9 months of age, but most often until 12 to 18 months of age. And then, by 18 months, everything is starting to close up tight.

So, question number two, what if one or more sutures closes too early? In other words, what happens when craniosynostosis occurs? Well, the skull can't grow rapidly and it can become misshapen. So the brain inside is still wanting to grow rapidly, but the skull can't grow out in all directions. So it's not going to grow as well where the suture close, and is going to grow on the direction of the still remaining open sutures. It's going to have unusual shape to it because of this.

0:18:22

Then, this can also affect proper brain growth and development as well, if you don't catch it. So this is definitely something that you want to diagnose and do something about if you can.

Which leads us to question number three, how do you identify craniosynostosis and diagnose it? Well, this is one of the reasons your pediatrician feels your baby's head and measures the head circumference.

Worrisome signs that craniosynostosis is occurring include premature closure of fontanelles, a bony ridge beginning to develop along suture lines. Because, that bone is still trying to grow rapidly, but since it can't grow into the connective tissue between the fused bones, it starts to ridge upward when it does hit the fuse bone, and you begin to see a premature slowing of skull growth. And then again, skull growing in different directions which gives an abnormal shape to the head and then, the head circumference measurements are going to start to be abnormal.

Diagnosis can be confirmed with imaging studies, plain films, head CT, MRI. Even ultrasound can be helpful in the diagnosis and precise characterization of the involved sutures.

So question number four, what do you do about it? Well, it depends. It depends on which sutures you're involved. It depends on the age of your child and the degree of the problem. Referral to a pediatric neurosurgeon is always in order, and really if craniosynostosis is suspected, that referral should be placed right away even before any imaging is done. Best to let the neurosurgeon decide what imaging to order because you want to minimize radiation exposure and avoid the need for repeat studies.

0:20:09

Some centers are going to prefer to do plain films; other, CT scans; other, MRI. For some, it really depends on the clinical situation. The skills of local radiologist have to be considered. Sometimes, it's a combination of imaging methods. The exception to this is if there's an agreement already in place between your pediatrician and the neurosurgeon.

In other words, maybe a particular neurosurgeon always likes XY or Z to be order at the same time the referral is made. That's a possibility as well. And again, your regular doctor is going to know about that.

If it is decided that intervention is necessary, which it commonly is, in order to facilitate normal skull shape and normal brain growth, then surgery is performed to open the prematurely closing suture to fix the shape of the skull. Sometimes that requires plates and screws, all of which hopefully allows normal skull and brain growth to proceed.

And there are different degrees of surgery. Some of them are open surgeries that take many, many hours. There's also some laparoscopic type surgeries that can be done, just with little holes under the skin that can accomplish the same thing. Again, it's going to depend on the experience and skill of the neurosurgeons at whichever facility that your child is being seen. You definitely want them to do it in a way that they're most comfortable doing it.

One more thing I do want to mention. Sometimes, an underlying genetic problem affects skull growth and brain growth and development together. Which means fixing the skull doesn't always result in normal brain growth and development, because sometimes, there's an underlying genetic condition at play.

So children with history of craniosynostosis need to have their development closely monitored even after the skull surgery. A trip to see a geneticist may be in order if an underlying genetic problem is suspected, because screening and diagnosing these conditions allows you to anticipate problems down the road, which allows helpful interventions with development sooner rather than later.

0:22:09

So that's craniosynostosis in a nutshell. Hope that helps, Theresa, and as always, thanks for the question.

[Music]

Dr. Mike Patrick: All right, next up is a question from Lorie, in Elmira, New York. Lorie says, "Hi, Dr. Mike. I'm a big fan of your podcast and especially appreciate your evidence-based approach. You have saved me countless hours of research, but I especially appreciate how well you take a difficult or confusing issue and explain it.

"I'm hoping you might be able to shine some of that talent on an issue that seems to come up a lot with other parents I talked with — the digestive system in babies. I realized you've touched on the topic of infant digestion in several different podcasts, but I'm wondering if you could dedicate time on how the infant digestive system develops, what issues may occur along the way, how parents can help and hinder this process, and what parents can look for in terms of things we should bring to our pediatrician's attention.

"I'm the mother of a 16-month-old son, and he's had a very good digestive health so far, but many family member and friends have children around his age who've had a very difficult time in terms of their digestive systems. Even though I feel my son has had a really good go of it overall, he did have at least a month or two of very extreme gas, or so it seem to me.

