Detergent Capsules, Circumcision, Hemangioma – PediaCast 228

Join us this week in the PediaCast Studio as Dr Mike covers the latest pediatric news and answers listener questions. This week’s news topics include the dangers of liquid detergent capsules and common household cleaners, child-resistant spray bottles, an update to the AAP’s circumcision policy, and declining rates of circumcision. Questions from listeners this week: hemangioma, postural orthostatic tachycardia syndrome (POTS), and dealing with frequent illness.


  • Liquid Detergent Capsules

  • Danger of Household Cleaners

  • Child-Resistant Spray Bottles

  • Circumcision (Policy Update from AAP)

  • Declining Circumcision Rates

  • All About Hemangiomas

  • All About POTS (Postural Orthostatic Tachycardia Syndrome)

  • Dealing with Frequent Illness



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, 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, where we are each and every week and it's great being with you. It 's episode 228 for September 26th 2012. We're calling this one Detergent Capsules, Circumcision and Hemangioma.

Of course we have much more coming your way today. It's a news and listener show so we always pack those with lots of great information. And we'll get to the complete lineup in a moment. First, I want to tell you about something cool and helpful, also brand new from Nationwide Children's. It is our Pediatric Health Library.

You don't have to be in the hospital campus to use it. It's not a brick and mortar type of library. It is available online and we have comprehensive answers to hundreds of childhood health topics from stages of growth and development to disease and injury prevention. We also have information on hundreds of tests and procedures with illustrations designed to clarify anatomy, answers to common questions and diagrams to take you through the expected steps of a particular procedure.

We also have incredibly detailed drug reference for you with 33,000 prescriptions, over-the-counter products and nutritional products. And best of all, like PediaCast it's aimed at parents so we include lots of detail but we keep the language understandable. And actually I think best of all is that it's free. You can't find a print reference with this much child health information and you don't need to, simply head over to And of course as always we'll put a link for you in the Show Notes at


So it's really well done comprehensive health library. Really one-stop shopping for all of your information needs when it comes to items on your child's health. So you definitely want to check that out. Actually, we're going to give you an opportunity to check it out a little bit later on in the program and you'll find out exactly what I'm talking about. Coming up!

All right. What are we covering today? You got a little bit of a hint in the title. Liquid detergent capsules. They're out there and they're dangerous. We're going to tell you how and why and how you can protect your kids from them.

Also we're going to expand that discussion on to the broader topic of dangers of household cleaners and kind of let that segue way into child-resistant spray bottles. You see how things are just flowing with this episode?

Then we're going to jump off the safety train and talk circumcision. The American Academy of Pediatrics has revised their policy statement. Let's see. Are they going to push for it more or they going to kind of pull back on circumcisions? We're going to let you know.

And then we're going to discuss circumcision rates and then the question is will those rates and particularly in the United States be affected by the new policy of the American Academy of Pediatrics as relates to circumcision.


Then we're going to cover some of you questions. We have listener questions this week on hemangioma, postural orthostatic tachychardia, also known as POTS, which is actually quite common and frequent illness. You got a kid in daycare and they just seem to be sick all the time, especially in the winter months. Is that a bad thing? What do you do for it? How do you deal with frequent illness in young kids?

I want to remind you if there's a topic that you'd like us to talk about it's easy to get a hold of me, just go to and click on the Contact link. You can also email or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

Also, I want to remind you the information presented in every episode of 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 and you can find that at

All right. Let's take a quick break and we'll be back with News Parents Can Use, right after this.



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

A growing number of toddlers are swallowing liquid detergent capsules, also known as liquitabs. This warning comes from doctors at the Royal Hospital for Sick Children in Glasgow, Scotland and reported in the Archives of Childhood Diseases. The authors described the situation as a "significant health issue", calling on detergent makers to provide the liquitabs in child-proof packaging and to include visible safety warnings for parents.

So what's the problem? Well there are lots of issues with these, there's the choking hazard, of course, but the bigger problem is kids swallowing them and then the capsule becoming lodged in the esophagus.

I'm sorry I have to pause there; I shouldn't say the bigger problem. I mean choking is a pretty big problem. But, I guess more common than choking, I should say, are kids swallowing these things and the capsule gets lodged in the esophagus.

The capsule quickly disintegrates so the caustic alkaline detergent leaks out. And it's sitting in there in the esophagus, it can erode through it and lead to swallowing problems, infection and possibly death.

The detergent can eat completely through the esophagus and begin to penetrate the trachea allowing detergent into the airway. The detergent can also be refluxed up the esophagus and then back down the trachea from the top. Either way, it results in ulceration and swelling of the airways and your esophagus. And it can quickly become a life threatening situation.


The authors of the report state that in an 18-month period at one hospital in Glasgow, Scotland five children were seen because of swallowed detergent liquitabs and they ranged in age from 10 to 24 months. Four of them required admission to the intensive care unit and required intubation, a plastic breathing tube was put down their trachea to help them breathe. And then they were on a ventilator for a few days because ulceration and swelling in the airway was so extensive. One of the kids even required airway surgery.

Now all the kids in Glasgow, Scotland did recover but the authors point out the outcomes could have been worse and if something isn't done about the packaging and warnings worse outcomes can be expected.

