Breath Holding, Broken Bones, Muscle Tone – PediaCast 262

Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include breath-holding spells, potty training, broken bones, swallowed glass, strep throat, low muscle tone, and the use of antibiotics (instead of surgery) to treat appendicitis.


  • Breath-Holding Spells

  • Potty Training

  • Broken Bones

  • Swallowed Glass

  • Strep Throat

  • Low Muscle Tone

  • Appendicitis




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

Dr. Mike Patrick: Hello everyone and welcome once again to Pediacast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. It's episode 262 for August 21st, 2013. We're calling this one breath holding, broken bones, and muscle tone. I want to welcome everyone to the show, we have lots more coming your way than just those three topics. And we'll get to the entire line up in a moment. This is another listener episode of the program that we have lined up for you this week. The listener edition is when we take your questions, put them on the show, and give you an easy to understand evidence-based answer. How do you get your question on the show? It's an easy thing to do. I'll give you the details on that. Coming up as well.

First off, if you missed the big news last week, I want to catch you up in a nutshell fashion. Pediacast is now available on iHeartRadio Talk, which is available on the iHeart radio app on the web, on iPhone and on Android. iHeartRadio Talk lets you stay connected with your favorite talk personalities anytime, anywhere so you can enjoy your shows when, where, and how you want. Also available on iHeartRadio talk is a brand new way to consume our content. I'm calling it Pediabytes. Isn't that clever? These are five to ten segments of Pediacast, each covering a single topic. And we release a handful of new pediabytes each week and they make a great addition to your Daily Pulse. What's the Daily Pulse? That's the custom radio channels that stitch together your programs and infuses them with your local news, traffic, and weather. Be sure to check out Pediacast and Pediabytes now on iHeartRadio Talk.


Of course, we're still at We have all the shows there as well and our normal feed on iTunes, but the pediabytes you'll only find for now on iHeartRadio talk. Be sure to check that out. You can find it again on the web iHeartRadio and also in the app store in Google Play. You can find iHeartRadio there as well.

All right. What listener questions have I lined up for you this week? First, at breath holding. You've probably seen it before — a baby or toddler gets really upset, they're crying like crazy when they suddenly hold their breath for a long time, and mom or dad is like, "Come on, buddy take a breath," but they don't. Instead they turn beet red and little blue around the lip and they pass out, which is actually fortunate because they start breathing again. These are scary episodes but are they dangerous? What causes breath holding spells? And if it's not breath holding, what conditions could causes similar attacks? So we're going to walk through that.

Then I have a question on potty training and in particular potty training for poop. Why does that take longer than potty training for pee? I have some tips to help make the training easier. This listener is also concerned that her toddler is constantly holding his boy parts through his clothes ever since he got out of the bulky diapers and pull ups. So we'll talk about that as well.

Broken bones. Do they really heal to the point of being good as new or should parents worry about recurrent fractures at the same location? When do you become concerned about a child over the course of weeks, months or even years, who has several broken bones? We'll have the answers to that, coming up.

And then swallowed glass. Another child swallowed broken glass, mom took her to the hospital and they just the child home without even getting an x-ray.  Mom is
concerned the glass could still be inside. So we're going to talk about swallowed foreign bodies, the typical work up, concerning symptoms, and what to do when the object never makes an appearance on the other end.

Muscle tone. We have a young child who is diagnosed with low muscle tone at the school screening and auto enrolled in school-based therapy. What's up with that? Did mom suspect the problem? Did the child's doctors have many concerns? And what do you when the school tells that there's something physically wrong with your child? What exactly is low muscle tone? What are the possible causes?  So that's all coming your way.

Then I have a final word about appendicitis. Research here in Nationwide Children's might have eventually change the way this common condition is routinely treated. Researchers believe that half of the case of appendicitis might not really need surgery. Could appendicitis simply be treated with a course of antibiotics? We'll let you know as we wrap up the show.


I had mentioned that it's possible to get your questions answered on the program. How exactly do you get your questions in my hands? Well, it's easy. Just send over to and look for the link at the top of the page that says, Contact Dr. Mike. And I read everyone that comes through. No screener folks, just me. So ask away and I'll do my best to get your question on the show.

Also, I want to remind you that 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 do 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 All right. Let's take a quick break and I will be back with answers to your questions right after this.



First up, we have Crystal in Vancouver Island British Columbia, up in Canada. She says, "Hi Dr. Mike. I just wanted to say thank you for your show even when I don't agree with your personal opinion I love hearing it along with the information you supply." Ah Crystal, you don't agree with everything that I say? That's OK. You know, sometimes I hear myself, I think about it some more or listen to the opinions of those wiser than me, and I change my mind. The important thing is that we observe, listen, and evaluate, and then make a conclusion based on what we see and hear, based on what we know, based on our past experiences because those are important, too, and often there for a reason, and then having done that, sometimes we must simply agree to disagree, which I think is what Crystal is saying with mutual respect for the conclusion each one of us draws, unless of course your opinion happens to be wrong. And that's where we run off the road into a ditch.

Back to Crystal, she says, "Here's my question: Why does my six and a half month old son holds his breath? Not to the point of fainting but until he is red. I asked my family doctor and he said it was normal and fine." Not really the answer, in my opinion. "You need a referral to see a pediatrician in Canada and my doctor said he doesn't see any babies at all."