"It was strong enough that it would make him up in the middle of a nap, and he would cry until he pass the gas and then go back to sleep. At the time, our wise pediatrician told us that babies' guts are sterile when they enter the world, and it takes time for them to populate with the bacteria they need to process food properly. He said this process could involve some uncomfortable side effects like gas, but with time, they would go away.

0:24:19

"We find this to be true of our son, however some of our friends and family members had dealt with a lot of gas, and others have kids with irregular bowel movements and chronic constipation. In most cases, the response of the parents have been to do many things to try to help their child. However, I sometimes wonder if some of these remedies actually make the situation worse.
Because of our pediatrician's very common sense approach, the only thing we did was give our son probiotics and do nightly massage and leg exercises. He responded very well and quickly to this, or maybe he just got better on his own. It seems like parents have very little information about how babies' digestive systems develop and what kinds of things require intervention versus waiting and seeing.

"I think you would just be the person to explain this kind of thing to us. I hope you can find time to fit this in. Thank you — Lorie."

Well, thanks for the questions, Lorie. As always, they are very much appreciated.

So there are several directions that we could go with this. You know, I really spent some time trying to decide which of those directions to go. I wanted to make the discussion as practical as possible, but I also wanted to keep it within reasonable time frame because we could easily do an entire hour on baby digestion. We have other baby problems that we're going to cover today, and so I wanted to make it practical but also brief.

So here's what I'm going to do. We've covered gut bacteria, colic, constipation, gastroesophageal reflux, lactose intolerance, milk protein allergies, and other infant feeding concerns pretty extensively on this program. And I'm going to put a link in the Show Notes for Episode 323 over at PediaCast.org to episodes that cover all of these topics. So if you have a particular interest in one or more of those, you'll be able to find it pretty easily.

0:26:16

Gut bacteria was Episode 243; colic, Episode 38; constipation, 292; gastroesophageal reflux, 176; lactose intolerance, Episode 9; milk protein allergies, Episode 259. So again, if you want to listen to any of those, just head over to PediaCast.org, click on Show Notes and find the Show Notes for Episode 323. I'll have links to all of them. If you do have a particular interest, you can find it easily.

Also, if you're interested in just sort of overall baby digestive issues like feeding, you definitely want to check out PediaCast 241, that's our baby basics podcast. So we covered infant digestion pretty extensively in that one as well.

So what haven't we covered? That's what I really wanted to try to focus on, and in particular, developmental problems of the digestive system. For the most part here, I'm talking about plumbing problems, because these are the things that can get babies into life-threatening trouble pretty quick.

So a lot of these other things are nuisance things. Your baby's going to get better as time goes by. You might have to figure out a different formula. But they're not life-threatening issues. They're really more of a nuisance.

But we haven't really covered what are the life-threatening problems. And I think when parent have babies who aren't doing well with their digestive system, that's really it. It's like, is this a minor problem, or is there something serious going on? And if there is something serious going on, how do I tell and what do I do about it?

The kind of plumbing problems that I'm talking about are things like duodenal atresia, malrotation with midgut volvulus, pyloric stenosis, intussusception.

0:28:03

So I know where you're coming from, Lorie, with your own baby and the babies of your friends and family because I saw it all the time during my years in private practice. Parents — and in many cases, grandparents — focus like crazy on infant digestion and poop.

It's natural to take note of spit-ups and passing gas and fussiness and stool color and character and frequency. Many people make logs of these things, put it in a notebook, and many a pediatrician has had mom or grandma pull that notebook during a visit with fast figures and facts of their child's digestion and poop habits. We see it all the time.

One thing that young pediatricians learn pretty fast is how to quickly separate the nuisance issues from the life-threatening issues, and this is a skill that parents really should have as well.

So let's face it, babies tend to be fussy, some more so than others. And when they're fussy for whatever reason, they tend to tense up their belly which leads to spitting up, passing gas, and pooping. In most cases, this is a pressure phenomenon. You have liquid in a tube. You apply pressure in the middle and the liquid and gas comes out the end it's closest to. It's a matter of physics, and then your baby stops crying and falls asleep.

So the question becomes, did their belly really hurt in the first place? Was gas really a problem, or did it simply come out, out and in, due to pressure? A lot of people can make gas come out at either end by applying a little bit of pressure, and it doesn't necessarily hurt prior to the gas coming out. You know what I mean.

Other times, gas may be uncomfortable, and we feel better when it does come out. We've all experience that in our lives, too. The problem is, your baby can't explain what he or she is feeling. Your baby can't communicate what's going on, so most of the time, we just don't know. Is the belly really hurting? Or is your baby mad about something and just happens to pass gas and stool then go back to sleep? Or is an immature brain telling your baby to cry for no good reason, and again stool and gas pass, and the problem wasn't really in the digestive tract to begin with?