In 2011, in the United Kingdom alone, 647 phone calls were made to the National Poisoning Information Service regarding swallowed liquid detergent capsules. And the Poison Service logged 4,000 website visits on their liquitab information page. The authors also point out that manufacturers aren't the only ones to blame because parents should keep detergents out of the reach of their children.

They say, "Dishwasher and washing machine liquitabs are now a common finding in most homes, but unfortunately, seem very attractive to young children due to their bright coloring and soft sweetie-like texture. We feel that the increasing trend in liquid detergent capsule ingestion poses a significant public health issue."


Across the pond, here in America, the American Poison Centers are also seeing an uptick in detergent capsule incidents. Debbie Carr, executive director of the American Association of Poison Control Centers, says, "U.S. poison centers are reporting an increase in calls from parents about exposures of children to laundry detergents packaged in small, single-dose packets." She explains that some toddlers swallow them and become extremely ill and need to be admitted to hospital, while others suffer severe eye irritation. In some cases the capsules burst inside the children's mouths.

Some examples of injuries reported by the American Association of Poison Control Centers include a 20-month old toddler who swallowed a detergent capsule. Within ten minutes the child vomited profusely, wheezed, gasped for air and passed out. The patient became unresponsive even to painful stimulation.

A 15-month old child swallowed a mouthful of detergent liquid after biting into a capsule and had to be rushed to a hospital. That child also ended up on a ventilator. And a 17-month old child bit into a capsule and then became very drowsy, vomited, inhaled the product into his lungs, also need to be placed on a mechanical ventilator.

Dr. Michael Beuhler, medical director of the Carolinas Poison Center, says, "The rapid onset of significant symptoms is pretty scary. Other laundry detergents cause only mild stomach upset or even no symptoms at all. Although we aren't certain what in the product making the children so sick, we urge all parents and caregivers to make sure laundry detergent packets are not accessible to young kids."

The American Association of Poison Control Centers recommends locking all detergents away; making sure it's kept out of the reach of children; following disposal instructions on the label carefully and seeking medical help right away if your child comes into contact with any detergent product.

And don't forget the number to your local poison center in the U.S. is always 1-800-222-1222, regardless of where you live. So this serious stuff, folks, I know liquitabs are convenient, there's no question about that. But they can be extremely dangerous. So again, keep them locked up and out of reach.


Speaking of the dangers of household detergents and cleaners, a study out of Nationwide Children's Hospital a couple of years ago, has prompted the development of a new spray bottle that may soon find its way to store shelves. First the study and then the product.

Every year in the United States, there are more than 1.2 million poison exposures among children younger than six years. In recent decades, household cleaning products have consistently been one of the leading sources of pediatric poisoning. A 2010 study conducted by the Center for Injury Research and Policy of The Research Institute at Nationwide Children’s Hospital found that from 1990-2006, over 267,000 children younger than 6 years were treated in U.S. hospital emergency departments for injuries attributable to household cleaning products. During the 17-year study period, researchers noted a 46% decrease in the number of injuries.

So that's good news, right? Well, liquitabs weren't available in the market when the study was done, so we'll see where the numbers go. The researchers say most of the household cleaner-related injuries were poisonings, with children ages 1-3 years accounting for 72% of the injuries. Bleach was the worst offender resulting in 37% of the injuries. And while approximately one-third of the injuries occurred through contact with the cleaning product, the more frequent injury was bleach ingestion at 62.7%. With regard to storage containers, spray bottles were associated with more injuries than capped bottles, cans, boxes or bags.

Dr. Lara McKenzie, PhD, principal investigator at the Center for Injury Research and Policy at Nationwide Children’s says, "Interestingly, spray bottles were the only major storage source that increased over the study period. And although rates of household cleaner-related injuries from regular bottles and original containers decreased during the study period, spray bottle injury rates remained constant making this an area worthy of further research."


So we're doing a good job keeping our kids from household cleaners when you look longitudinally, but spray bottles are still a problem. She points out the good news is that the number of injuries decreased by almost half during the study period, but again, the bad news is that there were still nearly 12,000 children younger than six years who suffered injuries from household cleaning products in 2006.

Young children are curious about their surroundings and tend to explore their environment by putting things in their mouth. This general sense of inquisitiveness, combined with increased mobility, the ubiquitous nature of household cleaning products and the ease of accessibility, place young children at high risk of injury.

But the researchers didn't stop upon publication of their report in the journal Pediatrics. Spray bottles remained a risk and they set out to make them safer. Dr. Lara McKenzie explains, "Existing spray bottles for household cleaning products can not be designated as a truly child-resistant. And while many spray bottles contain a nozzle that controls the stream configuration or closes the spray bottle (you know what I'm talking about the little square on the end), these nozzles are not effective if the user does not turn the stream adjustor back to the closed or off position after each use. Plus these nozzles are relatively easy for young children to manipulate on their own."

In a pilot study including 25 families of young children, Nationwide Children’s investigators found that 75% of the nozzles on the cleaning product spray bottles were not in the “closed” or “off” position and therefore posed a potential hazard to young children in the home.

To develop concepts and to design a child-resistant spray bottle, Dr. McKenzie’s research group partnered with Professors Carolina Gill, MS, BSID, and Scott Shim, MA, BFA, from the Department of Design at The Ohio State University and Dr. Blaine Lilly, PhD, from the Department of Mechanical and Aerospace Engineering at Ohio State. And together, they developed a distinct method for making spray bottles essentially unusable by children younger than six years of age.

