Cholesterol Screening, Dental Sedation, Cold Exposure – PediaCast 222

Join Dr Mike this week for more pediatric news and answers to listener questions. Topics include a challenge to the latest cholesterol screening recommendations, long-term safety of ADHD medications, breast milk and nut allergies, safety concerns with dental sedation, CHARGE syndrome, and the effect of cold exposure on the immune system.


  • Cholesterol Screening Recommendations

  • Long-Term Safety of ADHD Medications

  • Breastfeeding and Nut Allergies

  • Safety of Sedation During Dental Procedures

  • CHARGE Syndrome

  • Cold Exposure and Your Immune System



Announcer 1: This is PediaCast.


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

Mike Patrick: Hello, everyone! And welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike, coming to you from the the campus of Nationwide Children's Hospital in Columbus, Ohio. It is Episode 222, 2-2-2 for August 15th, 2012, and we're calling this one cholesterol screening, dental sedation and cold exposure.

Of course we have lots more topics coming your way, and we'll get to the entire line up here in just a minute. So the Summer Olympic Games are winding down. Actually they're winded down, aren't they? They are over.


So my question to you is did you watch many of them? Our family certainly did. And you know I always sort of get up on my soapbox and say, "Families don't spend too much time around the TV, you know, you got to be out there active doing stuff, playing games."

Don't just be couch potatoes and watch the screen all evening long. But during the Olympics I think is the exception. And you know, there's a lot of good conversation generated over it as a family because you don't watch sort of spellbound like you do some programs and movies. There's some interaction and talking while you're watching the athletes compete.

And I have to say I have mixed feelings about the Olympics ending because the Olympics in our house, it's almost like a friend that you don't get to see very often. You almost wish they would come by more often.


In fact my son was saying, "They should have Olympics every year." But then again I guess it wouldn't be special when those guests do stop by when the Olympics come back around. So we'll miss the Olympics and we'll look forward to the Winter Games in Russia in a couple of years.

On the other hand, as I mentioned we really have become TV junkies and couch potatoes. So it would actually be good to get up and do something again. All right. It's always sad though when the Olympics go away, when you get used to doing it every night. All right. What are we talking about today? Well like I mentioned we do have another big show lined up for you.

This is a news and listener podcast, so we're going to cover some pediatric news and answer some of your questions in the news department, cholesterol screening -there were some new recommendations that came out last November from the American Academy of Pediatrics.

And there's been little pushback amongst pediatricians, and so your particular doctor might not follow the new recommendations and may have a good reason for not following it.


So we're going to talk about the controversy and help you decide what you should do for your family with regard to cholesterol screening. Also ADHD medications -we know they're effective, and we know that they're safe in the short term.

The question for this study was, what about the long term safety of ADHD medication? So you have a kid who's on those medications for a number of years, are there any long term effects from ADHD medications? We'll talk about that and then we'll wrap up the news segment with breastfeeding and nut allergies. Is there a relationship?

Could breastfeeding help prevent peanut allergies and other nut allergies or could it promote those allergies? What exactly is the relationship between breastfeeding and being allergic to nuts? We'll discuss that and then we'll move on to answer some of your questions. Dental procedure sedation, what about the safety concerns with this?


Every now and then you hear of a kid who was in the midst of a dental procedure and they had a bad outcome because of the sedation. Of course, it makes the news and makes the dental staff feel just horrible that this happened.

So what can you do to increase your child's safety if they're going in to get a dental procedure done and sedation will be a part of that procedure, we'll discuss that. Also there's a syndrome out there called "Charge Syndrome", like a charge card or like you're going to charge, like the bulls charge, C-H-A-R-G-E. We had a listener that just wanted us to raise awareness and talk about what it is, so we're going to do that.

And then finally, cold exposure even though it's in the middle of or toward the end of summer I guess, we are going to talk about cold exposure to get you prepared for the fall and winter coming up I guess. We have a listener who just asked and actually this was a listener I think in New Zealand, but they are formerly of Russia.

They want to know, can cold exposure make you sick? In other words, can being out in the cold actually cause illness like grandma used to tell us.


Put your hat on, bundle up or you're going to catch a cold. The answer may actually surprise you, you know, those of you who know me are going to say, 'Well, of course not, cold can't cause. It's viruses that cause illnesses."