0:30:11

We do know this. Some babies have more problems with these things than others. We also know that when babies have these problems, they naturally get better with time. You don't see toddlers rushing off to preschool with spit-ups and gas passing problem. So, OK, maybe a few, but not many.

Now, like any good parent. There's nothing wrong with trying to help your baby. You want them to be happy and comfortable. You don't like seeing spitting up, or fussy, or passing gas or having problems with poop. We all get that. And so, you try some things like changing formula or mom's diet, if she breastfeed. You might change your diet to try to help out. Or you try an acid reflux medicine maybe if they seem to be really fussy when they spit up, or stool softener of some sort if constipation is an issue.

All of these things, of course with the guidance of your baby's doctor. And if you find something that seems to work you stick with it, knowing full well the issue may have just resolved on its own, and that our intervention might not really be helping. But as long as the intervention isn't harmful, we'll stick with it for a little while because we want our child to be happy, and if we stop, we're worried that he or she won't be happy anymore. It's called being a good parent.

As pediatricians, we understand that. Many of us are parents too and we get it. But we also know the truth that in many cases, you just have a fussy baby. And these interventions probably don't really do much, and it all will get better in time, you just have to get through it. And that's the bottom line.

Now, having said all that, there are some GI symptoms that we don't ignore, and you shouldn't ignore them either. So a predictable fussiness that happens for a few weeks or a few months, that doesn't bother us so much. You know, they are the fussy at the same time a day, every day for a long period of time. Happy spitters, those don't really bother us so much either. But sudden and prolonged and difficult-to-console fussiness that's out of character for a particular baby, that is worrisome.

0:32:11

Spitting up that's accompanied by choking or wheezing or difficulty breathing, that raises alarm. So as we think about the baby digestive system, what other signs and symptoms may cause alarm?
Well, projectile vomiting is always a concern. And by projectile, as a physician, we mean considerable force — so across the room. Out like a fountain, that's not really projectile. But across the room, that's more of a concern. That's really, truly projectile vomiting.

Bilious or bloody vomiting is always another concern. So if you see dark shades of yellow or any shade or green, you want to let your doctor know right away. Light yellow might be okay if this is the typical color of your child's spit-ups. But if the spit-ups are always tan or clear and then become yellow, let your doctor know. This might be OK, but it might not. That could be bilious vomiting. Best to let your provider decide.

Green colors, however, in the vomit are almost always a concern. Unless, your child's just eaten a green food like green beans. So I should say green is usually a concern. There may be exceptions, which is more reason to involve your doctor in these conversations because you have to look at the whole picture.

Red in the spit-up is also a concern. Red makes us think about blood, but again some things in the diet or medication could cause red in the spit-ups. But if you think it might be blood, that should be checked out right away.

In addition to force and color of vomit, we also consider timing. So a few minutes following a large bottle is less concerning than vomiting that is occurring between meals. Fussiness before and after meals is common, but fussiness that doesn't go away or that's accompanied by a persistently hard to distended abdomen, that's a concern.

0:34:01

With regard to poop, many babies go a few days, maybe even an entire week or a little more between bowel movements, and that may be OK if your doctor checked your baby out, and this is your baby's usual pattern. But sudden changes in bowel frequency, that's a bit more concerning, although changes in frequency can also be normal at times.

Bright, red blood in the stool is not normal, although this can be seen with some serious and some not-so-serious conditions. Black tar-like stool, those should be brought to your doctor's attention because that might indicate partially digested blood from a location further up the intestinal tract.

So to answer Lorie's question, what symptoms should you not ignore? Where do you abort the wait-and-see process? What signs and symptoms do you want to share with your doctor right away?

Well, here's the top ten list — unusual for your baby and difficult-to-console fussiness, projectile vomiting particularly across the room type of force, dark yellow or green bile in the vomit, red blood in the vomit, vomiting that occurs with new timing (especially when it's not immediately following a meal), vomiting the causes choking, wheezing or difficulty breathing, persistently hard or distended abdomen, red blood in the stool, black tarry stools. White stools might also be a concern. And finally, stool frequency or character that changes from your baby's usual pattern, especially if it's an association with any of these other symptoms.

So those are the don't-wait-and-see symptoms. You want to let your doctor know about those right away.

Now, I mentioned some plumbing earlier, ones that can be life-threatening. Well, as it happens, this top ten list includes the symptoms of these conditions. So let's define what those things are real quick. They're pretty easy once you get past the names.