“The two-stage trigger mechanism design restricts the ability of young children to trigger spray bottles because they lack the developmental capability to perform the correct operational sequence and because their hand size and strength are not sufficient to activate the mechanism.” Dr. Lilly says, “The spray mechanism is designed to be extremely challenging for young children to operate, yet will allow adults comfortable use.”

The prototype features a two-stage trigger mechanism that must be sequentially engaged in order for the spray mechanism to function. The spraying mechanism then automatically returns to a locked state after each use without requiring the user to consciously apply a locking feature, setting it apart from any other spray technology.

Dr. McKenzie says, “Our long-term goal is to reduce the number of household cleaning product-related injuries in young children through widespread adoption of our product. This technology may set a new ‘gold standard’ for child safe spray bottles.”

So kudos to Dr. McKenzie and her team for finding a problem and setting out to find the solution. And if in the future there becomes a spray bottle out there that you have trouble operating, you can blame us.


All right. Let's switch gears away from household safety and talk about a controversial rite of passage for many baby boys, circumcision. The benefits are greater than the risks. So says the American Academy of Pediatrics after carrying out a comprehensive review of available scientific evidence.

However, the academy emphasizes that it does not consider the benefit strong enough to advise every parent to agree to the procedure for their newborn baby boy. They say circumcision should remain a parental decision based partly on cultural, ethnic and religious beliefs, but because the benefit outweighs the risk the AAP urges insurance companies to cover the cost of the procedure for parents who decide to have one done.

This by the way is a change in the AAP's stance on circumcision with stronger language in support of the procedure. Why? Well because over the last 24 months a growing number of studies and reports show evidence of the benefits of male circumcision.

In July 2012, the Global Advocacy for HIV Prevention said that voluntary medical male circumcision is one of the most effective weapons against the spread of HIV infection. It urges countries where HIV infection rates are high such as many in Africa to make sure males have access to professional circumcision procedures.


HIV prevention isn't the only benefit of circumcision; the AAP's Task Force on Circumcision says the procedure also decreases the risk of transmission and acquisition of syphilis, genital herpes, human papillomavirus, penile cancer, urinary tract infections during the first 12 months of an infant's life and the reduction of the risk of cervical cancer in men's sexual partners.

A report published by the American Cancer Society demonstrates that males who are circumcised have a 15% lower risk of developing prostate cancer is the procedure is carried out before their first sexual intercourse.

Dr. Susan Blank, MD, chair of the AAP's Task Force on Circumcision says, "Ultimately, this is a decision that parents will have to make. Moms and dads are entitled to medically accurate and non-biased information about circumcision, and they should weigh this medical information in the context of their own religious, ethnic and cultural beliefs."

Circumcision is safest when performed during the first 12 months of a baby's life and the AAP advises parents who choose to have their baby boys circumcised to make sure the procedure is carried out by trained healthcare professionals who use sterile technique and proper pain management.

The American College of Obstetricians and Gynecologists (ACOG) endorsed the new AAP recommendations. Dr. Sabrina Craigo, on behalf of that organization says, "This information will be helpful for obstetricians who are often the medical providers who counsel parents about circumcision. She says, "The American College of Obstetricians and Gynecologists certainly support the idea that parents should choose and believe those who do choose should have access to the procedure."

We'll have a link for you in the Show Notes. We're going to have a link actually to the AAP's 2012 circumcision policy statement, so if you're interested you can read the entire policy statement in its entirety. Just visit the Show Notes for this episode 228 at


So just as the AAP comes out with a new policy statement proclaiming the benefit of circumcision as outweighing the risk, the journal Archive of Pediatric and Adolescent Medicine publishes a study showing how the decline in the number of boys getting circumcised will increase the overall cost of healthcare.

According to researchers at Johns Hopkins, the declining rates of U.S. infant male circumcision could increase avoidable healthcare costs by more than $4.4 billion. The researchers say increased cost results from new cases and higher rates of sexually transmitted infections and related cancers among uncircumcised men and their female partners.

They believed to be the first cost analysis to take into consideration the increased rates of multiple infectious diseases associated with declining rates of male circumcision including herpes, genital warts, HIV and cervical and penile cancers.

The author say 2 million baby boys are born in the United States each year, of these 55% are circumcised, which is reduction from 79% in the 1970s and 1980s. Contrast that with Europe where only 10 percent of male babies are circumcised.

Dr. Tobian, an assistant professor at the Johns Hopkins University School of Medicine, says, “Our economic evidence is backing up what our medical evidence has already shown to be perfectly clear. There are health benefits to infant male circumcision in guarding against illness and disease, and declining male circumcision rates come at a severe price, not just in human suffering, but in billions of dollars of healthcare money spent as well.”

The researchers estimate that the reduction in male infant circumcision has already caused the United States $2 billion. According to the team, each male infant who is not circumcised results in $313 more in illness-related expenses, a cost that would have been avoided if these men had been circumcised.

The authors point out that if the U.S. circumcision rates declines to the European rate, we could expect 12% more men infected with HIV; 29% more men infected with human papillomavirus; a 19% more men infected with herpes simplex virus; and a 211% more men suffering from urinary tract infections. In addition, there would be 50% more cases each of bacterial vaginosis and trichomoniasis infections and an 18% increase in female cases of human papillomavirus, which is strongly associated with cervical cancer.