But actually, there may be some truth to cold exposure making you sick and we'll discuss that coming up in just a little while. I do want to remind you if there's a topic that you would like us to discuss on PediaCast, just head over to, click on the Contact link.

You can also email, you go that route, make sure you let us know where you're from, it's always interesting. And you can also call the voice line 347-404-KIDS, that's 347-404-K-I-D-S. Also 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, make sure you call your doctor and arrange a face to face interview and hands on physical examination.


Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at And with all that in mind, we're going to take a real quick break and we'll be back with 'News Parents Can Use', right after this.


Mike Patrick: Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at

Three researchers from University of San Francisco have weighed in on recent guidelines that recommend universal screening of cholesterol levels in children.


They say the recommendations which were recently published in the Journal of Pediatrics last November in fact, failed to weigh health benefits against potential harm and cause. They say the recommendations are not based on solid evidence, but rather expert opinion which may in fact have a conflict of interest.

So what exactly was this recommendation and who made it? Well, again the new guideline written last November was handed down by a panel of pediatric experts assembled by the National Heart, Lung, and Blood Institute. They were endorsed by the American Academy of Pediatrics and published in the Journal of Pediatrics.

They call for non fasting lipid panels, so not just cholesterol, but your HDL and LDL, and your total lipids. So a non fasting lipid panel be drawn on all children sometime between nine and 11 years of age. In addition they recommend targeted screening with two fasting lipid panels between the ages of two and eight years, and again between the ages of 12 and 16 years.


And they say that 30 to 40% of all kids should receive this targeted screening which would primarily be made up of children with a family history of high cholesterol, bad lipids, and heart disease, high blood pressure that sort of thing.

Contrast this with previous recommendations which called on obtaining a simple non fasting cholesterol test and only performing that on children at the highest risk based on family history. The scientist who disagree with the new guidelines, Dr. Newman, Dr. Mark Pletcher, and Dr. Stephen Hulley, are faculty members of the UCSF Department of Epidemiology and Biostatistics.

And their commentary published last month in the Journal of Pediatrics, the scientist warns such a drastic increase in lipid screening has the potential to transform millions of healthy children in the patients labeled with dyslipidemia, which means bad lipids in the blood.

Dr. Newman argues, "The panel made no attempt to establish the magnitude of the health benefits or harms of attaching this diagnosis at a young age."


They acknowledge that costs are important, but then went ahead and made their recommendation without estimating what the cost would be and it could be billions of dollars. Dr. Newman acknowledges the fact that part of the argument for increased screening is due to concerns about the obesity epidemic in U.S. children.

However, he continues saying that this should not lead to more laboratory testing. He adds, "You don't need a blood test to tell who needs to lose weight and recommending a healthier diet and exercise is something doctors can do for everybody, not just overweight kids. Having to screen two fasting lipid panels in 30 to 40% of all two to eight year olds, and 12 to 16 year old children puts a particular burden on the families.

He explains, "Because blood tests must be done while fasting, they can't be done at the time of a regularly scheduled well check up like vaccinations can. This requires getting hungry young children to the doctor's office to be poked with needles on two additional occasions, generally weekday mornings.


Families are going to ask their doctors is this really necessary? Furthermore, the guidelines provide no strong evidence that it is. The UCSF scientists point out, "That all members of the panel who drafted the new recommendations disclosed an extensive assortment of financial relationships with companies making lipid lowering drugs and lipid testing instruments." That's a quote.

Some of these disclosures consisted of relevant relationships that include paid consultancies or advisory board memberships with pharmaceutical companies that manufactures cholesterol lowering drugs including companies like Merck, Pfizer, Astro Zenica, Bristol-Myers-Squibb,Sankyo and Roche.

Dr. Newman continues, "The panel states they reviewed and graded the evidence objectively, but a recent Institute of Medicine report recommends that experts with conflicts of interest either be excluded from guideline panels or if their expertise is considered essential they should have non voting, non leadership minority roles.

He points out, "What is needed is evident to estimate health benefits, risks, and cost of these interventions. And experts who have no conflict of interest to help attain this stating this recommendations falls so short of this ideal that we hope they will trigger a reexamination of the process by which they were produced. "


So it's pretty strong language and I think the take home, and first I have to applaud the Journal of Pediatrics because this is a journal of the American Medical Association. We have non pediatricians basically banging us over the head as pediatrician in criticizing these guidelines.