Thanks so much, Crystal. Well, thanks for the comments and the question, Crystal. As always, very much appreciated. And good for a laugh there, too. I didn't realize you needed a referral to see a pediatrician in Canada. I mean, that really stinks, especially if the general practitioners don't always have a lot of experience seeing babies. So that's interesting. See, we complain about our medica system here in the States. But different doesn't always mean better.


OK. So why do babies hold their breath and turn red? By the way, this phenomenon isn't always confined to babies. We sometimes see it in toddlers and young school aged kids as well. Like at time of the kindergarten shots, for example. But regardless of the age, there's always a common denominator — they're upset about something. Whether that something is being told NO or being put in the crib when they aren't ready or having a dangerous object taken out of their hands, maybe they fallen skin or knee, or they're getting a shot, or they just were dropped off the sitters and they don't want to be there.

So whatever the reason, the fact remains they're upset and angry or frustrated about something and they cry. And in the process of crying, they hold their breath. OK, so why does this happen? Well, the honest answer is we don't know. It appears to be a type of reflex, meaning, an involuntary response to a specific stimulation. And in this case, the specific stimulation is extreme emotion that, actually the stimulation is an activity or something that's happening to the child that brings out extreme emotion and the involuntary response to that extreme emotion is breath holding. By what mechanism does reflex occur? That, we really can't say because we dont know.


Now, if you think about it from a survival stand point. Now we're getting to the realm of opinion. So Crystal may have a little bit of an issue with this. Extreme emotion in a young child is loud. If there are predators or enemies around, loud emotional children may give away your location. Breath holding and will talk about this what it looks like this in a moment. Breath holding tends to break the loud emotional activity especially if your child passes out. I mean, it's like pushing the reset button. They come to and all is well again, or at least not as quite as loud as it was before.


This explanation of course is simply speculation and loose speculation at that. It probably has more to do with parents surviving the anxiety of having a screaming baby than it does with the baby surviving a predator. But again speculation and of course Crystal might not agree with my speculation which we already established and that's fine.

OK. So what does a breath holding episode look like? First you have a baby or young child who's upset. They're crying vigorously and then they take a deep breath., their chest kind of looks like rigid, they look like they're trying to breathe, a look of panic may cross their eyes, their face turns red as they increase the pressure in their head and blood vessels in their skin dilate. But then usually at about 30 seconds to the one minute mark, if they haven't started breathing again, the red starts to turn to a pale or dusky color and you may see some blue around their lips and cheeks as the body uses up available oxygen. And at this point, most moms and dads are at panic and ready to start rescue breaths and call 911. But then because the brain is starved for oxygen the child passes out, which is fortunate because at that point they start breathing again, their color improves, they wake up and they're usually less upset than they were when the child began, which is also fortunate.


Now, having described this and having pointed out that we don't really know the mechanism behind breath holding spells, there are a few important points to be made.

First, there are some serious medical problems. For example, heart issues, head injuries, seizure disorders, which aren't exactly like breath holding spells but can sometimes mimic them. So I do think it's important to talk to your doctor when this happens, especially if it happens after a head injury, or when your child is happy and not crying or upset, or if they are unconscious for anything but a very brief period of time, or if they are back to their normal baseline personality soon after the episode is over. Even if the event really does seem like a breath holding episode, always check with your doctor just to be sure. Your doctors can really be able to look at the history of what happened and the context of what happened and what it look like and really tease it all out to figure it out if is this really breath holding episode or is this something more serious. So because of the potential of this to be something really serious, you do need to check with your doctor.

Second, these things tend to run in families. So if you have breath holding spells as a young child or your first child had them, then there is some reassurance that when little Bobby has one, although keep in mind that it can happen to any child so family history is not required.


Third, they aren't dangerous, OK. True breath holding spells are not dangerous. It's just another point of reassurance. But again you want to make sure if it's truly is a breath holding episode.

And my fourth point. Kids do outgrow them usually by the time they're starting school. So that's a good news. They typically stop around the kindergarten age or so.

So there you have it, Crystal. My two cents on breath holding spells. Pretty common things but when they happen especially for the first time or two, you do want to describe the event to your doctor to make sure that's really what you're dealing with.

Thanks for the question, Crystal. Thanks for listening and for your support as well even when you don't always agree with my personal opinion.



All right. Let's move South. From Vancouver Island to Amy in Lamorinda, California. She says, "Love your show.  Been listening to you since the Birdhouse Studio days since almost the beginning. Anyways, I have a rather random question. My son is two and three quarter years old and just started wearing underwear a couple of weeks ago. I noticed that when he's wearing pants and normal underwear, so not a pull up. He holds himself a while. One hand will be playing with the toy and the other on his crotch, or he just keeps one hand there while walking around. My husband says it's probably because he is feeling it now as oppose to when he was wearing thick cloth diapers. Well I understand this is probably a normal part of toddler boy development. I'm wondering shall I try to discourage him or just ignore the behavior and it will go away on its own as a novelty wears off."

