Chronic Cough, Potty Training, Big Babies – PediaCast 278
Join Dr Mike in the PediaCast Studio for more answers to listener questions. This week’s topics include chronic cough, birthing center safety, potty training, vocal cord nodules, big babies and big tonsils!
Birthing Center Safety
Vocal Cord Nodules
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Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast a pediatric podcast for parents. And now direct from the campus of Nationwide Children's here is your host Dr. Mike.
Dr. Mike Patrick: Hello everyone and welcome 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. We're in Columbus, Ohio it is episode 278 for February 12, 2014. We're calling this one Chronic Cough, Potty Training, and Big Babies. Of course we'll have more topics and I'll run down the entire line-up here in just a couple of minutes. It is a listener edition of the program so we're going to answer your questions.
I have to apologize right up front you're going to notice that my voice is a little froggy today. It's one of the hazard of the job when you spend eight hours at a stretch with sick kids, you're bound to catch something, it's really surprising that I don't get sick more often than I do. But usually once or twice a winner I'll get a viral upper respiratory infection and I usually get a hoarse voice when it happens which doesn't make podcasting easy. But if you bear with me I may have to cough now and then grab a drink but I'm sure you'll understand and just fair warning right up top of the program. I did want to push through though because we have some great questions from you guys today and I wanted to make sure that we got to the hopefully, equally great answers. So what's going on in the world? Of course the Winter Olympics are kind of a big deal right now and like many of you we gather around the television in evenings and have been watching the coverage, so that's a lot of fun.
I really like to root on our favorites and in our case the PediaCast audience is definitely international so for the most part I'm rooting for the United States but I've got a large following in the United Kingdom and in Australia. In some cases I'm rooting for you guys too. But it's a lot of fun and we talk about limiting screen time which as you know I'm all for and doing more physical activities with the family and playing board games, and eating around the table but when the Olympics roll around all bets are off and we make exemption for the screen time rules. As long as you're doing this as a family and talking about it as you go, it's a way to connect and to share that experience and make memories with your kids watching the Olympics and someday they'll be watching the Olympics with their kids and thinking back to these times when they are watching them with you.
So that's kind of a cool legacy thing that we create when we watch the Olympics. I also want to mention our 700 Children's Blog, if you love PediaCast you're going to love our blog. We've got some great writers, some great topics, you can find it pretty easily it's at 700childrens.org. Some recent topics on the blog, Resources For Kids With Special Needs, Food Allergies, How to Safely Navigate Outings, Car Seat Rules Are Changing: We'll Let You Know What You Need To Know, How To Choose An Urgent Care, so some are good for kids others aren't so great for kids, how do you know if you need to take your kid to an urgent care? Which one do you pick? And what about the emergency department, is that a better place to go? Then what circumstances should you go there? That's one of the blog post that 700 Children's done by yours truly, I'm a contributor to that blog. Another good one recently was Signs of Carbon Monoxide Poisoning.
You know just with this cold as it's been, in large portion of the United States, if you use gas heat, or propane heat, or fuel oil, any combustion that's going on in your house there's always the risk of carbon monoxide poisoning and so we have a nice blog post to let you know what are the signs and symptoms of that would be so you can watch out. So again that's our blog, it's at 700childrens.org and that's written with moms and dads in mind so be sure to check that out. Let's consider the entire line-up for this week. First off is a question about chronic cough, we have a listener whose child has been coughing for a few weeks. You've probably been in that situation before, maybe yourself, or a child, or a family member, or maybe it was a co-worker just someone that you know if it wasn't yourself with a nagging cough that just wouldn't go away, what could it be? We'll explore the possibilities coming up here in just a couple of minutes.
Birthing center safety, we've covered home births in the past and we've established that hospital births are much safer than delivering at home and we've kind of detailed the reasons why that is for both mommy and baby but what about standalone birthing centers? It's not quite a home delivery, but it's not a full pledge hospital birth either. So are these standalone birthing centers safe? We're going to consider that question. And then potty training, here's another topic that we most certainly covered in the past in fact we've covered it many times on PediaCast but just when I thought I've covered every possible nook and cranny of potty training a listener possess a problem that I hadn't considered so I'll detail the problem and together we'll consider the solution so that's coming up. Vocal cord nodules, what are these? What symptoms do they cause? How do you get them? How are they treated? And why is it that nine year old boys with siblings at home are the most commonly kids affected by vocal cord nodules?
A listener wants to know and we'll explore answers to these and other questions regarding vocal cord nodules. And then we'll wind things up with a big babies, we've got a question from a listener what causes infants to be large for gestational age and once it happens what are the chances of it happening again? We'll consider those questions and then at the end of the program for my final word this week we're going to talk about big tonsils, so we'll consider those at the end of the show. I want to remind you if there's a question that you have, or topic that you'd like to suggest, or a new story you want to push me toward, just head over to pediacast.org and click on the contact link. I do read each and every one of those that come through and we'll try to get your comments on the program. 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.