Then the Journal of Pediatrics for including this, I think it's really great to hear that side of the coin. So the take home here for pediatric clinicians in the crowd, not everyone agrees with the universal lipid screening, and those who disagree with it.

It my opinion they make some excellent points, not saying it's bad, you know, make your own decision for your patients. But I think that these folks do make some valid points.


The take home for moms and dads in the crowd, some doctors will be following the new recommendations and some won't. If you have concerns about your child being tested for lipids, cholesterol, LDL/HDL's total lipids that sort of thing, talk to your doctor.

Some parents will want it done even if their doctors don't recommend it, and some parents won't want it done even though your doctor thinks it's a good idea. Your best bet really is just to communicate your concerns with your child's physician and see where the conversation takes you. All right.

Let's turn to the safety -I think again we just have to use common sense here and you know, screening is a good idea, but we do have to take into account the effects of that. What is normal in that age group? Do you put them on lipid lowering drugs that aren't necessarily approved for use in young kids.

So it's really is a gray zone that's out there. And I think it's going to take some time to figure out where we need to go with that as a pediatric community.


All right. Let's turn to the safety of long term use of ADHD medications. As many as five to seven percent of elementary school children are diagnosed with attention deficit hyperactivity disorder, a behavioral disorder that causes problems with inattentiveness, over activity, or a combination of these traits.

Now researchers have found that long term ADHD drug use appears to have no long term effect on the brain. The animal study conducted by researchers at Wake Forest Baptist Medical Center has published online in the journal Neuro Psycho Pharmacology. The majority of children with ADHD are treated with psycho stimulant drugs, medications like Ritalin, Adderall, Concerta, Vyvanse, Focalin, among others. Although the drugs are known to be effective, little is known about their long term effects.

Dr. Linda Porrino, professor and chair of the Department of Physiology and Pharmacology, along with fellow professor Dr. Michael Nader, both of Wake Forest Baptist, conducted an animal study in order to determine the long term effects of these drugs.


Dr. Porrino explains, "We know drugs used to treat ADHD are very effective, but there have always been concerns about the long lasting effects of these drugs. We didn't know whether taking these medications over a long period of time could harm human brain development in some way or possibly lead to abuse of drugs later in adolescents.

The team studied 16 non human primates whose ages were equivalent to six to 10 year old humans. Eight animals were treated with a therapeutic level dose of an extended release form or Ritalin, or methylphenidate for over a year which is equivalent to about four years in children. While eight animals the control group did not receive any drug treatment at all.

The researchers took images of the animal's brains before and after the study in order to measure brain chemistry and structure in addition to the team looked at developmental milestones in order to address concerns. The ADHD drugs negatively impact physical growth.

After the treatment, an imaging studies were completed, the researchers allowed the animals to self administer cocaine over several months.


The researchers examined how susceptible -I don't need a flood of emails, I'm not the one who did this study folks all right, so I don't want a flood of emails from the animal rights activist please, I'm just reporting.

After the treatment and imaging studies were completed the researchers allowed the animals to self administer cocaine over several months. The researchers examined how susceptible the animals were to the cocaine, how quickly they took it and how much they used in order to provide an index of vulnerability to substance abuse in adolescents.

The researchers found the animals who receive ADHD treatment were no more vulnerable to later drug use than the controlled animals. Dr.Porrino says, "After one year of drug therapy we found no long lasting effects on the neuro chemistry of the brain, no changes in the structure of the developing brain.

There were also no increases in the susceptibility for drug abuse later in adolescents. We were very careful to give the drugs in the same doses that would be given to children. That's one of the great advantages of our study and that it's directly translatable to kids.


Our study showed that long term therapeutic use of drugs to treat ADHD does not cause long term negative effects on the developing brain, and importantly it does not put children at risk for substance abuse later in adolescents.

One of the exciting things about this research is that a sister study was conducted simultaneously at John Hopkins University with slightly older animals in different drugs ad their findings were similar. Dr. Porrino concludes by saying, "We feel very confident of the results because we replicated each other's studies within the same time frame, and gotten similar results.