Duodenal atresia — the duodenum is the first portion of the small intestine right after the stomach. Atresia means blocked or closed. So some babies are born with the blocked or closed segment of the duodenum, which results in bowel obstruction, which leads to projectile bilious vomiting, dehydration and weight loss. It's usually diagnosed soon after birth and requires stomach suctioning, IV fluids, and a surgical repair. Left on its own, it's deadly. Fortunately, it's usually diagnosed before your baby leaves the hospital.

0:36:25

Although a similar condition, duodenal stenosis. It may show up later. Stenosis means narrowing instead of complete closure. So if the narrowing isn't extreme, it may take a bit more time to reveal itself. That's why if there is projectile vomiting or green bile in the vomit, you want to let your doctor know right away.

Another condition is malrotation with midgut volvulus. The intestine is a very long loop, right? And as you can imagine, if it weren't positioned and tacked down just right, it could twist on itself, causing obstruction and compromising blood supply. Now, fortunately, most of us are born with a small intestine that is positioned and tacked down just right. But some folks aren't as lucky. They have a small bowel that could move around more than it should, which results in a condition called malrotation.

Now, malrotation, in and of itself doesn't really cause much of an issue, but if the malrotated bowel twist on itself, then we get a condition known as a volvulus, which is a very big concern because it can result in bowel obstruction. More importantly, it can compromise blood flow to the bowel, which results in ischemia of the bowel wall, meaning that cells die due to lack of oxygen because of the lack of blood flow.

And that can result in bowel wall perforation (which means that the inside contents of the intestine can spill out into the abdominal cavity) and infection (as microbes move from the inside bowel to inside the abdominal cavity), along with sepsis and shock. So this is life-threatening condition.

It can be difficult to diagnose if the volvulus is intermittent and the symptoms minor. When the symptoms are severe, it's important to figure out what's going on and correct it surgically as soon as possible.

0:38:11

This is usually diagnosed in infancy, but every now and then, you'll have an adult with a history of a congenital malrotation. Of course, they didn't know it, who shows up with their first significant episode of volvulus as an adult. So it can be an issue at any age, but it most commonly comes to attention during infancy.

Pyloric stenosis — the pylorus is the muscular valve between the exit of the stomach and the beginning of the small intestine. Stenosis, as you'll recall, means narrowing. In this case, the muscular valve gets thicker as the baby grows. If it gets too thick, it can result in a significant obstruction at the exit of the stomach, which results in projectile vomiting without bile, because the bile enters in to the intestine after the pylorus. You'll also get electrolyte disturbances, dehydration, weight loss.

Pyloric stenosis most commonly shows up around one month of age, but it can happen a little earlier or a little later. So again, projectile vomiting, pretty forceful across-the-room kind of vomiting. Even with pyloric stenosis, it is going to happen right after a meal. That is something you want, of course, let your doctor know right away.

Intussusception, unlike pyloric stenosis, it occurs a little bit later. Pyloric stenosis usually happens again about one month of age, give or take. Intussusception can occur at any age including adulthood, but it's most common in babies and young toddlers.

Intussusception occurs when a portion of the intestine telescopes into itself, sort of like pushing down on a retractable antenna. And that results in obstruction and the possibility of compromised blood supply and intestinal perforation, kind of like you see with the volvulus. The most common and problematic site for this is the ileocecal junction, which is where the small intestine meets the large intestine. So the small intestine telescopes into the large intestine.

0:40:07

It typically results in severe but short-lived abdominal pain that recurs in colicky episodes. So you have a kid, who in between episodes are fine, but then all of the sudden, they're bend over, crying, in significant pain that last for a little while, and then they're fine. And so, when you see episodes of severe abdominal pain in a young child, that does make you think about intussusception.

Blood and mucus in the stool is also common, which has been described as currant jelly stools, thanks to the British — currant jelly. Vomiting is also common. However, vomiting and blood in the stool isn't always present, so episodic bouts of severe abdominal pain in an infant or young child should always bring up the possibility of intussusception, which, like the other plumbing issues, can be deadly if it's not identified and treated.

Intussusception is diagnosed with X-rays and/or ultrasound, commonly treated with an air contrast enema. So air is used, so you put a tube in the rectum, put in air, and the air is used to push the small intestine back out of the cecum or the beginning of the large intestine. Although sometimes a surgical procedure is necessary.