Dr. Mike Patrick: First up we have Carla in Quito, Ecuador. I told you that PediaCast audience is pretty international. I haven't seen Ecuador in the winter Olympics, I don't think they're big winner sport there but I'll be on the lookout just in case, maybe you have bobsled team or something, I don't know. Carla in Quito, Ecuador says, "Dear Dr. Mike I wrote to you a while back and was very thankful for your thorough response, I wish common doctors will have your talent to explain important topics. I'm writing today because my two and a half year old daughter is now affected by something that seems to affect every other person in my city. Some call it an allergic cough, other allergic rhinitis, others claim they're allergic to the cold but I find this diagnosis unhelpful. My daughter caught a simple cold over two months ago all symptoms left except her cough which is triggered generally by exercise or cold weather, it's sometimes phlegmy and sometimes like a bark."
"As a side note our city has a lot of air contamination and even though my doctor says this shouldn't be the reason I'm about five coughs away from packing my bags. I would really appreciate one of your famous differential diagnosis podcast on chronic cough. Thank you and as always keep up the great work, Carla." Thank you for the question Carla I always appreciated and really appreciate that we have listeners in Ecuador and I appreciate you telling your family and friends about the program too down there. Let's talk about chronic cough it's a good time of the year to do it. Here's the deal, the differential diagnosis for a chronic cough is a long one, some of the possibilities are easy things to manage, others are difficult, a few are life threatening. So chronic cough is not something you want to mess around with by treating it yourself at home, it is important that you see a doctor for this so you can get the right diagnosis and the right treatment.
I do think it's a good idea right from the beginning to define what is a chronic cough, when does an acute cough become a chronic cough? And when should you consider seeing a doctor for it? It's not a hard fast rule here but in general if a cough is severe, or it's associated with wheezing, or trouble breathing, trouble swallowing, drooling, soar throat, any other concerning symptoms about this or with this cough then you should seek medical attention right away. If the cough is mild and especially if it's accompanied by nasal congestion, or runny nose, maybe even a fever it's OK to wait a few days unless your child is a young infant with a fever and a cough in which case you should have your baby seen right away. Older babies, toddlers, and children with fever, cough, and runny nose it's fine to wait a couple of days unless other concerning symptoms are present like the ones I mentioned previously.
Or like vomiting and you're worried about dehydration, or they have a rash that you want someone to check on then you probably ought to go ahead and see somebody. But if it's an isolated fever with nasal congestion and cough that's just lasting for a few days this is probably a virus. If the fever last more than a couple of days, with most viruses fever's going to last two or three days but you get into four to five days of fever and it's time for someone to take a look. If the fever goes away but the cough now is lasting longer than seven to ten days but there's no other symptoms that you're worried about, it's just this nagging cough but it's lasting seven to ten days then it's probably time for someone to take a look. Just to kind of boil that down, an acute cough is going to last less than seven to ten day range, where is a chronic cough now we're talking it's lasting two weeks or more.
So less than about two weeks is an acute cough, more than two weeks is a chronic cough so that's a definition of chronic cough is one that's lasting more than a couple of weeks and Carla it does sound like your child's cough falls into that category. What could cause this? Lots of things which again is why it's important to see your doctor, but what are the possibilities? One of the most common reasons is this, you get a viral upper respiratory tract infection and it happens to be a virus that is more likely to infect the cilia cells which line the trachea. We have lots of different cells in upper respiratory tract, we have cells that line the nose, we have cells that line the back of the throat, we have the tonsils, and we have cells that line the trachea and some viruses are more likely to infect certain types of cells than other viruses.
Some of these viral upper respiratory tract infections have a tendency to infect the cells that line the trachea which goes from the back of the throat down to the lungs before it branches off into the left main stem bronchus and the right main stem bronchus. The trachea is lined with cells that have cilia, and cilia are hair like projections that beat upward and if you think about it think about it this way, in the back of the throat you got mucus, you've got mouth bacteria, normal stuffs that's there that you don't want to get down into the lungs. One of the ways that the body protects the lungs is by having the cilia beating upward it's like an elevator going back up so anything other than air that tries to go down the trachea, this hair like projections are going to bring them back up and out of the lungs including bacteria and mucus. If you have this cilia cells being infected by a virus, basically the virus is turning this cells into a virus making factory and it destroys the cell in the process and it also destroys the function of this cilia cells.
And so your body has to resort to coughing to protect the airways, so since the celia is not going to bring the stuff up your body knows this and you start having a tickle and a cough and that helps to protect your airways so that the mouth bacteria and mucus don't get down into the lungs. Basically you're going to have that cough until the cilia cells are re-made until you have new cilia cells and it takes the body a few weeks to do that. It's not out of the question then to have cough that's lasting three or four weeks while especially if it's a virus that really just did a number on the cilia cells that line the trachea. If you ever had a lingering cough following a cold, one that last about a month that's a likely reason and you just have to give it sometime. The cough in these cases isn't such a bad thing it has a job to do, it's protecting the airway and keeping stuff out.