We think that's pretty powerful and reassuring." So I know many of you out there have kids on ADHD medications, and many of your kids are using them long term. So I hope these findings give you -the parent some reassurance as well.

Let's move on to our final new item this week, nut allergy and breast milk. Researchers in the Australian National University have discovered that children who are exclusively breast fed during the first six months of life have a higher risk of developing a nut allergy.


The study has been published in the online issue of the International Journal of Pediatrics. Researchers from the Australian National University College of Medicine in the Australian capital territory health directorate also known as ACT examined the association between breastfeeding and nut allergies by surveying parents of children starting primary school using the ACT kindergarten health check questionnaire.

Parents had to report on various factors including the child's feeding habits during the first six months of life and whether their child suffered from a nut allergy. The results demonstrated the number of ACT children that suffered nut allergies are increasing and that those who are exclusively breast fed for the first six months had a higher tendency to develop a nut allergy.

Study author Dr. Marjan Kljakovic who is a professor of general practice at the Australian National University College of Medicine says, "Nearly four percent of parents surveyed reported their children have a nut allergy" This is significant because it's nearly twice the rate of British children of the same age.


The researchers found that chances of developing a nut allergy were 1-1/2 times higher in children who were exclusively breast fed compared with those were fed solid foods, formulas, and juices. So 1-1/2 times as much, it's not quite double, but it was statistically significant.

Dr. Kljakovic says, "Our results contribute to the argument that breastfeeding alone does not appear to be protected against nut allergy in children, it may in fact be causative of allergy. Over time health authority's recommendation for infant feeding habits have changed recommending complementary foods such as solids and formulas to be introduced later in life.

He continued saying, "Despite breastfeeding being recommended as the sole source of nutrition in the first six months of life, an increasing number of studies have implicated breastfeeding as a cause of the increasing trend in nut allergy. Peanut allergy accounts for two thirds of all fatal food induced allergic reactions, it's important for us to understand how feeding practices might be playing a part."

So just to give you a little bit of background, you know, back when I trained it was pretty much standard at about four months is when you begin to introduce solid foods and you start with those cereals and then you'd go to the vegetables and the fruits, and then you'd finally go to the stage two baby foods with meats somewhere between six and closer to nine months of age.


And at that old general introduction of solid foods would begin at about four months, and here recently it's really gone to more let's back it up to six to nine months. And there's even some advocates for exclusively breastfeeding through the first year of life.

And so there's different recommendations out there and it can be sometimes confusing for parents to know exactly what to do. Now, the results of this particular study really shouldn't come as a surprise, I mean, we've implicated avoidance of environmental allergy as playing a role in the rise of allergies and asthma's in the past, we've talked about that on this show.

When you're not exposed to something and then suddenly you are exposed to a big load of it, you're more likely to have an allergic reaction than if you're slowly exposed in small amounts over time and your body gets used to it or sensitized.


So we've implicated avoidance of environmental allergens as being a part of allergies and asthma, and the rise of that that we're seeing. And it appears that maybe food allergen avoidance in young infants may play a similar role in the development of food allergies at least in the case of nuts and at least according to this particular study.

Now, for those of you still scratching their heads, this is the general idea. Again when we're exposed to allergens in a small amount during infancy the thought is that we develop a tolerance for those things. In other words our immune system begins to tolerate or ignore them and then later on when we have a larger exposure to those allergens, our immune system is okay with the exposure and we don't have a reaction.

On the other hand if we don't have a low level of exposure and our immune system doesn't build that tolerance, when the big exposure comes down the road, we're more likely to become immediately sensitized to that and then go on to have an allergic reaction.


And in the case of nuts, that allergic reaction could be life threatening. By the way the same concept is at play when we give allergy shots, you know, we actually inject a kid with a thing they're allergic too, but we do it in a very small amount, and we do it persistently week after week, and eventually the hope is the immune system will develop a tolerance to the allergen and your child will have an allergic reaction when a bigger exposure comes along.

So what does this mean for you the parent? Does this mean that you should introduce formula, solids, and juice, in an earlier age? Well not so fast, you know, other studies have shown an increase in the incidents of some food allergies associated with the early introduction of foods.