"Also do you have any tips for giving him to go to the potty to poop? He does excellently at letting us know he needs to pee and stays dry all night, but hasn't any much luck letting us know he needs to poop, though he's very quick to let us know after the fact. Thanks again for your informative show."


Well, thanks for the questions, Amy. First, let me say a word about Birdhouse Studio. Pediacast was born in Birdhouse Studio in 2006 and lived there  until we moved to Florida in 2008. Birdhouse Studio is not fancy. In fact, it occupied a corner of my basement. But many of you maybe wondering how does a pediatric podcast that's focused on pediatric medicine and parenting issues, how does it get a name like Birdhouse Studio? How does a home based studio get a name like that? Well you know how you get a gift for Christmas or any other occasion and you don't like it, OK. It may not be your favorite gift in the world but you're polite. You point out something you like about it, you say thanks. The giver on the other hand, they get the impression you love it and they're enthusiasm spread to others in the room and pretty soon everyone sees this is the perfect gift for you. And on the next gift giving occasion, everybody's giving you a similar gift seemingly trying to outdo one another. It becomes a vicious cycle and you might not really even care for the thing, to begin with. I know someone who always gets Snoopy-themed gifts, for example, another one who gets frogs, for another it's Curious George items. So you get the picture?

Once upon a time, someone bought our family a birdhouse, which led to another, and another, and another. So when it came time to build a studio in the basement, and because I really hadn't gotten around to doing anything with these birdhouses, and to be fair, most of them were decorative only. I mean they weren't really constructed with avian occupants in mind, you know that kind I'm talking about.


So for all of these reasons, my wife Karen thought it will be a good idea to give the birdhouses a home in the small corner of our basement. Just happened to be the same corner that I'm trying to build a studio. So I named that little patch of real estate, Birdhouse Studio, which gave birth to Pediacast back in the summer of 2006. The birdhouses, I believe at this point, are boxed up from our last move. You know how that goes. So who knows, maybe Birdhouse 2.0  is in my future. So if that materializes, I'll take pictures but don't count on it.

OK, Amy has some actual questions that we should get to.

First up, her two year old has a habit of holding his private parts through his pants and this began after his transition from diapers to underwear. Yup, that sound about right to me. And I'm sure many moms and  there, those with older boys are like, yup we know exactly what she's talking about.

Look, boys are proud of what makes them different. You know what I'm saying. But then again, there's a time and a place. And you do want to make sure that there isn't a problem or a fear that might be playing a role. For instance, does your son have a rash or a sore, which is causing pain? Maybe he has a foreskin adhesions that are starting to separate. Those hurt.

Does it hurt when he pees? Or is he holding himself because he is worried about peeing his pants? Or because he feels like he has to go but he wants to keep playing instead. So you do want to make sure there is a reason and if there's a reason you should address it.

And having said that, there probably is not a reason but there is but it's a reason you may not want to hear like he enjoys holding it or it feels good. If that's the case, at least in the beginning I agree your best bet is probably ignoring it because the novelty, at least in public, will probably wear off.

But what if it doesn't? What if he keeps holding himself in public and people are talking? Well, that point probably even before that point, it's a good idea to begin telling him those are private parts and you shouldn't touch them except in private places and at private times or whatever the terminology you want to use.

And that's also a good opportunity to introduce the concept of good touches and bad touches. That it's OK for mommies or daddies or doctors to look at and appropriately touch private parts but it's not OK for others and if anyone tells you differently or tries to touch you there, you need to let mommy or daddy know.  So I do think you can and should use this opportunity to teach important concepts about private parts.


Now, some of you may be asking what words do you use? You know, anatomically correct words or code words? Personally, I think using the right words out of the  gate is best. But that's my opinion, you and Crystal may have a different one, and that's fine.

Another important point. Sexual talk or innuendos are not normal at this age. Kids are not born with the common knowledge of the sexual functions of private parts even if they  enjoy  touching themselves, so if your child make sexually explicit comments or simulates sexual actions or uses words you didn't teach them, don't ignore that. Start asking question and find out where they heard it or learned it. It's important stuff.

OK. Amy's second question: her two year old son is potty trained well for peeing but not so much for poop. Although he does let me knows as soon as he goes because he wants his underwear changed. Potty training for poop does take longer and some kids are ready sooner than others. I think it is a good sign that he wants changed immediately after going. My son, and he won't like me telling you this because his sixteen years old now so sshh let's keep this just between us. He was afraid of poop in the big boy potty he'd pee in it but there is something about  hanging over the water the long drop, the splash – he didn't like that. So if we are out and about, even when we are home, he would ask for a pull up, do his business, and wants to changed.

So if your child is not telling you he has to poop  couldn't be he is  not ready or he might be scared so explore that possibility as well. In the end, ask  often. Do you have to go poop? Just keep asking them, especially if it seems like it's the right time. You know i haven't said and tried to poop at times when you think he might have to go, like after a big meal or when his acting likes  he has to go.

And the signs for that are differently for different kids. Maybe here she  gets strangely quiet, or hides behind the couch or start to crouch. That's the good time to notice and put them on the potty and to set them up for success. And when they do succeed, lavish them with praise and rewards a  sticker charts  were great especially with x numbers stickers earns bigger rewards. So make it a game. Have fun, create memories. It maybe frustrating at times but trust me a days coming when you will think fondly of your child potty training days, especially if  you make it fun.