Now having said this you don't want to assume that that's what's going on, you want to see your doctor and let him be the one, or her be the one to make this diagnosis because there are other things that can cause a chronic cough. The viral upper respiratory tract infection that you had may not be one that has a tendency to infect those cilia cells so your chronic cough may be for another reason so you don't want to assume the scenario that I just mentioned although that is a common one. Chronic cough can also be caused by allergic rhinitis which is post nasal drip, you got mucus draining from the back of the nose down the throat and can irritate and that mucus lands on the vocal cord and that causes you to cough and so you have a kid who's coughing up phlegm but it's really phlegm that's mucus that's coming from the upper airway and draining down and then you're bringing it up, it's not really coming from the lungs, so that's a common cause.
Asthma, or reactive airways disease including exercise induced and cold induced asthma, and Carla you'd mentioned that your child's cough is been lasting longer than a month and it does seem to get worse with exercise and with cold so even though your child's not wheezing it could still be asthma or reactive airway disease, some kids cough with that instead of wheeze or addition to their wheeze. You can also have overlapping viral infections, you may just have a cold virus and you have virus A and just as you getting over that you catch virus B and just as you're getting over that you catch virus C and if each of these viruses last seven to ten days or 10 to 14 days even then three viruses you've been sick for six weeks with three different viruses that just kind of overlap over the winter time. Sometimes that is the cause of chronic congestion, and runny nose, and cough. You can have pneumonia, pneumonia is usually accompanied by a fever but not always and so a chronic cough could be a pneumonia.
A typical infections like mycoplasma, pertussis or whooping cough especially in older kids and in adults again present as a chronic cough rather than the characteristic whooping cough that we see in little kids, tuberculosis, histoplasmosis, foreign bodies in the airway of the lung, gastroesophageal reflux or stomach acid coming up and irritating the airway can cause a chronic cough, air pollution outside, also air pollution inside like cigarette smoke exposure, all of these things can cause a chronic cough. Another example is the psychogenic cough, this is a cough that's someone is doing on purpose with or without secondary gain, it may be just a habit, it may be like a tick, you feel a funny feeling in your throat until you cough and then you feel better and it happens over and over again and it becomes a habitual thing, or it could be with secondary gain where you're paying a lot of attention to your child because of their cough and when they don't cough you're not really paying a lot of attention to him and so sometimes kids will develop a bad habit to get your attention, so that's a possibility as well.
Also cancers in the throat and around the vocal cords and the lungs can cause chronic cough and heart failure can cause chronic cough. There's a big long list of things that can cause a cough that's not going away and so it is important to see your doctor. A detailed history of the cough is going to be important as is the physical examination and your child may or may not need x-rays, nasal swabs, skin tests, blood work, referral to a specialist, scope of the airway or the GI tract and the exact work up is going to vary from one child to another depending on the situation, depending on the accompanying symptoms, depending on the history in the physical exam, depending on response to any treatments that may have already been tried. Lots to think about when it comes to diagnosing and treating a chronic cough and it's not something that you want to try to do yourself at home, you definitely want to see your doctor.
One more thing I do want to point out, you also need to be somewhat patient with your doctor. You might not get the right diagnosis the first time you go in and that's OK, we don't necessarily want an invasive million dollar work up straight out of the gate. Let your doctor collect the facts and narrow the cough down to some possibilities, sometimes it takes presumptive treatment and then waiting to see the response. If the cough goes away with allergy medication and then you try off of the allergy medicine and the cough comes back and so you restart the allergy medicine and it goes away, great! You know what the reason is. If it doesn't get better with the allergy medicine then you go back and you narrow down the diagnosis further. Maybe try something else maybe do a bit more of a work-up at that point when a couple of things have failed.
Too many people go to the doctor and then they tell their friends, "The doctor didn't know what was wrong with me, the treatment didn't work." You bad mouth the doctor and you go see someone else don't do that. If the treatment doesn't work go back, it's a process and your doctor is avoiding that invasive million dollar workup right out of the gate, you should be thanking him for that and following up as requested especially if the treatment isn't working. Sometimes it's trial and error and you figure out what it was. Sure you could have done the million dollar workup right out of the gate, you would've found out what it was but was it worth a million dollars? No, and the complications that can come with some invasive test. You definitely want to give your doctor a little bit of room here but if it's not getting better go back then they'll continue down that pathway to figure out what's going on. I hope that makes sense Carla and as always I really do appreciate your writing in and for being a good sport about making fun of the Ecuador in the winter Olympics.