All right. So USA we don't want to see these increases and we don't want to decline to the European rate, according to the study. I'm not going there. "The numbers of U.S. infant male circumcisions have been significantly reduced as a result of state funding cuts in Medicaid," Dr. Tobian explains. "The financial and health consequences of these decisions are becoming worse over time, especially if more states continue on this path. State governments should start recognizing the medical benefits of circumcision and acknowledge the eventual costs savings it provides.”

In the article, Dr. Tobian says, "The problem in the United States is compounded by the failure of the American Academy of Pediatrics to recognize the medical evidence in support of male circumcision."

Dude, you just needed to give them a little more time. So simmer down, Dr. Tobian, read the AAP's new policy statement, which you can find in the link in our Show Notes at PediaCast's show number 228.


So you see kind of where this is going as in our economic downturn there's a lot of baby boys who are covered by state Medicaid. And in some states Medicaid had started to say hey, is circumcision really medically necessary, let's save some bucks and let's not cover it and so these kids aren't getting circumcised and so then we can expect to see an increase in these diseases which is going to overshadow the cost savings of not covering the circumcision. The state governments now are going to be spending more money to fight the diseases, not to mention the human suffering.

So I'm just kind of summing it up here, but you can see where this all fits in. So we have folks complaining about it, now the AAP coming out more strong, with a stronger statement to try to get Medicaid to continue to cover it.

My point is just to say hey, parents out there, the risk appears to be minimal when you consider the benefit. Speaking of the risk, what are the risks of circumcision? I'm going off script here but that's sort of the next logical question if we're saying the benefit outweighs the risk, what's the risk?

The risk really goes along with any surgical procedure. You're going to have the possibility of bleeding, of infection, of pain. However, those risks are drastically minimized when done in experienced hands and with proper sterile technique and pain management as it was noted earlier in the presentation.

All right. We are going to take a quick break and we're going to come back to answer some of your questions, right after this.



All right. We are back and a quick side note, I find this interesting, I get to the office today and outside the door of the studio is a bottle of Gatorade that's sealed. I mean, it's like a brand new bottle of Gatorade sitting on the floor outside the door to the studio. And I just want to say thanks to whoever put it there. It was sitting up right against the door.

So I thought this is a little strange and I bring the bottle of Gatorade in set it down on the counter and really didn't think much of it. I wasn't really planning on drinking it because I don't know whose it was, where it came from, how it got there. It's kind of odd. People aren't really gifting Gatorade around here very often. But then, here's why the big thanks though, normally I bring a jug of water to kind of have at my side as I'm recording just to kind of wet the whistle in between takes and when we cut away to the music I grab a little sip.

And today, for whatever reason I forgot my bottle of water. And so guess what, I had a bottle of Gatorade to take its place. Whoever left the Gatorade, thanks and it was appreciated and well used.


All right. Let's start with our listener questions this week. Tiffany in Grants Pass, Oregon says, "We'd love your comments or input on hemangiomas. My son was born with a small one on his back. It has gone away, he is age three now. A friend of mine's daughter was born with a larger version on thigh. She is eight months old and her parents wonder how long it will remain. Thank you for this wonderful podcast, I tell everyone who will listen about you and all your great information."

Well, thanks for the vote of confidence, Tiffany, appreciate that. And thanks for listening in Oregon. So let's talk about hemangiomas. To start with just sort of the definition, hemangioma is a benign tumor made up of a clump of blood-filled blood vessels and they can occur anywhere in the body.

So when they're on the surface of the skin they kind of appear as a red lump and the size and shape can vary. When they're deeper in the skin they appear as a faint bluish swelling of the skin and again the size can vary. And if they're in the body, so around internal organs or as a part of internal organs you can have a hemangioma, obviously you can't see them in that situation.

Now they're present at birth or appears sometime in the first few days, weeks or months of life. And in fact, infantile hemangiomas are the most common tumor of infancy. They're seen in all races, but they're most common in Caucasians. And some studies show they affect up to 10% of all Caucasians. Some of the older studies say 10%, there are some newer ones that show maybe it's more like 4 or 5%, but somewhere between 5 and 10% of all Caucasians are affected, but then again it can affect other races as well.

It's more common in females than in males. In fact, three to five times more likely, although we do see a number of them in boys, just more often in girls. They're also more common in twin pregnancies, so if you're one of a twin, you're more likely to have a hemangioma. And they're also more common in premature babies, older maternal age, mom having placenta previa or pre-eclampsia are also risk factors for the baby than having a hemangioma.


Eighty percent of hemangiomas are located on the face or neck. And the next most prevalent location is actually in the liver, so one of the internal hemangiomas. Like all tumors, hemangiomas result from unchecked growth of cells. We want cells to multiply, especially as infants grow, but uncontrolled multiplication results in tumors. And in the case of hemangiomas it's the endothelial cells, the cells that line the inside of blood vessels, those are the cells that are multiplying out of control.

We don't know why this happens, although we're beginning to think that there is a protein produced by the placenta that could play a role in the development of infantile hemangiomas. And then it kind of makes sense then why they're more common in twins, you have more placenta material, so more production of that protein and then that will result in more incidents of hemangiomas in the baby. It may also explain why placenta previa and pre-eclampsia can make them more common.

So it kind of makes sense but we really don't have all the answers for the pathophysiology of infantile hemangiomas quite yet. All right. So what kind of signs and symptoms can we expect with hemangiomas?