All right. Next stop is Rose in Massachusetts. "Hi Dr. mike i have a six year daughter who broke her left collar bone about a months ago. She recovered from this injury pretty well. She was seen by the orthopedist six weeks after the injury and we were told she didn't need any further check ups. About two months ago, she fell in love with the monkey bars and every time we go to a playground, she spends most of her time hanging on the bars. I'm guessing her broken collar bone is completely healed and there's no harm of her hanging from the monkey bars too much. But I wonder if you could talk on the show about what happens to a broken bone. Is it really good as new or are there long term effects from such injuries? I really love your show. Please keep up the good work. Thank you. Rose."

Well, thanks for the question Rose. So in general, when the orthopedic doctor tells you that the bone is completely healed and the orthopedic doctor gives you the green light to resume a normal activities, then you can expect the conditions of the bone  to be just as you say: good as new. And in many cases the bone may turn out better than new with strong growth where the break used to be. Having said that, you notice i said, in general. There are  times  when healing is sub optimal and may infect, put  your child at an increased risk for future injuries at that location but this is rare. And the most of the time the orthopedic doctors are going to let you know that this is the case.

So when might this happen? Well, some fracture location heal better than others. Now, the good news for you, Rose is that the collar bone or clavicle tends to heal very well on children even when the initial x-ray looks terrible. There are other bones however which don't heal so well. Usually it's because they have a compromise blood supply and the example on this includes the scaphoid bones in the wrist, and  the head on the femur, and the hip.  That doesn't mean that the fracture of this locations won't be good as new but there is a greater risk of healing problems.


Other considerations include was the bone angled and or displaced? If so, was the degree of angelation and  or displacement outside the limits required for proper healing effects on that given  location? Was there a delay in seeking treatment? Was there a pre existing or previously unknown anatomical problem like a bone cyst at the fracture site? Does your child has a chronic disease or genetics syndrome which makes fractures more likely things like celiac disease, inflammatory valves disease, type 1 diabetes, osteogenesis imperfecta? So lots to be considered, but in general you're  going to know about these things and your orthopedic doctors can talk to you about these things. So there are some risk factors for repeat fractures but in  the absence of these risk factors in general if your orthopedic doctor says its good as new, I would consider its good as new.

Now some of you out there may be saying may kid has  had several fractures or he she  break a bone in the same place two years in a row what about that? Well let's take multiple fractures first. This really comes in a mechanism if your child has a multiple or has  had  multiple fractures and the mechanism for the fracture doesn't seem like a fracture should have occurred, then here she may need a work up to evaluate her bone density or the presence of other disorders .

On the other hand, if each mechanism makes sense they fall off the monkey bars, then they wreck their bikes, then they fell off roller skating. if each mechanism  make sense on its own, then there probably isn't a problem other than being very active  and or very clumsy. Now what about those who do break a bone on the same spot. Does this  mean the fracture site was weaker? Not necessarily. Again, you have to look at the mechanism  if they fall in the similar fashion with a similar force, then it makes sense they break that bone again, just like before. But that doesn't mean the bone was weaker.

What other point I want to make with broken bones is once the cast comes off, it doesn't mean your son or daughter is going to be a hundred percent A-OK immediately. Immobilized body parts lose strength and flexibility, which can be improved through physical and occupational therapy but it may take some hard work to get back to there before the injury base line. And while they are working on regaining their strength and flexibility, they may find themselves with a different injury if they try to do too much, too soon. So that's something else to keep in mind.


So the short answer to your question, Rose, healed broken bones are usually really are good as new. But there are some cases when they aren't. The good news is your orthopedic doctor will generally let you know when those cases exist and can guide your return to activity appropriately. So hope that helps and thanks for the question.


All right. We're going to move on to Ashley back in Canada. She is in Toronto. And Ashely says, "Hi Dr. Mike. I spent the day in our local emergency room last week after discovering my two year old chewing on a piece of broken wine glass that the vacuum had failed to pick up. We called the doctor's office first, and they said if we thought she might have swallowed any of it, we have to go to the hospital. After spending five hours in the minor treatment room, we saw a nurse practitioner for five minutes. I brought along the shard glass I had plucked from my daughter' s mouth and showed it to the doctor who said go watch for blood and send us home. At her two year baby check up which is two days later. Her doctor agreed that it was right to take her to the emergency room but also said she'd probably fine and after 72 hours totally in the clear. I expected an x-ray, at least, but they felt the shards were too small to show up. Is she really in the clear now? Should I assume she didn't actually swallow any of the glass? Could it still be in there waiting to hurt her?"

"Another question, that night I came to have a horrible sore throat that turn out to be strep. If I haven't been already tingling and soldering our day in the E.R. I might suspect I caught it in the hospital. My four and a half year old daughter is currently taking antibiotics for an ear infection but I'm worried about my two year old whether I should expect her to come down with strep soon. I have no idea where I got this or why got it and no one else I know has it. I do work in the university so perhaps I caught it from a student. Anyway, I'm worried about my two year old if she'll end up in the same agony that I had. What should I watch for and when can I assume she and my husband are safe. I love your show. Ashley."