Next up is Kristina in Philadelphia, Kristina says, "Hi Dr. Mike I listen to your show when you talked about home birth being more dangerous than hospital birth. I'm curious if the same statistics apply to birthing center births. I am 32 weeks pregnant and planning to deliver the baby at a free standing birthing center and would like to know your opinion on this. Are birthing center births considered just as safe as hospital births? Thank you for your help." Thank you for the question Kristina, the main issue with home births is that you aren't setup with an operating room, an intensive care unit, and a full staff of medical professionals there in your house.
If something goes wrong even though you would've predicted that everything would be fine, healthy mom, healthy baby everything going to be fine but then something goes wrong with mom, or the baby, or both which happens in fact it happens frequently. If something happens during a home birth there is a delay getting mom and or the baby to the help that they need and it's this delay that results in the possibility of serious complications and death. That's not to say that there aren't excellent nurse midwives out there, even with OB-Gyn at the house they don't have the tools they need to save someone's life in the event of a serious emergency. What about standalone birthing centers? They vary widely with regard to the resources that they have available and honestly I have not seen any studies that compare them directly to home births or to full pledge hospital births.
I can say this however, if it were my wife, or a loved one looking to deliver at a free standing birthing center there would be some things I would want to know. Number one, is there a fully staffed operating room, an OB-Gyn, an anesthesiologist onsite 24 hours a day, seven days a week? Because you don't know when you're going to go on to labor and it can be quick and emergency can happen fast. You want them to be ready for you 24/7 with an O.R, an OB-Gyn, and an anesthesiologist you also want a fully staffed, and fully stocked intensive care area where mom and baby could be treated long term or at least appropriately stabilized until a safe transfer could be arranged. You don't want to have to have an emergent transfer, that's going to delay the emergent care that you need so you want a facility that has everything that you need in the event of an emergency.
Now sure you may not be able to stay there long term, you and or the baby but you want to be stabilized and not endanger your life when you're being transferred from one facility to another. If the answers to these questions is yes they have a fully staffed O.R, an OB-Gyn, an anesthesiologist onsite 24/7, and a fully staffed, and fully stocked intensive care area then I'd feel pretty good about it. On the other hand if there's only a nurse midwife on the premises, or if an OB-Gyn, or anesthesiologist would have to be called in from home, or if there is not an operating room, or an intensive care area onsite then again you're getting into the problem of delay in emergent care and I would be very concern about the possibility of complications or possible death in the event of the emergency. That's my two cents Kristina, you have a little bit of research to do regarding the resources available at the birthing center where you plan to deliver. I hope that helps and as always thank you for writing in.
Next up is Sammy in Brooklyn, New York. Sammy says, "Hi, thank you for putting on a great show, I know you discussed potty training several times before but I don't think you've directly address this problem. I'm the dad of three and a half year old who refuses to use the potty, we've tried everything. Originally she'd at least sit on the potty while we watch videos on my wife's iPad or read books but she would never actually use it instead holding her pee until she got a diaper back on. Then she didn't want even sit on the potty anymore and we tried incentivising her with cookies, that stop working. We figured it was a battle of wills and we stopped pushing thinking once she started pre-school she'd want to copy her peers. She's been going to pre-school since September and she still has no interest in using the potty, we offered her toys and she still refuses.
I fear forcing her to sit on it would just harden our position but I'm not sure what else to do. The issue is pretty clearly behavioral and I suspect this is her way of controlling us. If incentives don't work, do we start withholding some of our favorite things like no more TV until she start using the potty. We are at our wits end and any suggestions would be appreciated. Thank you, Sammy." Thank you for writing in Sammy. You're right we have covered potty training pretty extensively on PediaCast most recently in episode 273 which was our listener question marathon but we also covered potty training in episodes 4, 27, 35, 117, 176, 196, 238, 244, 262 so lots of resources at the archives for those of you who want the big picture on potty training. You're also right in saying that we have not covered your particular situation which is this, you have a child whose developmentally ready to potty train, she's demonstrated this ability to be able to go on command, maybe not on the potty but when you put the diaper on then she knows once you put the diaper on so I can go, you put it on and she goes, that let you know she's got control over her bladder.
You really sense that this has become a control issue, you've used an incentive approach but she's not buying into the incentive and it appears to be all about control and you stepped away from the problem giving everyone a break and then trying again fresh and it still goes out. So what do you do now? I think you're right on the money here Sammy, it's all about finding your child's currency and if TV is the currency that's going to work eventually you're going to have to exploit that. I will say this when you're having trouble with potty training in a child who's older that you expect is developmentally ready I would visit your doctor just to make sure that there's not anything medically going on that could explain why this is not working out.