Well, hemangiomas again these infantile ones began in early infancy. They typically get larger during the first year of life and again the ultimate size and shape of the hemangioma can vary greatly from person to person. And then once the baby is about a year old they typically gradually recede during toddlerhood and in the childhood and half of them are gone or have little visible trace by age five and nearly all of them are gone or have very little visible trace by the age of 10.


Most of them are small and really result no problems or symptoms. Now in rare cases, the surface of an exposed hemangioma on the skin may erode resulting in recurrent bleeding, also rare complications or rare problems associated with hemangiomas.

Large ones inside the body can compress nearby structures and/or basically occlude nearby structures even if they're on the skin. And the symptoms of that are going to really depend on which nearby structures are involved.

So just as an example, if you have hemangioma around the eye it could interfere with vision; if you have one in the ear canal it could interfere with hearing; if there's a hemangioma around the airway, particularly inside your body, it can compress the airway and cause breathing problems; and it can cause elimination problems if you have a hemangioma anywhere in the GI tract or the GU tract. Their presence can cause a problem, although most of the time they're small and they don't cause an issue.

What about differential diagnosis? Well there are other vascular tumors that can have somewhat of a similar appearance but differ with regard to expected course. So in other words, they may appear later, not during infancy and they may not regress. You can differentiate between hemangioma and other vascular tumors and we'll talk about how here in just a minute.


But what are some other vascular tumors that will sort of be in the differential diagnosis? One is a capillary vascular malformation, also known as port-wine stain; masses of abnormal swollen veins, we call those venus malformation; also what's called a nevus simplex or also a macular stain is another name for it and sometimes are called salmon patches; if they are on the back of the neck we call them stork bites; if they're on the forehead we call them angel kisses.

These are not hemangiomas. These are something called nevus simplex. Another thing that can sort of masquerade itself as a hemangioma is something called a pyogenic granuloma, another name for that is a lobular capillary hemangioma.

These typically result where you have some trauma. So you have some skin trauma, the skin is repairing itself and the blood vessel component of that repair goes a little out of control and you get a benign tumor of blood vessels that looks kind of like hemangioma.

These tend to be friable and bleed easily and their peak incidents are in the second or third decade of life. So this isn't something you see in babies, but if you have an older kid or young adult, pyogenic granuloma is something that could be mistaken for hemangioma.

And then another one is called a tufted angioma. A tufted angioma has a similar appearance to a hemangioma, but it typically has a later onset. So usually during childhood or into adulthood. They have a slow growth and a benign course like hemangiomas do, but they don't resolve, they typically stay.

And then there's something called a cavernous hemangioma and there's some argument in the histological world. Yes, there is a histological world. Some folks would argue whether these are hemangiomas or are they a vascular malformation. But basically what they are are benign tumors of blood vessels but the blood-filled portion is quite large and this can result in blood clots forming inside the structure.

And if it's connected to the circulation in a significant way it can also cause shunting of blood away from an important organ system like the liver into this cavernous hemangioma. So that's a little bit different than the infantile hemangiomas, but I wanted to mention it in case you hear about that.


All right. How do you differentiate all these different types of vascular tumors? Well, to get a definitive diagnosis you would do a biopsy. If you can reach it, you'll pluck it out, have a histologist look at it under a microscope and tell you exactly what kind of tumor that it is.

However, most of the time biopsy is not necessary and that's because most hemangiomas can be diagnosed clinically based on their appearance and their course. When did it start? Did it start right at birth or soon after birth? Did it get bigger until one year of age and then slowly regress? Just sort of what is the course and description of it. And most of the time, an infantile hemangioma can be diagnosed just based on the appearance and the history.

Now, in cases that you're not quite sure and there are problems with it, so if you have a tumor of blood vessels on the skin or the surface of the skin and it's recurrently bleeding or it's having some kind of problem associated with it and we're going to get in to what some of the problems you can have with hemangiomas, then it may be worthwhile to do a biopsy.

Remember biopsies come with their own risks. Risk of bleeding, infection, pain, anesthetic or sedation issues. So doing a biopsy is not a benign procedure and so if you have something that you feel is going to be benign and it looks like an infantile hemangioma and it's not causing any problems then why risk doing the biopsy? On the other hand, if lesion is not typical, it's not following the expected course or it's causing some sort of problem, then a biopsy might be helpful to make the diagnosis clear.


What about treatment? Well treatment is rarely needed again, because they usually resolve on their own and they rarely result in complications. However, disease complications are possible but the good news is the complications with infantile hemangiomas are pretty rare.

So what kind of complications are talking about? Well we kind of hinted at one a little bit ago. The overlying surface of the hemangioma if it's on the skin can erode and that can result in recurrent bleeding, pain, the possibility of an infection and scarring. Also periorbital, the orbits, we're talking about the eye, if you have hemangioma around the eye it could interfere with vision depending on how large the hemangioma is.

And during infancy vision is important because if your eye is not seeing and it's not sending sight signals to the brain, the brain can actually kind of ignore that eye. And so the act of seeing is important for visual development and so if you have a hemangioma blocking vision on one eye that potentially could cause blindness in that eye. So it's important that we keep the eyes free of obstruction and if you had a hemangioma around the eye that might be one that you do have to treat.

Hemangiomas in the ear canal are a little bit different. The hearing does not require hearing in order to continue to develop. So if you can't hear on one side because your ear canal is blocked by hemangioma, when the hemengioma recedes you will be able to hear. So ones in the ear canal aren't quite as detrimental as ones that would be around the eye.