Well as always, thanks for the questions, Ashley. They're good ones. Let's tackle the swallowed glass or possibly swallowed glass.

First, it's a common story that a mom or dad finds something in the baby or toddler's mouth. They rescue the object but the question is always the same. Did another object go down the hatch before I had the chance to pull this out? And unfortunately, very often, as in your case, we end up not being able to say for sure.

Now, if the object is metallic or a large piece of plastic or something else that will reasonably be expected to show up on an x-ray, then we get some films to see what we're dealing with or a what location the foreign body resides. The location is important because it allows us to make a reasonable prediction of the outcome. For instance, if the object is located in the airway so aspirated or swallowed it must come out. If it's high in the esophagus it usually must be retrieved because we worry about it coming up and causing a choking episode or aspiration or the object goes down into the airway.

If it's in the lower esophagus, that sort of the gray zone. It really depends on the object in the child. It might need to be removed but it may also make it sway into the stomach give it a more time. So if it's not removed these kids are followed very closely because you dont want the object going to the opposite direction and coming up and the child chokes or aspirates on the object.

If the object is in the stomach when we get the x-ray, the majority of the time is going to work its way into the intestine. And if it's already in the intestine, the vast majority of the time it's going to work its way out of the body and into the poop.


Now, having said all of that, there are many foreign bodies that would be very difficult to find on an x-ray including small pieces of plastic and small shards of glass. So if a child has no symptoms and we don't know if anything was really swallowed and even if it was what we think might have been swallowed is small and unlikely to show up on an x-ray, then we use our risk versus benefit meter to make a determination. And since x-ray do involve radiation exposure, which we know adds up overtime and since given this set of facts, the x-ray is unlikely to be helpful, then it is reasonable to make the decision not to get one as it was the case for your daughter.

Now, if your child has symptoms, and we get to those in a moment. If your child has symptoms or a large object that we are likely to see on an x-ray, a coin for example. Then the risk versus benefit meter is more likely to swing in the direction of getting the films.

So as I typically point out in situations like this, you can't practice medicine in a cookie cutter fashion. You have to take all the facts, make a decision based on risks and benefits, and realize that each case is unique.


OK. So what are our worries and symptoms when a foreign body has been swallowed or if you believe that swallowed foreign body is possible but you don't know for sure? Well, concerning symptoms for a swallowed or possibly aspirated down in the airway foreign body include difficulty swallowing or feeding, drooling, difficulty breathing, coughing, wheezing, chest pain, abdominal pain, vomiting, blood in the stool, and especially in young kids, fuzziness or irritability for no apparent reason.

These kinds of symptoms will make us concerned that the foreign body is indeed present and the foreign body is in a dangerous location or causing some concerning harm. And in these situations, we really do want to quantify and locate the object  and evaluate it support of care and close observation as appropriate or if the object should be retrieved.

But what if there aren't any symptoms as in Ashely's case? Well then you wait and watch and seek if any symptoms develop. Ashley's doctor mentioned the 72 hour time frame. Meaning, her daughter will be in the clear if no concerning symptoms developed in the next 72 hours. And while you will expect symptoms to develop within that time frame, most of the time, keep in mind, most of the time is not all of the time, so there is a slight possibility of symptoms developing further out. So I'd say really for the next few weeks if your child develop concerning symptoms and has a history of swallowing a foreign body or there are concerns they might have swallowed a foreign body and let your doctor know.


But that doesn't mean the foreign body or potential foreign body is absolutely the cause of your child's symptoms. You know, if they start vomiting two weeks later, it could be a virus. Your doctor should know about your concern, they should know about the history of a foreign body a couple of weeks ago so he or she can add that bit of data to there evaluation and decision making process.


The other thing you can do which is helpful in providing and in point to your worry, if your child swallows a foreign object and its location in the body has been pinpointed and determined to be in a safe location as long as no concerning symptoms develop, you can watch for the object in the stool. And once it comes out which usually within a few days, you can stop worrying. There's an endpoint.

Of course, this is not helpful if you aren't sure if a foreign body was ingested or if the object is very small like a shard of glass, so you may never see it even if it does come out. So what if you never find it in the poop? As long as your child has no symptoms, we really don't worry about it. If you're neurotic and you worry, which some moms and dads are ought to be, then we can get another x-ray down the road .to put your mind at ease and to show that it's not there anymore. And if the x-ray is negative and there are no symptoms — your child is happy, healthy and playful then it's really is time to stop worrying.


Before we put this discussion to rest, I also want to point out a few particularly concerning objects that kids may swallow. Once you take a little more seriously than others because the rest of complications is much greater. A glass as it turns out at least what we're talking is small shards is really not one of them. Small bits of glass usually pass fine. although do want to watch for the onset of concerning symptoms.

Objects we really worry about include magnets, when there's more than one because they can stick together through opposing loops of bowel and cause obstruction or erosion of the bowel wall, which can lead to a life threatening intestinal perforation. Batteries – because the acid may cause serious chemical burns. Also detergent pods, they're colorful and look like candy but they can also cause serious chemical burns. And of course pills and capsules and other forms of drugs and medications. These must always be taken seriously because of concern for the possibility of toxic effects.