You definitely want to do that, most of the time you're not going to find anything and it is behavioral, and it is about control as you've mentioned Sammy but I would have your child check out just to make sure that the reflexes below the waist are normal, they don't have a tethered spinal cords, that there's not something else going on that could explain delay in potty training in the kid who you otherwise expect to be doing it. Again we're going on the assumption that there's not something medical going on here and it really truly is behavioral and you've stepped away from it and you've tried everything. And at that point you do have to use what works and I would say if nothing else is working absolutely take the TV away and develop a program by which she's going to earn it back. Now here's what I would not do, I would not tie in using the potty to immediate screen time, instead I would let her earn a sticker or a token or whatever system you're going to come up with.
Let her earn something which then can be traded for screen time down the road. Now in the beginning this might be right away so that she can clearly see the cause and effect. You might just have that, you go to the potty then you can watch TV but you're going to get a token or a sticker and turn it in and then you can watch the TV. Because you didn't want her controlling TV time by using the potty otherwise you'll just have a different control issue. When she wants to watch the screen she's going to make herself go and there's going to be melt down if you don't let her because you now aren't playing by the rules. If you establish right from the beginning that you're going to give her a sticker or a token or whatever that she can turn in at an appropriate time then you still ultimately control win and how much screen time that she's going to get. By putting that layer of reward sticker, token in there you can begin to make her earn more to get the reward.
In the beginning you have to earn one sticker or one token and in an appropriate time we're going to let you watch some screen but after few days it's going to take two stickers, or two tokens to earn that and the it's going to take three and now you're going to have earn four. Of course you could also each time four of them is going to get you a little bit longer time, or a better show you can figure out, you can come up with a list like, this show will cost one sticker, this show will cost two stickers and kind of build up to that. In some point then you're probably going to be able to wind that game down once you get her going. The important thing here though is to find your child's currency and if screen time is what it is then that's what it is.
There's going to be experts out there who disagree with me, when your feet hit the road it's what works and it can be frustrating especially if you want your child to be in the day-care that maybe they're considering kicking your child out because they're not potty trained and you need that place in order to work. There's certainly situations where you need to try to make this happen and you've got to get control over it. In my opinion that's fine, use what you have to use to make it happen. But I would not tie the potty use to immediate reward, put a sticker or a token in between that way you're not really transferring one control issue over into another, you can still control win and how often, in which programs and all of that by putting that layer of sticker or token in between the desired behavior and the eventual reward. I hope that makes sense Sammy and as always, thank you for writing in.
For the rest of you who may be interested in hearing much more on potty training and maybe the name of the program, the title had potty training in it so you're expecting to hear a nuts and bolts approach to potty training. Check out some of those other episodes, again there're PediaCast 4, 27, 35, 117, 176, 196, 238, 244, 262, 273. Let's move on we have another international listener Catherine in Wiesbaden, Germany. Catherine says, "My son now seven years old has always had a very deep, loud, and hoarse voice, a smoker's voice as many people say.
Even though no one in our family or neighborhood smokes. In addition he always has a stuffy nose, not runny but stuffy, he never complains about any pain but sometimes does say it's a nuisance that he can't fully breathe through his nose. My husband and I have also noticed that he tends to speak with his head tilted slightly upward. We have him examined by an ear, nose, and throat doctor a couple of years ago when he was approximately five and he said there was no need to act upon anything. The doctor said he had nodules on his vocal cords and this would probably go away as he grew older. He guessed correctly that he must be a younger sibling, he had an older sister and a younger brother. Apparently nodules are more common in children with one or more siblings. The doctor also suggested continuing the speech therapy my son was attending due to a lisp. Interestingly enough speech therapist said that she did not noticed his unusual voice or tilted head during the lesson so there wasn't much she could do with respect to this issues. Can you Dr. Mike please give me some details as to what exactly vocal cord nodules are and what we should watch out for?"
"Do they really just disappear or might he always have this hoarse voice? Can the nodules get bigger, and do we need to have them checked regularly? Our son is otherwise healthy, very active, and has great appetite. Thank you in advance for your feedback and for your very entertaining and informative podcast, keep them up." Thank you for the question Katherine. Let's talk about vocal cord nodules then I want to make a couple of observations based on the comments of your son's speech therapist. Vocal cord nodules, they're the most common cause of chronic hoarseness in school aged children. They are more common on boys, they are more common when siblings are present and the average age of onset is about nine years of age. Katherine your son definitely fits the bill but why? Why boys with siblings who are about nine years old?
The reason for this demographic is simple, vocal cord nodules most commonly occur from repeated trauma and abuse of the vocal chords. In other words they occur in kids who've done a lot of screaming and shouting in their lives and let's face it school age boys with siblings in the house they tend to do a lot of yelling and screaming which causes inflammation of the vocal chords which leads to fibrotic healing and the formation of nodules which in turn change the characteristics of vocal cord vibration which changes the quality of the voice into one that has a deep hoarse tone. There are other things other than nodules that can cause voice hoarseness and they include things like polyps, scar tissue, for example if your child had ever intubated where breathing tube was put down their throat that can cause damage and scar tissue formation which could cause a hoarse voice, tumors, vocal cord paralysis, gastroesophageal reflux where you have stomach acid that's coming up and then goes back down the airway and irritates the vocal chords.