The truth is likely this, you know, our immune systems are complex things and for some kids earlier introduction of food may lead to allergies and another kid's earlier introduction of foods may help prevent allergies. So which kids will respond in which way and when should you introduce formula, solids, and juice in your baby?


Unfortunately there are some no easy answer to that question, that's the truth there's just no easy answer to it right now. And your best bet in my opinion is to ask your child's doctor and their opinion. Have an informed discussion your choice of timing for the introduction of non breast milk nutritional items and make a decision that's right for you and your family.

I know I'm hedging, but really folks, I don't think there's an absolutely right or wrong with this one at least not one that we can see with the information we currently have. All right. Well that wraps up our News Parents Can Use this week. We're going to take a quick break again and we'll be back to answer some of your questions right after this.



Mike Patrick: All right. We are back and we're going to move on to our listener question segment of the program today. First stop is Tiffany, she writes in from LAs Vegas, Nevada. She says, "In line of recent news about the death of a child due to sedation at the dentist, how can a parent tell when it's appropriate to sedate a child for dental work and what qualifications should we look for in a dentist when that point is reached?

Great question, Tiffany. So here's how I would go about finding a dentist, and trusting a dentist, and dealing with a sedation issue. And this by the way is how I went about the process with my own kids because they have required sedation in the dental office before or at least my daughter has. So first you want to find a dentist who sees a lot of kids.

And a dedicated pediatric dentist would be preferred, but if that isn't possible depending on your location, you definitely want to choose one with a good reputation for seeing children.


You know, your primary care doctor is a good source for this information is they're used to making referrals. And so, they get a good idea of you in your local area sees lots of kids, and who they trust. And if your doctor trust them, and you trust your doctor, then it's probably a dentist that you can trust.

You also want to talk with your family and friends about their experience with different offices, that will give you some insight. And if you live in an area that doesn't have a pediatric dentist or a general dentist who is really experienced with seeing kids, don't be afraid to travel to see one. Most large cities have pediatric dentist and it maybe worthwhile for you to drive the distance to see someone who sees lots of kids.

And this is important because a dentist who sees lots of kids has experienced working with kids. And you know, they're actually probably less likely to use sedation, and when they do have to use it they're going to have the best skills of providing it, but because they're used to working with kids, they may have some other techniques that they can use before they have to resort to sedation.


You definitely want a dentist who is pretty confident about which procedures really requires sedation and which ones don't, and which kids will require sedation based on age and temperament. So if you see dentist that sees lots of kids and they recommend a procedure, I'd probably go with it.

I say probably because you know, if the dentist seems unsure or can't adequately explain why he wants to do the procedure, or you were just uncomfortable with the whole thing you know maybe something just doesn't seem right. You know parents have that sixth sense of knowing when something just doesn't quite add up.

And you know, in that case it doesn't hurt to get another opinion. But a word of warning does come with that suggestion, you know, a second opinion isn't better just because you get it second. And it isn't better just because you know, they tell you what you want to hear. Let me say that again because it's important, a second opinion isn't better just because they tell you what you want to hear or because it's the second opinion.


The first opinion may seem drastic to you, it may seem unnecessary, you may be anxious about it, but at the end of the day it might still be the right one. The one that will take care of your problem and prevent worsening issues down the road.

So you do have to be careful about second opinions because sometimes it can muddy the water, but sometimes they're necessary and you're going to feel better by getting one. So OK, you have a dentist that sees lots of kids, is someone you trust, they recommend a procedure, you decide to pursue it, what about sedation?

Yes or no? I say absolutely yes if your dentist is comfortable doing it, we're going to get to sort of some of the things to look for. If your dentist is not comfortable performing a particular procedure on a wide awake child, then by all means they shouldn't be performing the procedure on a wide awake child.

It's not safe for your child and it's not safe for your dentist. So absolutely I would go with their recommendations again if this is a dentist who sees lots of kids and whose opinion you trust.


OK. So let's say you're going with the sedation, what should you look for to maximize your child's safety? Well first and you know it's coming here, you wanted a dentist who performs lots of sedations in kids.

You know, you can ask how many he does, that's a fine question, and it's one of the reasons you wanted dentist who sees lots of kids because they're also the ones who is most likely to do lots of sedations in kids not necessarily sedations that aren't needed like some other dentist could be doing if they're not comfortable with kids.