So, hope that helps Ashley. It's pretty common not to know for sure if a child ingested something and it's also common not to get an x-ray if the x-ray is unlikely to be beneficial. Again, you got to take each case on its own merits. You simply watch for the development concerning symptoms and seek medical treatment right away if any developed and I won't be hesitant to put a 72 hour time limit on your watch from this.


All right. Let's tackle Ashely's other question which has a quicker answer. She has strep throat which I hope was diagnosed with a rapid strep test or a throat culture or a gene or DNA probe. Why? Because viral sore throats can present with clinical signs and symptoms that are similar to strep throat. Since antibiotics cannot kill viral sore throats there is no sense blasting it with normal bacteria that live in our bodies in a worthless attempt to get better.

So I'm going to assume Ashely really does have strep throat, even though she didn't mentioned that in her question if the testing was actually done. Actually, Ashley has a family at home and she's worried she could pass this strep to one of  her family members. She has a four and half year old daughter who is currently taking an antibiotic for an ear infection. she doesn't mentioned what antibiotic her daughter is taking and that does matter because some antibiotics kill strep while other don't. And of those that kill streps, some kill it better than others.

Let's assume her daughter is taking antibiotic for her ear infection that does kill strep well. If this is the case, it makes it less likely that her four and a half year old is going to get strep. But it's not impossible so you still want to be on the look out for new symptoms such as sore throat, fever, headache, abdominal pain, vomiting and/or distinctive rash. These are the most common symptoms of strep throat. You don't have to have all of these sometimes its just a sore throat sometimes its everything but the sore throat, sometimes its a different combination.


OK. What about her two year old and her husband? Will they will be more susceptible to getting strep that the four year old who's taking the antibiotic? But let's also not afford on conclusion that they're going to get Ashley's strep throat. If they don't have symptoms, we generally don't test or treat unless there is a special circumstance such as frequently recurring strep within the family. So really, you just want to watch for symptoms and have your two year old or your husband or your four and a half year old seen if any of them begin to have symptoms of strep throat.

So how long must you worry? Well, generally speaking, once you've been taking antibiotics for 24 hours and its been at least 24 hours since the last fever, we don't consider the strep throat contagious anymore. notice I said generally speaking. There are those who dont follow the rules. Unusual, its possible.

Also, you may have passed the strep along before you begin antibiotics but the symptoms did not show up in your kids or husband until after you started the antibiotics. Why? Because strep symptoms make take a few days from exposure to symptoms.


So bottom line, Ashley. If anybody in the family has symptoms of strep which again include any combination of sore throat, fever, headache, abdominal pain, vomiting, sometimes a distinctive rash. If anyone develops symptoms whether it's a couple of days following your diagnosis, or a couple of weeks, or couple of months at any time a strep is suspected that person should be seen. Because untreated strep throat will usually get better on its own it can be lead to a serious condition brought on by your immune system know as a rheumatic fever down the road. So you don't want to ignore symptoms that can be strep, really, at anytime.


With regard where you acquired this strep, Ashley,  since you dont recall any specific ill contacts, well it turns out its commonly were we cant identify the source of the infection. They could be that you touch a door handle, or shopping cart that was contaminated from an individual that you didn't even see. They may have cough into their hand, touch something left you came along five minutes later touch the same thing, you know, rub your face its easy to spread this thing you don't know the source of the infection or maybe you are the strep carrier or maybe its just dormant strep that was sort of sleeping in the back of your throat and and due to a hiccup of your immune system and your environmental conditions the strep woke up, meaning, you infected yourself.


So that's the story on the strep throat, Ashley. I hope that was helpful as well.

Alright.  I have one more listener question for you today. This one is from Tiffany in Concorde, Massachusetts.

"Hello Dr. mike I've been listening to your podcast since I was pregnant with my first  child in 2007." That would have been during the Birdhouse Studio days." I appreciate your fact in research base answers to the many question parents have. Our five year old son was recently evaluated at his school the physical therapist said  he has low muscle tone. His now going to get services for physical therapy, occupational therapy and speech therapy. She told us this is a neurological condition. Of course I've done my share of reading about this but I would really appreciate hearing more information about it from you. "


Also, his birth was traumatic. He aspirated on mecomium and was intubated. Could this have contributed  to his condition? Thank you very much and keep up the great work. Tiffany. "

Thanks for the question, Tiffany, and for listening  since the Birdhouse Studio days of 2007. I really appreciate  your enduring support.

So let's talk about low muscle tone. Diagnosed at a school screening in a five year old. You didn't mention it tiffany  and maybe you did this but the first thing i would do is absolutely touch base with your child's  doctor. I also want to know did this finding come as a surprise to you? And is the low muscle tone interfering with your child's ability to run, jump, play, speak and otherwise function and engage in life?  And if this isn't something your doctor as previously picked up so the first that you heard about is from the school. And if it comes as as a complete surprise to you,  and if your child really has had  no evidence of disability whatsoever in their daily living, and if you see your doctor following the school assessment and  if a nerve muscular examination performed by your child's doctor is normal and if your doctor really has no concerns, then I'd be a little suspicious of the screening.