Also if you have a hemangioma in one ear canal, you probably don't have one in the other so you still have hearing, just you have hearing in one ear instead of the other and so then is the risk of treatment does that outweigh the benefit. If you had large hemangiomas in both ears then the baby would be hearing impaired, which could affect things like speech development and so in that situation you would want to do something about it.

So you really have to take this on a case by case basis to decide whether you need to intervene or not. Hemangiomas about the airway, they interfere with breathing; hemangiomas of the tongue and oral cavity could interfere with eating, swallowing or speech.

So these things, again, you just really have to look at whatever problems it's causing and then decide is intervening, where are we from risk versus benefit scenario. By the way, hemangiomas rarely cause significant problems, I just want to mention that again.


Vascular malformations like venus malformations on the other hand, which we mentioned in our differential diagnosis, those are much more likely to cause problems which require intervention. They tend to get much larger and compress things that are important like the airway inside and also aren't going to regress or get better over time.

Hemangiomas typically don't require treatment. Now let's say it does. What are our options for treating infantile hemangiomas if they do cause problems and we decide that the benefit of treatment outweighs the risk?

OK. So what can we do? Well we can have surgical removal that's an option; there's also laser therapy; and steroids injected into the lesion or topical or even oral steroids. Of course, these treatments come with their own set of problems and so again you have to look at risk versus benefit.

So with surgical removal if you'd leave a little bit behind it can regrow. That's the problem, the cells are a benign tumor that are multiplying and so even if it looks like you take it out but you leave a couple of cells it can regrow. With surgery you also have the risk bleeding, infection, scarring and of course the anesthesia risks.

Laser therapy usually requires multiple treatments and we still have to deal with pain, infection, bleeding and possible scarring. And also laser therapy can result in permanent skin color changes to surrounding skin as well.


And steroids, long-term use is typically required during the proliferation stage. And so we're talking during the first year of life you're using a steroid on a long-term basis. And this can result in problems of its own. It can actually cause more erosion of the lesion causing bleeding, pain, infection and scarring. And the steroids have effects on the rest of the body so it could cause poor growth, high blood sugar, high blood pressure and even cataract formation in the eyes.

So again, you really have to make sure the benefit of treatment outweighs the risk of treatment and in the vast majority of hemangiomas, even ones that parents consider ugly or disfiguring. And in the vast majority of these and they can get big, I mean you can have a golf ball-sized hemangioma on a child's forehead and parents don't like it there, it's on all their baby pictures; but in the vast majority of these the treatment benefit is just not worth the risk since the lesion will be expected to regress on its own.

But again in the rare case if lesion is causing a significant problem then the benefit of treatment may well outweigh the risk. If you want to know more about hemangiomas, guess what? Our Nationwide Children's Hospital Pediatric Health Library has more information and we're going to have a link in the Show Notes so that you can try out the health library for yourself. See, I was hinting on that in the intro and that's where we are with that.

All right. That wraps up our discussion on hemangiomas. Thanks for the question, Tiffany.


Let's move on to our next listener question. This one comes from Mary in Chicago, Illinois. Mary says, "My niece was recently diagnosed with postural orthostatic tachycardia syndrome, also known as POTS and I've never heard of it before. I thought this might be a great topic to discuss on PediaCast. I love your show, I listen to every episode. Thanks for your hard work and great information."

All right. So postural orthostatic tachycardia. Let's break that down – postural means position of the body, orthostatic means standing that's the position that we're talking about and tachycardia means rapid heart rate. So postural orthostatic tachycardia, also known as POTS, is a rapid heartbeat that results from standing.

It's a common disorder that's out to affect 500,000 Americans, most commonly seen in teenagers and young adults. And the highest age of incidents is between 14 years of age and 45 years of age.

So why would standing cause a rapid heart rate? Well to understand this we have to take a quick look at the normal function of the autonomic nervous system. The autonomic nervous system is responsible for things your body does that you don't have to think about. So automatic things. You can easily come up with a list of the types of stuff we're talking about here. Your pupils dilating and contracting, your spit glands making saliva, your baseline breathing when you aren't thinking about breathing, secretions of stomach acid and digestive enzymes, contraction and relaxation of smooth muscle inside your airways and inside your blood vessels and your heart rate.


Well as it turns out there's a very good reason why standing would result in an increase in your heart rate. Your brain wants blood that's how it gets oxygen and glucose and not only wants oxygen and glucose, your brain needs oxygen and glucose. In fact, if the brain doesn't get oxygen and glucose it doesn't take long for your vision to go all spotty and you'll feel lightheaded and dizzy and then pass out.

So with that in mind, when you stand gravity exerts a greater force on your blood compared to when you're sitting or lying down. So gravity is exerting a force on the blood away from your brain. Your blood is pulled away from your brain and toward your feet by gravity when you stand.

Now something has to counteract this, otherwise we would pass out every time we stand up. And one of the ways we counteract this effect of gravity is regulated by the autonomic nervous system. And what happens is smooth muscle in our blood vessels contract and this tightens the blood vessels grip on the blood and raises our blood pressure which helps counteract that force of gravity and our heart rate increases which increases cardiac output so we have more blood flowing out of the heart, which equals more pressure pushing the blood up against the force of gravity.