Allergic rhinitis can do it so you have mucus that's constantly draining down the back of the throat, that mucus clings on to the vocal chords and makes them thicker and so you have hoarseness that kind of comes and goes because of the allergic rhinitis or allergic symptoms. Also congenital anomalies, laryngeal webs, and clefts, and hemangiomas which are benign tumors of blood vessels that can occur around the vocal chords. You can also see psychogenic hoarseness where kids are talking with the hoarse tone on purpose either out of habit or for secondary game because when they talk that way you pay more attention until some kids can start to talk hoarse on purpose.
As with many things we've talked about on PediaCast chronic hoarseness is not something you diagnose yourself at home, your child needs to see a doctor, your child was seen by an ear, nose, and throat specialist, has a scope on and was diagnosed with vocal cord nodules rather than one of those other things. What do you do for vocal cord nodules? Most of the time these are going to heal on their own and symptoms usually resolved within three to six months. Speech therapy is usually recommended to help kids to learn to communicate in ways that are gentler on the vocal chords, no more yelling and screaming, no more talking with the hoarse voice on purpose. If you address it as, "You're doing that on purpose," that's probably not going to go over well, but if through speech therapy you can train kids to modulate their voice a little bit differently because if you talk with a hoarse voice chronically that could cause inflammation which could lead to nodules.
Having a speech therapist just helping kids learn to talk in a way that's easier on the vocal cords is usually how you help this and then the nodules just go away on their own. If the nodules are very large or have been accompanied by more significant trauma with hemorrhaging or frank scar formation, or if the hoarseness is so bad it interferes with daily life and the ability to communicate then surgery may be necessary. In general we take a wait and watch approach, we get these kids in speech therapy and if things improve over three to six month period then great, if they don't improve or they get worse then a re-check with the ear, nose and throat doctor is certainly an order. Now I do also want to make some observations based on your speech therapist comments Katherine, you said the speech therapist told you that she didn't notice his unusual voice or tilted head during the lesson.
Couple of comments on this, first, hoarseness from vocal cord nodules would not be expected to come and go, it may gradually improve but if your child speaks in a hoarse tone in some social situations but with a normal tone in other social situations then he or she may have some control over the hoarseness which would not be characteristic of a vocal cord nodule. If your child is speaking in such a way on purpose again that could result in trauma and that could result in a nodule but in this case the hoarseness would be psychogenic but a nodule would start to be present, yes but the nodule was not really the problem, the hoarseness is there in some situations but not another's because your child is doing it on purpose. Another thing that can cause hoarseness of the voice that comes and goes would be allergic rhinitis an you did mention that your child has a stuffy nose often and kind of tilt his head back so maybe he's learned that if he does that he can clear some of the mucus, drains down instead of being stock in the nose and when it does drain, if it lands on the vocal cords that could cause hoarseness that kind of comes and goes so allergy is a possibility. But again you got to see your doctor and go to the whole history and physical to see if that's what's going on.
On the other hand it could be he's just doing it and eventually that's going to cause trauma and a nodule. I'm not saying that your son Katherine is doing it on purpose but if hoarseness comes and goes especially depending on the social situation then I would definitely consider that too as a possibility. The other comment that I have based on the report from the speech therapist, sometimes we notice things about our kids that others don't notice, and sometimes we notice these things because we're looking a bit too close. If this speech therapist doesn't really notice that unusual voice or head tilt I would find that reassuring and if you stop thinking about your child's voice or the position of his head you may start to not really notice it either and then you have to ask yourself if nobody is noticing, is there really a problem?
At the end of the day Katherine you did do the right thing having the hoarseness looked into, vocal cord nodules are common in your son's demographic and it sounds like your child is on the recommended treatment path and it's actually getting better according to the observations of the speech therapist. In terms of a re-check it always makes sense to see the ear, nose and throat doctor again or at least call your regular doctor, if things aren't progressing as expected, or if they're getting worse, or if any new and concerning symptoms pop up. I hope that helps Katherine and as always thank you so much for writing in.
Alright let's move on to Anonymous in Boulder, Colorado Anonymous says, "Hi Dr. Mike I'm considering getting pregnant again but I'm somewhat daunted by my first experience. It turned out well in the end but was quite the roller coaster, I went on the pre-term labor at 32 weeks which was stopped. I was then induced at 40 weeks and then ended up with a cesarean. My son was on the large side at eight pounds 15 ounces, other than the pre-term labor I seemed a very healthy woman and didn't have any form of diabetes. I have an appointment to talk with my OB over the details of my last pregnancy and the odds of complications this time. However I have a question about the risk factors of large babies. When I went in the pre-term labor at 32 weeks my son was given several steroid injections to try to make sure his lungs were mature enough in case he was born early. Could this have encouraged him to grow larger than he normally would have? His size is a bit of a puzzle because neither side of our family have had large babies before and I didn't have any of the normal health problems that would increase the chances of having a large baby."