So those are the things you don't want to miss. Fussy babies are a dime a dozen. And whatever the cause, whether it really is their digestive system or not, fussy babies usually get better on their own. And you can think about reflux and gas and lactose intolerance and constipation, and you may find something that seems to work, which is great, whether it really is what's working or not, as long as it's not something that causes harm.

This is a journey you want to want to make with your child's doctor, even when it include a let's-just-wait-and-see approach. But, you want to keep vigilant for our top ten list and let your doctor know right away if any of those things are happening because it could mean that one of those life-threatening plumbing problems is going on.

0:42:04

So what's our top ten list again? Unusual for your baby and difficult-too-console fussiness, projectile vomiting particularly across the room type of force, dark yellow or green bile in the vomit, red blood in the vomit, vomiting that occurs with new timing, especially when it's not immediately following a meal, vomiting that causes choking, wheezing or difficulty breathing, persistently hard or distended abdomen, red blood in the stool, black tarry stools. White stools might also be a concern. And finally, stool frequency or character that changes from your baby's usual pattern, especially in association with any of these other symptoms.

So hope that helps, Lorie. And if you want a more complete discussion of infant digestive issues, be sure to include this episode with other PediaCast episodes. Again, I'll have links in the Show
Notes for Episode 323, which will take you to more complete discussions on gut microbes, colic, constipation, gastroesophageal reflux, lactose intolerance, milk protein allergy. Of course, don't forget Parenting 101: Baby Basics, that's PediaCast Episode 241. You definitely want to check that one out.

[Music]

Dr. Mike Patrick: Next up is Lorie in Elmira, New York. "Hi Dr. Mike. I'm so grateful for your show. Not only has it helped me understand many aspects of my child's help, but I've been able to introduce your podcast to many friends, and it's helped them understand their children better too. Your evidence-based approach and clear way of describing things is very reassuring.

0:44:04

"With that in mind, I wonder if you can help me understand more about a condition my son seems to be experiencing. After birth, he was checked by nurses and doctors and both of his testicles were descended into his scrotum. As a new mom, I didn't focus in so much into that area. I was far too busy cleaning him. So I was a little surprised when we made a visit to his doctor at his year checkup. And while as the pediatrician was examining the area, she noticed that one of the testicles was undescended. She then pressed in his groin area and then it descended into the scrotum. She brought me over and had me feel to show me that the testicle was there. She was very calm about it.

"Since that time, I've been paying a lot of attention to the area and noticed that the testicle is never in the scrotum. I've been meaning to bring it up to our doctor at the next appointment. Then, he had a slight fever, and I noticed the testicle was in the scrotum again. I asked her about it, and she told me it was very normal for the testicle to move up and down and not to worry.

"Of course, I wanted to learn more and did some Internet research. I learned this is called a retractile testicle, and it usually resolves on its own before puberty. Can you talk more about this and tell us more about what this condition entails? Is there anything else that parents should watch for? Also, is there any concern about a young child's testicles being in the body cavity in terms of heat.

"Thanks again for any information you can give on this. I know next to nothing about male anatomy, but I'm learning a lot as I change his diaper. Peace — Lorie."

Well, thanks for the question, Lorie. It's another good one.

So let's start with a little review of testicular development. The testicles form inside the body near the kidneys. But unlike the ovaries, which stay inside the abdominal cavity, the testicles migrate down, travel through the inguinal canal which connects the abdominal cavity with the scrotum.

So, the normally descended testicle has successfully made this journey and resides in the scrotum. Now, contrast this with the undescended testicle which has not completed the journey and does not reside in the scrotum. It's never been in the scrotum. Instead, it may still be up near the kidneys, or it may have stalled somewhere mid-route — could be in the opening of the inguinal canal or could have avoided its trip inside the canal. The point is, it never reached its intended destination.

0:46:23

Undescended testicles are given a little bit of time even after birth to complete their trip. However, if they haven't completed the journey, usually about by one year of age, then we consider a surgical procedure to bring them down and attach them to the inside of the scrotum with a procedure that's called an orchiopexy.

Now, why do you wait until one year? Well, because if you just leave things alone, about half of all undescended testicles will come down on their own. OK, so why not wait longer? Because very few of the remaining undescended testicles come down on their own after about one year of age. So if it's going to come down, it usually is within the first year of life, if you go after their first birthday, it's much less likely that they'll just come down on its own.

There is concern with leaving a testicle undescended including decreased fertility, increased risk of testicular torsion, which is when the testicle cord twists upon itself and can cut off blood supply to the testicle, and there's an increased risk of testicular cancer.