But you know, the dentist who sees lots of kids are going to end up doing lots of sedation in kids, so you got that experience on your side. Second, and I think it's perfectly reasonable to inquire about these things; your dentist should take the time to sit down and explain everything to you about the sedation, what drugs are going to use, how it's going to be administered, what benefit would the sedation provide, what complications could arise from the sedation and then of course you're going to look at the risk versus benefit and decide if it's worth the risk of those complications.


You want to know how is the office staff prepared to minimize the chance of complications and how well prepared are they to deal with complication that do arise. These are all really good questions. And your dentist should be willing to sit down and talk to you about those.

The most common sedation used in dentistry for kids is going to be nitrous oxide or laughing gas, and that should give you reassurance because it does have a long history of safe use for dental procedures. About IV sedation medications are also a possibility. It's important that there's a staff member whose sole job is to monitor the sedation,

OK. The dentist is doing the work in the mouth, and his assistant is likely helping him out, and there should be a third person who is not distracted away from the sedation. So they're managing the administration of the medicine, and your child's vital signs, and so they're in charge of the sedation. You don't want the dentist who's working on the mouth to be the one who is watching your kid. So that's a key thing to ask about.


And you want the entire staff working on a sedated child to have special training in pediatric advance life support also known as PALS and there should be a well stocked crash cart when you buy them with emergency supplies and the office staff should run through mock codes on a regular basis so they feel prepared if a real problem presents itself.

And again I do think it's fine to ask these questions and make sure these requirements are met. So sort of to sum up your dentist should see lots of kids, should be someone you trust, someone who does lots of sedations, and someone who is intentional about sedation's safety and well prepared for the unexpected.

Now if all those pieces are in place, is your child guaranteed to be safe? No. But they will be in the best place possible, and remember we've already determined the benefit of the procedure and the sedation outweigh the risk, otherwise you're dentist wouldn't be doing it as long as you sat down and asks those questions.

Do we really need to do this? The risk is low in the setting I've described, but it's not a 100%. Of course you know, driving to see the dentist isn't 100% safe either and in fact statistically the drive is more dangerous than the sedation in the type of setting that I've described.


So be sure to keep you that perspective, but you know nothing's guaranteed. So hope that helps Tiffany, and again thanks for the question. All right. Next stop is Crystal in Gatineau Quebec, Canada.

And Crystal says, "Hi there Dr. Mike. my friend's son has been diagnosed with charge syndrome. I was wondering if you could talk a bit about this condition and it's symptoms and possible treatments. Doing this would also help raise awareness. Thanks. Keep up the excellent work, "Crystal. Great topic, Crystal.

Charge syndrome is certainly off the beat and path and perhaps not a condition I would have thought about including if you hadn't brought it up. So thanks for the suggestion. What exactly is charge syndrome?

Well today we know that it's a genetic disorder, but back in 1981 we weren't sure what caused a specific set of defects that were frequently seen together. And based on those defects, doctors came up with the name charge as a mnemonic to remember.


So let's go to the letters and identify the defects that we're talking about. So C is coloboma of the eye, just basically a hole in the eye and a place where there shouldn't be a hole.

Heart defects -that's the H, A is atresia of the choanae, that just means absence of a hole in the back of the nasal passage on one or both side, so you have an impede to airflow through the nose. R is retardation of growth and development. G is genital and/or urinary abnormalities. And E is ear abnormalities and deafness.

So we we got the eye, the heart, the nose, growth and development, genital and urinary systems, and ear and deafness. So that makes up CHARGE, and so we would see that group of defects together, and again back in 1981 we weren't really sure what caused that set of defects, but we did know they were frequently seen together and we became suspicious of a genetic cause.


But it wasn't until 2004 that researcher in The Netherlands discovered a specific gene associated with the syndrome. That gene is called CHD7 and it's located on a long arm of chromosome number eight.

Of course it's a bit more complicated than that, there are other defects we now associate with charge syndrome not just the ones that make up the spelling or the mnemonic charge. And not everyone with charge syndrome has those six classic findings described by the name.

So the exact expression of charge syndrome varies and it probably depends on exactly what mutation is present at CHD7, and there are likely other genes as well that just have not been identified yet. So charge syndrome does show up differently in different people. But we are learning more about it as research continues.