So with these normal functions in mind, we can understand POTS, which is a disordered response to standing. And the exact nature of this disordered response varies from person to person. There isn't really a single mechanism of disease. Several things are happening and they kind of cascade into a series of events.


So a typical scenario is this, although again this is kind of like what came first, the chicken or the egg, and so there are some different ways that this can actually happen in the same person depending on which forces are coming into play more. But this is a typical scenario, instead of an increase in blood pressure when a person with POTS stands up, we see a decrease in blood pressure.

And why do we see this? Well, there are several possibilities. One is that they run a little bit low in terms of blood volume. You're not necessarily dehydrated but you're just running on a low blood volume side of things. And so you don't have as much blood for the blood vessels to grip on to increase that blood pressure. So one of the initiating events may be you just have lower blood volume than other folks do.

Another possibility is that the smooth muscle lining the blood vessels may fail to respond or they may respond less vigorously than we would otherwise expect. Normally, when you stand up the smooth muscle inside the blood vessels contracts and pushes on the blood and if you don't have an adequate response or no response at all then you're going to have a decrease in blood pressure when you stand up because of the effect of gravity and you're not counteracting it very well.

And in a lot of these kids you have both things going on. So you have sort of low blood volume and not a great contraction response and so gravity really starts to win and blood is pulled away from your brain. Now the heart responds to this by kicking in to overdrive and it attempts to keep blood flowing to the brain by increasing the force and rate of its beating. So the person starts to feel their heart beating hard and fast because it's the only thing that's working to counteract gravity at this point.


And then if that's not enough and blood flow to the brain is not adequate despite the heart's best effort, then they're not getting enough oxygen and glucose to their brain and their vision goes spotty, they may feel dizzy or lightheaded and they pass out. Of course when they pass out now they're not standing anymore and the effect of gravity goes away and blood goes right back to the brain again.

So this is sort of the mechanism by which this POTS thing occurs. Other frequent signs and symptoms include shakiness, anxiety, nausea, abdominal cramps, diarrhea and these symptoms are all caused by this disordered autonomic response. So disordered autonomic nervous system response. Passing out of course is the worst and most dramatic of these symptoms and it actually occurs at least once in about 40% of people who suffer from this disorder.

Let's talk about a little bit differential diagnosis. What other things can cause these symptoms? Well, the biggest thing that we worry about is certain heart arrhythmias because heart arrhythmia so that the rhythm of the heart, the normal heart cycle is not what we would expect it to be. And arrhythmias can result in decreased cardiac output, which decreases blood flow to the brain and then you can get that loss of vision, dizziness, lightheadedness, followed by passing out. And we call that cascade of symptoms syncopy where you pass out because the brain isn't getting enough oxygen and glucose we call that syncopy. And there are other potentially life threatening problems that can cause syncopy.

So this is not something that you want to diagnose at home. If your child's having syncopy you need to see your doctor or if they're getting lightheaded and dizzy or losing their vision, these are all dramatic symptoms and so it's not something that you're going to say oh yeah, this is just POTS. No. You go see your doctor or go to the emergency room if you need to try to get this figured out.


Symptoms of generalized anxiety disorder can sometimes mimic POTS. Actually sometime POTS gets misdiagnosed as a generalized anxiety disorder and then having POTS can also cause anxiety because you feel lightheaded every time you stand up, it's pretty stressful, you're worried something's wrong with your heart and so that can lead into the anxiety picture with this too.

And there are other medical conditions things like thyroid problems, autoimmune disorders and sometimes even diabetes can cause nervous system malfunction and they result in similar symptoms. So again it's important to seek medical help for this in a timely fashion. Again, not something you want to diagnose at home on your own. We never recommend that anyway.

OK. So what about a workup? How does your doctor differentiate POTS from other disorders? Well we look at the history and course of the symptoms. We look at family history, there may be some blood work that's required. Generally, we check out the heart, might do an EKG or possibly a chest X-ray. Sometimes a holter monitor is helpful if an arrhythmia is suspected, that's an EKG monitor that's warn and constantly recorded into a little box that you hook up to your waist; that way you can keep a diary when you're having symptoms you can jot down what time it is or push a button on the recorder so then the cardiologist can go back and say hey, this is what the heart was doing when you had those symptoms and that can help with the diagnosis.

Speaking of a cardiologist, after referral to a cardiologist is made and they may also do an echocardiogram where they look at the heart with soundwaves as part of the workup. Something called orthostatic vital signs are sometimes helpful that where you check the blood pressure and heart rate with the patient lying down, sitting and then standing. And the people with POTS you may be able to see a significant decrease in blood pressure and an increase in their heart rate as they go from lying to standing.


The problem is though that many people with this disorder it doesn't happen every time they stand. And so even though you check orthostatic vital signs where you're checking blood pressure, heart rate when they go from lying to sitting to standing, you may not find anything because they don't have the problem when they stand for you when you're taking the vital signs. So many people may have the problem at home or school but when they see the doctor and there's no problem when you stand up there.

So one thing that cardiologist can do they can sort of make this happen in affected individuals and it's something that's called a tilt-table test. And basically, you're strapped down to this table and you're moved from lying to standing in very quick order. It's very quick and abrupt. Lying. Standing. And your vital signs are monitored. And that often times will stimulate the response in affected individuals and then you can make the diagnosis.