Now, I do want to point out, there is still some risk of these things, even when the undescended testicle is brought down because there may have been an inherent problem with the testicle that caused it to be undescended and infertile or more likely detours or to develop cancer. In other words, being in the body cavity might not what necessarily be what leads to these problems in every case. The problem may be intrinsic to the testicle which is also why it didn't descend.

With regards to cancer, it's better to have the testicle in the scrotum than in the abdominal cavity if you have an increased risk because of the possibility of self-exams and earlier detection, if the testicle's in the scrotum.

0:48:12

So it is important for boys and men to know that if they have a history of an undescended testicle, even when it was brought down surgically, they still have a higher risk of testicular cancer, even though the testicle has been brought down. So regular self-examination is important as it is in all boys and men, but particularly so if there's a higher risk including a history of undescended testicle.

With regard to torsion or twisting, that risk is diminished once the testicle has been brought down because the orchiopexy procedure attaches the testicle firmly in place. It's still possible, so intense testicular pain is always a cause for alarm and should be evaluated immediately even if you've had an undescended testicle that's been brought down and attached.

So that's normal testicles and undescended testicles. But what about retractile testicles? Well, a retractile testicle is a testicle that has made the journey. It just likes to hang out inside the inguinal canal, that tunnel between the abdominal cavity and the scrotum. So it's made the trip. It did go into the scrotum at one point but it likes to go back up inside.

This is usually due to an overactive cremaster muscle. Now, the cremaster muscle is a muscle that pulls the testicle up and its function is primarily one of temperature regulation. So the testicles like to have an ideal temperature range when possible. They're picky like that. They function best with regard to sperm production in that ideal range. When they get too warm, they like to hang lower, away from core body heat. And when they get cool, they like to come up where it's warm. And the cremaster muscle accomplishes this job of moving up and down for the testicle.

0:50:02

Some cremaster muscle are better at their job than others. And some like to contract and keep the testicles up inside the canal for no apparent reason, so we just say they're kind of hyperactive.

Now experienced pediatrician hence can usually coax the most stubborn of testicles into the upper scrotum. Sure, the testicle may dart back up after the doctor lets go, but as long as your provider can demonstrate that the testicle goes into the scrotum, then it's descended . It's completed its journey, even if only for a moment. That's reassuring and just something we watch.

Now, sometimes, a testicle does reach the scrotum but goes back up and can never be coax down again. This is called an ascending testicle, and they're actually very rare. So your doctor may not be able to coax the testicle down with every single visit, and that's OK, but if he or she has never coax it down, then it may be undescended.

If he or she has coax it down once or twice but can never get it to come down again over the course of multiple visits, then it's possible the testicle has become an ascending testicle. Sometimes those need surgery too. But again, a true ascending testicle is rare.

In any of these cases, there's no need for parents to try and coax the testicles at home. Just let them be where they be, and let your child's doctor do the coaxing and the deciding.

In any case, testicles that remain truly undescended at age one year, it's a good idea to get a pediatric urologist involved at some point soon after that. And if your doctor is concerned about an ascending testicle because it never comes down again after multiple office visits and attempts, and your child's over one year of age, then again, it's worthwhile to get a pediatric urologist involved.

What's left are the testicles that go up and down. Sometimes they're up, sometimes they're down, sometimes they can be coaxed, sometimes they can't. That is the retractile testicle, and it usually comes down and stays down by the time a child enters puberty. If it's still retractile at that point, a trip to the urologist may be in order because retractile testicles after puberty do have an increased risk of torsion and may need to be attached down inside the scrotum. You want to get the opinion of a pediatric urologist on that.

0:52:20

Also, the heat that's associated with staying in the canal after puberty, that may interfere with fertility. Although that's a temporary thing. It doesn't interfere with permanent fertility, just when it's overheated.

Although, again, does the retractile nature and heat really cause infertility problems? Or, is there something intrinsically wrong with the testicles that results in a retractile nature and fertility problems? So, if you do have fertility problems even after a retractile testicle has been attached
down, then it could be that there was an intrinsic problem to begin with. That's a question that's still being debated.

What about all that time spent inside the canal before puberty? Well, no sperm was being produced then. At least, at this time, with what we know now, there does not appear to be any association with future risks.

And I'll say this again because it's important — when you consider undescended testicles and retractile testicles that remain retractile after puberty, the current thinking is that if any problems occur down the road, and in particular, infertility or cancer, it's not because of time spent with body heat pre-puberty. It's more likely to be an intrinsic problem with the testicle, which results in the testicle not descending or remaining retractile after puberty and those other issues like infertility or cancer.