So what other defects are possible in charge syndrome? Well in addition to the six things making up the mnemonic 'Charge', we can also see cranial nerve abnormalities, cleft lip and cleft palate, tracheoesophageal fistulous which is a abnormal connection between the trachea and the esophagus.


So stomach contents can go from the esophagus to the trachea and down into the lungs and cause aspiration and pneumonia. You can also see kidney abnormalities and growth hormone deficiency. So again, not everyone will have all of these things and some people may have additional problems.

It really depends on what genetic mutations are present. And what we do know is some of the genetics of this syndrome again, we don't know them all. In terms of diagnosis most of these kids, because they have so many different problems, they do end up seeing a geneticist who actually makes the diagnosis based on clinical presentation.

Now blood testing may be helpful to see if there is a mutation of gene CHD7, but remember the problem may be someplace else, or the particular mutation may be a different one than what we're looking for and that particular gene is just one we know about, so just because they have a normal CHD7 gene on chromosome number 8, they still could have charge syndromes. So it's really more of a clinical diagnosis.


In terms of treatment, there's no specific for the syndrome itself. Charge is a problem with development, right? We have abnormal structures that then cause symptoms and problems, and there's no real way to reverse that.

But we can deal with any problems that arise, and this is often done through a multidisciplinary approach, which is tailored for the individual child's exact set of problems. So typically the geneticist, along with your primary care doctor are going to sort of be the quarterbacks hooking you up with the specialist that you need.

And those specialists may include ophthalmologists, ear, nose and throat doctors, plastic surgery, cardiologists, GI physicians, pediatric surgery, kidney specialists, endocrinologists, dentist, psychologists. Again, a child's exact team really is going to depend on their specific problem list which will vary from child to child with charge syndrome.


And again the geneticist and your primary care doctor often work together to sort of build that team. Of course it does means lots of doctor's appointments at different places because it's not a common enough disorder that any place that I know has a charge clinic.

Although if you know of one write in and let me know, and we'll share that with the crowd. So thanks for your topic suggestion Crystal and your effort to raise awareness about charge syndrome. We do have a great resource for you, the Charge Syndrome Foundation has a great website with lots of information and you can look for a link to that in the show notes over at

All right. Our final question is a fun one, this one comes from Maria in New Zealand. And Maria says, "Hi, Dr. Mike." We have listeners in New Zealand, I don't know. Set here in Columbus, Ohio that's just kind of crazy to make contemplating that, but Hello, New Zealand. Maria says, "Hi, Dr. Mike. My name is Maria.

I'm originally from Russia, but now my husband and I live in New Zealand. we have an 11 month old baby boy, and I've been listening to your show since he was born. I enjoy your show a lot. It's packed with good stuff everybody needs to know when raising a child." Thanks, Maria.


It is summer where you are, but here in New Zealand it is mid winter, and we are in the midst of flu season. We all know the common colds is caused by viruses and that cold temperatures do not cause the common cold. However does exposure to cold compromise the immune systems functioning and the way that your body becomes more susceptible to infection.

There seems to be so many opinions on this one starting from well intention grandmothers who are sure that taking your baby outside after certain time of the day causes croup, flu, etcetera, to even health care professionals with some of them they keep telling me that the first step in protecting my child from infection is to keep them nice and warm.

Others would tell me there's no relationship at all. Is there connection? How much cold exposure are we talking about that would be a problem? does only a part of the body such as the nose, ear, and neck, and feet need to be exposed or would it have to be real core body temperature decrease? Well, you're asking a tough questions Maria.

My baby just had croup last week, but he's better now, can I take him to his swimming lesson in a pool with a weakened immune system after a virus or does that put him a decreased risk of getting another infection by exposing him to the cold water?


Being from Russia myself, I was told since that if you want to be healthy and strong, you should do body squinching or cold training from the early years. I've never tried it myself, but some Russians are pretty hard core on it with walking in the snow, swimming in nearly frozen river, etcetera. Is there any science behind this?

My question may seem a bit long and annoying, but these questions are eating me inside and out. Please help, Maria. Oh, Maria. Your questions are not annoying at all and hopefully we can find some peace for you so they stop eating at you. OK. so you're absolutely right with your initial observation, the common cold is really an upper respiratory infection caused by a virus, and cold weather does not cause the common cold.