Now, I'm not saying this is true in your case, Tiffany. I'm not saying that at all. But there are situations where school screening find problems which are problems. Now why would this happen? Well, school based programs need numbers to keep their funding. just saying. Not necessarily in your case, Tiffany, but something others may want to keep in mind.

OK. So let's give your school the benefit of the doubt and say your son really has low muscle tone. What does this mean? Low muscle tone. Well, muscle tone describes the rigidity of muscles in their resting state. So increased muscle tone results in stiffness and in decrease in flexibility. And this is mostly apparent in the arms and legs but it can affect any group of muscles.

Decreased muscle tone, on the other hand, are low muscle tone results in weakness and increased flexibility. And in babies are likely to describe this as being floppy. In young school aged kids, this may present as a child who seems clumsy and has trouble completing physical tasks other kids his age can do.


So with these definitions in mind, let's talk about the potential causes of increased or decreased muscle tone. And actually it turns out there's a huge list. This is another reason you want to see your child's doctor. You see your doctor first to see if a problem really exists. Keep in mind too, that there's family differences in muscle tone. You know, some families are more athletic than others. And if a school is trying to make everyone into a super athlete, you know, that's a problem. We all have our skill sets and the things that we're good at and that does often run in families. So you want to make sure that sort of thing is not happening.

So first you want to see your doctor to see if a problem really exists. And second you went to your doctor to embark on a quest to find the cause of a problem, if there really is a problem. So what's sort of things make our list?

Well, neuromuscular disorders, metabolic disorders, and genetic disorders. And lots of them need to these categories. So lots of things can cause a problem with muscle tone and often this requires a disciplinary work up with neurologists and physical medicine doctors and geneticists, all putting their heads together to arrive at the right diagnosis.

Now, I do want to focus on one of the many possibilities because it's a common problem and because your son's birth has extremely made me think about it. As always, I'm not saying this is your child's problem, Tiffany. That would be silly of me. That would be practicing medicine in the form of a podcast and that's not what do here.

But this does come to mind and Im sure your doctor will consider this sas well especially fi there is a significant problem with muscle tone when they interfere with daily living. That disorder is something called cerebral palsy. You probably heard of this term before and maybe you wondered what it is. Well, cerebral palsy is a neuromuscular disorder that results from a problem during early brain development.

There are lots of possible causes of cerebral palsy including genetic mutations, maternal infections leading to fetal infections when mom is pregnant, traumatic head injuries as an infant from a fall or from child abuse. And there are many other causes of cerebral palsy, some known, others unknown. but the causes of cerebral palsy I want to focus on here is lack of oxygen from a difficult delivery.


So, Tiffany, you mentioned your child aspirated mucus which is thick poop. Sometimes babies are stressed out during or just before delivery and they have a bowel movement while still inside mom. And when they take their first breath, the poop goes down the lungs and can cause breathing and respiratory problems, which I assume happened in your son's case, Tiffany, because you described the experience as traumatic and your son was intubated, meaning, a breathing tube was inserted into his airway.

So there was definitely the potential for a period of low oxygen during all of this, which may have a affected early brain development. So what does cerebral palsy look like? Well, that depends on the severity of the insult and the area of the bran affected. So the classic case of significant cerebral palsy is increased muscle tone, so rigidity of the limbs and trunk, exaggerated reflexes, abnormal posture, involuntary movements, and difficulty walking.


And again, depending on the parts of the brain affected, we may see things like intellectual disabilities, vision or hearing problems, or feeding problems. So really there's a wide range of possibilities. And the description that I gave there really is more of a serious significant cerebral palsy or classic cerebral palsy.

But there's also a possibility of more subtle symptoms like decreased muscle tone and clumsiness. We might only see a problem with fine precise movement of the fingers or delay in speech development or difficulty speaking.

So given your child's birth history, Tiffany, a mild form of cerebral palsy comes to
mind, but again there are lots of other possibilities and your best bet is to touch base with your child's doctor and include him or her into the school's concerns.

With regard to treatment, there's no cure for cerebral palsy, just supportive care, which can range from physical, occupational, and speech therapy to medication and surgeries to walkers and wheelchairs and other mobility enabling devices depending on the exact nature and severity of an individual's symptoms.

So, hope that helps, Tiffany. School screenings and services can be great but you definitely want to touch base with your child's doctor and let he or she take a look.


All right. That wraps up our answers to listener questions this week. Don't forget if you have a question or comment for the program, it's really easy to join in. Just send over to look for the contact link and send me a message and we'll try to get your comment or your question on the program.

All right. Let's take a quick break. and I will be back with a final word on appendicitis. Right after this.




All right. We are back, My final word this week focuses on a new research study under way here in Nationwide Children's Hospital and involves kids with appendicitis. In the first study of its kind in the United States, researchers here at NCH will examine the effectiveness of antibiotic therapy alone to treat appendicitis in children. Research say they could allow patients to avoid a surgery many may not need. The 1.6 million dollar project will also explore the impact that involving children and their parents in medical decision making may have on a child's response to treatment.