It's not the lack of descent or the persistence of retractibility that causes these issues. They're just both associated more than likely with an underlying cause. That's the current thinking anyway.

The vast majority of truly retractile testicles resolve on their own, with no further problems down the road. That's not true of the undescended testicles, the ones that never made it down and have to be brought down. There is still an increased risk of cancer even after those are brought down, so self-examination in those kids and adults is particularly important throughout one's lifetime.

So I hope that helps, Lorie. And as always, thanks for the question.

0:54:17

OK, this question comes from Jessica in Utah, "My twins are six months old and don't yet have teeth, but I know we're getting close on the topic of fluoride. Do we need to worry about getting them a supplement? I breastfeed and they're also getting a few ounces of Similac NeoSure formula to make up the difference and meet their hunger. The water in our area is fluoridated. Will this come through in my milk? Thanks — Jessica."

Well, thanks for the question, Jessica. The answer is yes. Fluoride from your drinking water will be present in your breast milk, although it is present in small quantities. So you want to make sure that you are getting plenty of the water. It's important to stay hydrated when you're nursing anyway, and drinking plenty of water is a great way for moms to stay hydrated. So, as long as you're doing that and your water is fluoridated, then your baby is getting enough and there's no need for additional supplementation.

The best practice rules on fluoride supplementation are pretty simple. For my guidance on this, I'd like to use the guideline on fluoride therapy from The American Academy of Pediatric Dentistry, which is evidence-based and frequently updated as new information is revealed. In fact, it was last updated in 2014.

I'll put a link to it in the Show Notes for Episode 323 over at PediaCast.org, so you can find it easily.

Less than age six month, no fluoride is needed. After that, it depends on how much fluoride is in your drinking water. Keep in mind, milk, juice, ready-to-feed formula and bottled water, those things have zero fluoride unless the label states otherwise. Some bottled water has added fluoride. If it does, the amount in parts per million should be clear on the label.

0:56:01

If you have well water, your Health Department can test it for the amount of natural fluoride. Sometimes, it's low. Sometimes, it's actually too high and dangerous to give a kid because there's too much natural fluoride in the well water. And, of course, you should have your well tested for microbes, too.

If you have city water, your water department can tell you how much fluoride if any that they add to the water.

So if your child is over six months of age, the first thing you want to know is how much fluoride in parts per million is in the bulk of whatever they're drinking. And your ranges for this are going to be less than 0.3 parts per million, 0.3 to 0.6 parts per million or over 0.6 parts per million.

Then, once you know which range you fall into, then you use your baby's age and the amount of fluoride that's in whatever they're drinking and The American Academy of Pediatric Dentistry's fluoride chart to figure how many milligrams of fluoride supplementation that she need.

Or you can ask your child's doctor because they probably have the chart hanging up somewhere in their office. But again, you'll need to know the amount of fluoride in parts per million in your baby's drinking water, or if you're making a formula, whatever the water is you're using to make the formula, how much fluoride is in that. You need to know that before your doctor can give you the right answer.

Again, if it's ready to drink formula, the answer is zero. If you add water to powder or concentrate, then you need to know how much fluoride is in the water that you're adding, either from the label or your health department, or your water department.

Appropriate supplementation ranges from 0 to .25 milligrams, to .5 milligrams, to 1 milligram depending on amount of fluoride in the drinking water and your child's age. You'll need that chart again to figure it out, which is included in The American Academy of Pediatric Dentistry's guideline on fluoride therapy, and again you can find that by following the link in the Show Notes for Episode 323 over at PediaCast.org.

0:58:01

Getting the right number is important because your child can get too much fluoride which results in a permanent staining of the teeth in a condition called fluorosis. So you do want to be precise about it.

The American Academy of Pediatric Dentistry's guideline also covers when to start using fluoridated toothpaste, how much toothpaste to use. So good stuff, and as I've said evidence-based with citations included. They also have a guideline on infant oral health care, which includes more evidence-based information on preventing dental carries, good diets for healthy teeth, assessing your child's oral health and more information on breastfeeding, and I'll include a link to that in the Show Notes as well.

So thanks again for the question again, Jessica. Keep on breastfeeding and keep drinking plenty of your city's fluoridated water, and your child's teeth will thank you. That's not literal by the way. I mean, they would if they could, but we all know that teeth don't talk. OK, I'm just getting silly now.