"Also this is probably outside your area but just in case you have an answer what percentage of largest babies born to non-diabetic moms need to be born via a non-elective cesarean? I found a fair amount of information discussing diabetic moms and instances where the doctors suspected the baby might be a large ahead of time and suggested an elective cesarean. However I didn't see much information about healthy moms where the babies were actually large. Thank you for your podcast I've been listening for more than six years now and always enjoy it." Thank you for the question Anonymous and thank you too for your support over six years, I really appreciate you writing in. Let's talk about big babies, first I want to say I'm not an OB-Gyn, I'm a pediatrician and so making the decision of whether to go ahead and try a vaginal delivery, or do a C section depending on mom's size and the baby's size at the time when you're deciding what kind of delivery you're going to do.
I suspect that that's an individual decision that the OB-Gyn is going to look at a lot of data points to make. He's going to look at the size of the mom, look at what other babies she's had, how big those babies were, was there a history of failure to progress to the delivery, has labor started and you are failing to progress, what's the baby doing, are they healthy, are there decelerations at heart rate to make you think that there's fetal distress which is going to make you more like to do a cesarean section. There's lot of data points the OB-Gyn is looking at and I think it's really going to be an individual decision and if you had one large baby your chances of having another large baby are higher but whether that's actually going to be the baby's going to be too big, then there's also you're going to factor in that you already had a cesarean, so is this safe for now to do a repeat one.
Lot's to consider and really out of the scope of a pediatrician to answer those questions but I can talk about big babies. As you mentioned maternal diabetes can result in large babies, you may be asking yourself how did that happen. If mom's blood sugar is high, the blood sugar is going to cross the placenta and now the baby's blood sugar is also going to be high. Mom is not responding with insulin like she should whether she's not making enough insulin, or whether her body is resistant to insulin, but the baby on the other hand they have this glucose low but they're making their own insulin so they are able to modulate that higher blood sugar with their own insulin. The baby's insulin also acts as a growth factor so it's actually the presence of higher insulin which is there because the blood glucose is higher which is there because mom's blood glucose is higher.
The baby has more insulin and that's over a prolong period of time having that increase insulin load increases the baby's growth and so that's why babies of mom's who have diabetes grow large. Now genetics can grow large babies, also being off on your dates can grow large babies. In other words the baby is actually older than what you think so it appears to be large for gestational age but you got to gestational age wrong because you are wrong in your dates so that's another possibility for why you might have a large baby. I do want to go back to genetics, even though there's not a family history of large babies, not everyone remembers what size their baby was when they were born 20 years later.
And you aren't asking all of your aunts, and uncles, and grandparents, and great grandparents there could be a history of large babies in your family from genetics that you just aren't catching because you aren't asking the right people or the right people aren't remembering correctly so I wouldn't discount genetics as a factor here. You ask specifically about the steroid injections, ones that are given because an imminent delivery of a pre-mature baby. You're 32 weeks supposed to go to 40 weeks, baby's lungs aren't mature yet and you want to give them the best opportunity to become mature and so we do know that steroid injections can help an infant lungs get ready to perform their ventilations and respiratory function prior to their appointed time. Let me admit I'm not an expert on this and a fairly exhausted search did not reveal a good answer but my guess is that the steroid shots did not result in your child being large for gestational age.
These shots were given at a point in time, they did their thing with regard to lung maturation and then they were metabolized in other words your child did not have continued exposure to corticosteroids from 32 weeks to 40 weeks gestation, they were given during a point in time, they did their thing end of story. There have been cases where maternal steroid injections can worsen a mother's diabetes which can lead to a large infant but Anonymous you say that you did not have diabetes during your pregnancy unless they did not check for maternal diabetes after the steroid injections in which case maybe you did have mild maternal diabetes and just didn't know it because they weren't checking that might be possible or it may just again boiled down to genetics and even though there's not a history of big babies, maybe the family genes were shaken and roll out in the right combination to make a big baby, that's possible.
Honestly I don't know what your chances are of having another large baby other than to say that there probably increase compared to others and I sort of doubt that a genetic counsellor would be able to reliably tell you anything different. Bottom line is this, if you want to have another baby by all means talk to your OB-Gyn and make your decision, they'll follow the size of your baby closely and if he or she is getting too big they'll make a decision of which way the delivery ought to go and I would think that even if the baby isn't to big you might need a repeat C section anyway. But again all speculation, I'm a pediatrician not an OB-Gyn, I'll be the first to admit I don't know the answer. If there are any OB-Gyn in the crowd out there who have a better answer, by all means write in, let us know and I'll share that response. Eight pounds 15 ounces is a big baby but it sound like everybody is healthy which may make the decision for another go around a little easier, of course it's not a guarantee and in the end you got to make your decision and not look back.