We tend to see viral upper respiratory infections more often in cold weather, but it's not because of the cold weather itself, it's because when it's cold outside, everyone is inside close together, and the inside air is re-circulated to the heating systems, so we are exposed to more viruses when the weather outside is cold.


Also at school is usually in session when the weather is cold, so kids spread their viruses to one another in the classroom, and kids bring the germs home to share with moms and dads who in turn share them with their co-workers, so everybody is sick in the winter.

And we blame, you know, when it's cold outside or the rain, or the change in the weather, but it's because of increase viral exposure. So, good job with that observation.

OK, you're right on target, it's the viruses and the winter, you have increased exposure to viruses regardless of what grandma tell you, no offense to grandma of course we still love and respect her, but sometimes she's wrong. Perhaps not often, but sometimes this is one of those times. All right.

Now your next question is interesting, can cold exposure somehow decrease your immune systems effectiveness and make you more susceptible to getting sick at a time when you are expose to a high viral load?


So it's a very interesting question and there have been some studies in mice that suggest cold exposure may increase susceptibility to infection. Researchers over the years have tried to replicate these findings in humans, they've dunked people in water, in cold water.

They've had them set naked in sub freezing temperature, they've studied people living in Antarctica, and on expeditions in the Canadian Rockies. And the results of these studies have been mixed.

One study showed competitive cross country skiers who exercise frequently and vigorously outside in cold air do have an increase in viral upper respiratory infections, but is that from cold exposure or could there be another reasons like intense exercise? Could that decrease your immune system or dry air exposure?

Another study found exposure to cold does increase the body's production of cytokines which are known to be chemical messengers within the immune system, but how that relates to the function and efficiency of the immune system we really don't know. A group of Canadian researchers reviewed hundreds of medical studies on the effect of cold exposure and conducted some of their own research.


The concluded that moderate cold exposure has no detrimental effect on human immune system. So it would appear from what we know now, moderate cold exposure probably does not affect the efficiency of your immune system.

But again, there are mixed studies out there we really don't know everything about this at this point in time. To answer your third question, Maria. Can cold exposure toughen your immune system?

I didn't come across any studies on that one, sorry. So what should you do? Well, I think your best bet is to bundle up when you go outside and do it in such a way that you and your children are comfortable, and if you get uncomfortable put on more layers or go inside.

You can use your body's comfort as a measure of are you dressed appropriately. I wouldn't walk barefoot in the snow or take a swim in a nearly frozen river because frostbite and hypothermia are real concerns.


By the way if you're interested in strategies to strengthen your immune systems, strategies that actually work, I have a great resource for you from Hartford University, it's an article called "How to boost your immune system".

And it covers the immune system's relationship to lifestyles, age, nutrition, supplement, stress, and exercise. And of course we'll put a link to that article in the show notes at

I don't really thought I can answer your question, Maria. I'm really sorry about that. But I did looked up the research and that's what it is, and so we really don't know, keep your kids warm, don't go up barefoot in the snow, don't go swimming in nearly frozen rivers, it's a sure way to get you killed, just don't do that, that's just not smart.

Those Russians, those crazy Russians. All right. That wraps up our -I say that with all love Maria, really., really I do. I love Russia. You know, actually I've not mentioned -here we go, I'm going to mention it.


Actually in college went to Russia when it was part of the Soviet Union which is kind of scary being on a communist country, and being an American. We went to Moscow and to Leningrad -St. Petersburg was called Leningrad at that time and Riga Latvia, second exchange program for a couple of weeks and it was definitely interesting time.

But you don't live in Russia anymore, Maria, you live in New Zealand. All right. So well that wraps up this week's listener's questions. I do want to remind you if there's a topic or a question that you have for me on pretty much any topic you like in the world of pediatrics or parenting, you can just head over to, click on the contact link, and write your question that way.

You can also email, or call the voice line at 347-404-KIDS, that's 347-404-K-I-D-S. All right. We're going to take one last break, and we will be back with some final thoughts right after this.



All right. We are back to wrap up the program and opening celebrations in our new hospitals have winded down, but our wishing tree project is still alive and kicking. You can share your wishes to the world, and you can check out the wishes of other families from around the world, and just look for a link in the show notes.

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