[Music]

Dr. Mike Patrick: OK, we are back. I want to thank all of you who contributed to this episode with questions. Don't forget the whole idea of PediaCast, really, is to arm moms and dads with evidence-based information. And so my priority, really, is getting you questions answered. And so, if you do have a question for me, make sure you let me know. Just head over to PediaCast.org, click on the Contact link, and put your question in there.

You can also call our voice line, 347-404-KIDS, 347-404-K-I-D-S, 5437 if you want the digits and you can leave your message that way.

1:00:09

All right, I have a final word for you on SIDS and residential altitude. New study suggests that living at higher altitude is associated with increased risk of sudden infant death syndrome or SIDS. The study is called "Sudden Infant Death Syndrome And Residential Altitude". It was published in the June 2015 edition of the journal, Pediatrics.

Investigators examined birth and death registries in Colorado from 2007 and 2012 and compared the records with the altitudes of the infants' homes. Compared with infants who lived below 6,000 feet, infants who lived in an altitude higher than 8,000 feet had a 2.3 times higher rate of SIDS death. The study confirmed several other factors that had been associated with increased risk of SIDS including smoking, decreased birth weight and lower socioeconomic status.

Researchers also compared rates of SIDs before and after the 1994 introduction of the Back to Sleep campaign, and found the campaign produce a similar reduction in SIDS deaths at different residential altitudes.

So the authors conclude that while the overall risk of SIDS is lower than it was prior to the Back to Sleep campaign, the data suggest the altitude is independently linked with SIDS and they should be considered when counseling new parents about safe sleep. Further investigation is required to demonstrate the pathophysiology behind this association.

So there you go. I know it's not necessarily helpful information for the hometown crowd. The highest point in Ohio is Campbell Hill, and the fact they used the word "hill" to describe it, that should tell you something. How high is it? One thousand five hundred fifty feet. But for my listeners in lands with tall mountains — and you know who you are — elevation should be a consideration if you have the option of choice and a young baby or soon-to-be young baby at home.

1:02:02

Better that your baby lives below 6,000 feet compared to over 8,000 feet, at least as far as the risk of SIDS death is concerned.

Researchers did mention the Back to Sleep campaign. For those of you who are scratching your heads at that terminology, it means all babies should sleep on their backs — not their sides, not their tummies, not propped up, but always flat on their backs unless you baby's doctor tells you otherwise and until your baby's doctor tells you otherwise.

For more information about SIDS, infant mortality and up-to-date safe sleep rules, be sure to check out PediaCast 302 over at PediaCast.org. Another good one to consider is a little bit more recent, PediaCast 320 where we talk about safe sleep and car seats and infant carriers. Spoiler alert on that one, those places are never safe, unless your baby is supervised and traveling in a car.

I'll include links to both episodes in the Show Notes for this episode, 323, over at PediaCast.org.

So again, sleeping babies living at elevations above 8,000 feet have a higher risk of Sudden Infant Death Syndrome compared with sleeping babies living below 6,000 feet, and that's my final word.

I want to thank all of you for taking time out of your day to make PediaCast a part of it. Really do appreciate that.

It's all the time we have today. PediaCast is a production of Nationwide Children's Hospital. Don't forget, you can find PediaCast in all sorts of places. We're in iTunes and most podcasting apps for iPhone and Android, including the Apple Podcast App, Downcast, iCatcher, Podbay, Stitcher and TuneIn.

We're also on iHeart Radio, where we not only have this program, but also PediaBytes, B-Y-T-E-S. Those are shorter clips from this show. They can be weaved together with other content providers to make your own custom talk radio station.

And then, there's the landing site, PediaCast.org. You'll find an archive featuring hundreds of past episodes, transcripts of each program in case reading suits your taste, and a handy contact page to ask questions and suggest show topics.

1:04:06

We also have a voice line, if you'd rather phone in your question or comment. As I mentioned before — 347-404-KIDS, 347-404-5437.

We're also on Facebook, Twitter, Google Plus and Pinterest with lots of great content you can share with your own online audience.

And, of course, we also appreciate you talking us up with your family, friends, neighbors and co-workers, anyone with kids or those who take care of children, including your child's healthcare provider. Next time you're in for a sick office visit or a well-check up or sports physical, or a medicine recheck, whatever the occasion, let them know you found an evidence-based pediatric podcast for moms and dads. We've been around for nearly a decade. Lots of great content deep enough to be helpful, but in language parents can understand.

And, while you have your providers' ear, let them know we have a podcast for them as well, PediaCast CME. Similar to this program, we turned up the science a couple notches and provide free Category 1 CME Credit for listening. Shows and details are available at PediaCastCME.org.

That's all for this one. 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.