Thank you for writing in Anonymous and again if someone who's qualified writes in with a better answer I'll be sure to let you know. That wraps up our round of listener questions this week. I really appreciate everybody for writing in and contributing to the program in that way. If you have a question for me about your child or someone else's child, any child, any pediatric question, fair game and apparently OB-Gyn questions are fair game too. If you have a question or you like to make a comment, or you want to point me in the direction of a new story, or you just have a topic idea just head over to pediacast.org and click on the contact link. I do read each and every one of those that come through and we'll try to get your question on the program so be sure to check that out. Let's take a quick break and I will be back with the final word on big tonsils, that's coming up right after this.
Dr. Mike Patrick: Alright we are back and I want to talk about big tonsils, this is one of those things that pediatricians get asked a lot. Parents will say, "My kid's tonsils are big," and it may not even be the reason that they're coming in. If you have big tonsils and you have a bad sore throat there could be an issue there, but I guess what I'm really talking about here is kids who just have chronically big tonsils. And they aren't necessarily causing a problem, most of these kids do snore at night and so parents are wondering, do my kid's tonsil need to be taken out because they're big.
At the current time obstructive sleep apnea is an indication to get your tonsils out and so you can have a sleep study and if you can document that the kid does have obstructive sleep apnea then that maybe a reason to remove big tonsils. However there's also some studies out there that are showing that even when you remove big tonsils in kids with obstructive sleep apnea it doesn't always necessarily remove as well. There is some debate in the pediatric community about indications for taking tonsils out and ongoing research into that but if right now as it is obstructive sleep apnea that you've documented with the sleep study can be a reason to remove big tonsils. Another reason to remove big tonsils is if you do have recurrent infections with group A strep or you're in an increased risk for rheumatic fever if you have group A strep that isn't treated.
If you have a kid that just keeps getting strep throat that may be an indication to get tonsils remove as well. But just these chronically large tonsils in kids, they may get colds a lot and they may get a little bit of a scratchy sore throat with it but it's not a severe sore throat. Those kids are a diamond dozen and what I would like to encourage parents when I talk to them about this is the tonsils are basically like lymph nodes, the lymph nodes act as a filter system where invading organisms get trapped and your body sends in white blood cells to fight the infection there and that's why when you get sick you get enlarge lymph nodes or when you have cancer you get enlarge lymph nodes because they're filtering out those cancer cells and the body's attacking them. When you think about the tonsils when they're enlarged remember invading organisms through the nose and the mouth the tonsils are the first line of protection that they're going to encounter.
That's not necessarily a bad thing and you could argue that if the tonsils weren't there the invading organisms are more likely to invade further and you can get pneumonia, ear infections, sinus infections, the fact that you're child gets frequent tonsillitis as long as it's not strep tonsillitis it's not necessarily a bad thing. Invading organisms coming in, it's going to caught somewhere or you might as well have it get caught in the first line of defense rather than going further. Big tonsils aren't always a bad thing, parents always wants to take a look and we're happy to look but just because they're big is not a reason that they automatically need to come out even when they're big, and certainly tonsil and adenoid surgery has a whole host of potential complications associated with it.
Complications that range from bleeding during the surgery, bleeding after the surgery, infections, and the risk of complications associated with the anesthesia, it's not a risk free thing and so you really do have to weigh the pros and cons, the advantages and disadvantages when you're deciding whether to take tonsils out or not, it doesn't always swing in the direction of taking them out just because they're big you really got to look at the whole situation and to have that conversation with your doctor. In some cases it is worth the risk, other cases it's not and each kid is going to be a little bit different. I just want to talk about that because it's something that a pediatrician we hear a lot, parents always saying, "His tonsils are so big, what are you going to do about that Doc?" And it's not even the reason that they come to see you, it's just something that we do come across quite often. That's my final word, big tonsils we'll try to get another good one in for you next time we're together.
Don't forget PediaCast and our single topic short format programs PediaBytes are both available on iHeart Radio Talk which you'll find on the web and the iHeart radio app for mobile devices both the iOS and android. I want to thank all of you for taking time out of your day to make PediaCast a part of it, I really do appreciate that. Reviews and comments on iHeart Radio and in iTunes would be most helpful. I have not had any recent comments or reviews in iTunes or on iHeart Radio especially if you're a new listener of the program and you have read through some of the old reviews and that's the reason that you decided to take a chance on PediaCast, give us a try and now you're hooked would you please consider just paying that forward and leaving a review of your own to entice new listeners and that's not that we want to grow the audience exponentially really that's not the point here, the point here is that we want more moms and dads to have a source they can trust to get evidence based pediatric information.
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