Appendicitis caused by bacterial infection in the appendix is the most common reason for emergency abdominal surgery in children sending more than eighty thousand young people to the operating room each year. And as many as half of those cases the condition may have been treatable with antibiotics alone. That's according to Dr. Katherine Deans, one of the lead authors and co-director of the Center for surgical Outcome Research at Nationwide Children's Dr. Deans says the idea that the surgery is the only treatment for appendicitis goes back to 50 or 60 years ago when high resolution imaging studies were unavailable for early diagnosis and antibiotics were less effective in treating intra abdominal infections. Surgery was established as the main stay therapy for appendicitis because the risk of death that could occur if an intra abdominal infection was not adequately treated. But that's not the case today. Thanks to access to ultrasound and CAT scans and a wide range of antibiotics, allowing physicians to more accurately diagnose and treat appendicitis early.


The new research will built on findings from a small pilot study the investigators launched last year. Preliminary data suggest that when cut early appendicitis can be treated with antibiotics, making surgery unnecessary. The results were similar to those from a series of European studies performed in adults that found in most cases appendicitis is not require surgery at all.

For this study, researchers will conduct a randomize controlled trial of a novel application that involves engaging patients and families as critical decision makers in choosing the therapy that is best for them. Medical decision making in pediatrics involves not just the medical care team and the patient but the patient's parents and family as well. Dr Dean says, I love this study because it gets to the heart of what is needed in medical care right now., engaging the patient and in this case the parents and care givers in making decisions that are right for the family's own personal values. Researchers will work with two Columbus based companies– Soul Theatre and Clot Interactive to design an ipad app with an interactive tool that patients and parents can use to learn more about the causes of appendicitis, treatment options, and what to expect during and after each kind of treatment. The app will feature version for kids and adults.

Children who come to the emergency room and are diagnosed with appendicitis will be invited to participate in this study with their parents. Participants will be randomly assigned to one of two groups. both will discuss appendicitis and treatment options with physician. One group will also get the information via the app on an iPad provided to them.

Once participants have received all the information, they will either opt for surgery or course of antibiotics alone. Patients who choose antibiotics therapy alone will be admitted to the hospital for at least 24 to 48 hours so the physicians can monitor whether the drugs are working. If their condition hasn't improved they will have surgery to remove the appendix.

Participants will be followed until 18 years of age to ensure that the appendicitis does not recur in the group that shows antibiotic therapy. Dr. Lauren Moss Nationwide Children's surgeon and Chief says,  the study represents a ground breaking investigation that will hope to determine whether children with appendicitis can be safely treated without undergoing surgery and brings the patient and family into the decision processes partners with the surgeon. This underscores the Nationwide Children's Hospital's commitment to family centered care of every child.


So interesting study and when it's all said and done and we have defended the result, we'll see if I can get the researchers here in the studio to talk more about the project.

Treating appendicitis with antibiotics or at least early cases of appendicitis may be the way of the future, we'll see. And that's my final word.

All right. I do want thank all of you for taking time out of your day to make Pediacast a part of it. We really do appreciate that. Don't forget you can hear pedia cast on iHeartRadio talk which is available in the iHeartRadio app on the web, on iphone, and Android. iHeartRadio Talk let's you stay connected with your favorite talk personalities anytime, anywhere. You can enjoy these shows when, where, and how you want. And also available on iHeartRadio Talk, pediabytes.

These are 5-10 segments of Pediacast each covering a single topic and we're releasing a handful of new pediabytes each week to make a great addition to your Daily Pulse that the custom talk channel on iHeartRadio Talk that stitches together your favorite programs and fuses them with your local news, traffic and weather.

So be sure to check out Pediacast and pediabytes on iHeartRadio Talk. Pediacast is also available on iTunes and as I usually mention I or views are very helpful.

We haven't had any new ones in the last month or so. So if you found Pediacast through iTunes, I would just ask that you kind of pay for a little bit. You probably read through some of the reviews before you made your decision to try Pediacast and the more views that we get, the more kind of propels us to the top of the kids and family section of iTunes. So we really appreciate new reviews because it helps us to get the podcast infront of the eyes of more parents who may have not heard of the programs. All it takes is a couple of minutes to write an iTunes review. So if you did come across us that way, if you could just pay forward  as those who came before you did, we'd really appreciate it.

Also, links, mentions, shares, and retweets, repins, all of these things are helpful. Pediacast is on Facebook, Twitter, Google+ and Pinterest. By the way on Pinterest, we also have a news parents can use boards, which generally has topics and stories on it that are not covered on the podcasts but things which I think are used you'd be interested in seeing so be sure to check that out over at Pinterest. Just search for Pediacast and you'll find it that way.


Also, be sure to tell your family, friends, neighbors, and co workers about the program. And of course your child's doctor. Let them know, there's and evidence based pediatric podcast aimed to moms and dads. Lots of educational information and just let them know it's at so they can tell their other patients about it and posters are also available under the Resources tab at

Again, the Contact link is available at and I do read each and everyone of those that come through. So if you have a comment or question for me, just send it over. We'll see if I can get you on the show.

Also, we have a connect with a pediatric specialist from Nationwide Children's Hospital. Link in every shown notes under the links section at It's just a quick way for you to get in touch with the specialist here at the hospital and they'll get back to you just in terms of making appointments or referrals. Just a convenient way for you to connect with Nationwide Children's.


All right. That wraps things up for this week and until next time. This is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long everybody!


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

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