I do want to point this out, the workup items that I've mentioned, so EKG, chest X-ray, orthostatic vital signs, echocardiogram, holter monitors, all these things I've mentioned, you don't have to do all these things to make the diagnosis of POTS, but these are some of the things that you may run across depending on your doctor and your exact presentation. So just things to be aware of but don't feel like you didn't get an appropriate workup if you didn't get all those things done because those aren't always necessary.


Seizures are another thing that parents often worry about when their child passes out, although the presentation of seizures is quite different than syncopy and so again just kind of teasing out the history and really hearing a description of exactly what happened is helpful in differentiating those. But again if your child is getting lightheaded or passing out, see a doctor. OK? That's important. Right away.

All right. So let's say you have been diagnosed with postural orthostatic tachycardia syndrome, what do you do? How do you treat it? Well first you want to avoid triggers. Remember I said that a lot of people who have this it doesn't always happen every single time they stand up. It may be if they're standing for a prolonged period in a warm room. It might be after they've exercising a lot and then they sit down and then they stand up quickly.

If you notice anything that triggers the response then you want to try to avoid the triggers. So that's one way that you deal with this. Another is to increase blood volume and since we kind of gone through how this happens it makes sense if you increase blood volume you're going to increase blood pressure, which will make you be able to tolerate the effect of gravity a little bit better.

And so it's important for folks who have this to stay hydrated, to drink lots of water and also to increase their salt intake. Salt has a bad rep out there. People who have high blood pressure we say watch your salt intake. One of the ways that salt increases your blood pressure is the more salt you take in, remember salt is sodium chloride and so the higher your sodium and chloride levels in blood go, while your body doesn't want your sodium and chloride to get too high and so have all these extra particles in the blood, water comes into the blood through a semi-permeable membrane by osmosis.

We've talked about this before; you got to think back to middle and high school science class where water flows across the semi-permeable membrane in a direction from less particles to more particles. So if you have a higher amount of sodium in your blood, water from your other tissues is going to go into the blood in order to bring your sodium level back down to where it should be and so increasing salt intake will increase blood volume in that way and that will increase blood pressure, which will help folks who have this problem.


Now, you don't want to do too much salt, you don't want to raise your sodium level too high too fast because that can result in seizures among other things. And so it's got to be a slow process. This isn't something you do at home on your own. You do it under the supervision of your physician. But increase salt intake and water intake to increase blood volume can be quite helpful.

And that by the way is why salt is bad for folks who battle high blood pressure because it increases your blood volume and it increases your blood pressure even more and so that's why adults who are having blood pressure problems and kids too ought to stay away from salt. But these folks have a different problem and so it's OK for them to eat more salt. A little bit. And again, under the direction of your doctor. You don't want to eat the whole salt shaker. All right. You know what I'm saying.

There's also a medicine called Floranef, which is a corticosteroid that increases sodium and water retention and it may be helpful if lifestyle and dietary adjustments aren't enough. Sometimes other medications are required if episodes remain frequent and severe despite initial treatment.

But fortunately in most cases increasing salt and water intake and avoiding triggers is all that's required. And as teens pass into adulthood the issue typically goes away. All right. Well thanks for the question, Mary.


Let's move on to our next listener, this time from Jessica in Canberra, Australia. So Jessica in Australia says, "Hi, Dr. Mike. I have recently found your podcast and I'm loving it. Your show gives great background information and is a fantastic parenting resource. I have a question for you today, my 14-month old son started daycare three days a week at eight months of age and since then he has been sick seemingly all the time. Pink eye twice, hand-foot-mouth disease twice, colds, tummy bugs, unexplained diarrhea all in the space of just a few months. Every couple of weeks he seems to have something and that something is usually going around the daycare. I know parents can expect their children to get sick a few times during the first few months of child care but this seems extreme. At what point, if any, do you start to worry that a kid is getting sick too often? What do you do when she reaches that point? Do you just wait it out and hope things get better? Or do you consider switching care environments or are just some kids' bodies not ready for daycare? I'd love to hear your perspective on all these. I'm very frustrated. Thanks so much for your advice. – Jess."

Well thanks for your question, Jess. And yes, I hear your frustration and I'm sure many listeners out there are just as frustrated as you are. But here's the deal, any time your child has significant contact with a virus that he or she doesn't have immunity against, he or she is likely to become ill from that virus and is likely to pass it on to others.

Now the good news is once you have that virus or you're immunized against that virus, then you're not as likely to get sick or at least not as sick from that particular virus the next time it comes along. Now that bad news is there are hundreds if not thousands of different viruses and strains of viruses out there. And as many times as your child is exposed to a new one that's how many times you can expect your child to get sick.


So how does your child come into contact with the virus? Well from other kids whose parents send their kids to daycare when they are sick and contagious and in defense of parents some kids are contagious even when they don't appear very sick.

Then also from poor hygiene of the other kids and your kid. So child A rubs his nose, scratches his bottom then plays with a toy and your child comes along plays with the toy then rubs his face or puts his fingers in his mouth. So these are things that you the parent really have very little control over. They happen all the time at daycare and it's just a fact of life.

Your only choice is if they go to daycare and if they do go to which one? Now I will say some daycares are worse than others. Some daycares have stricter illness policies so your child has less risk of exposure, others have workers who are more in tune with hygiene issues, they may distract their kids when they see them rubbing their noses and scratching their bottoms and they may keep a bottle of hand sanitizer on their hip.

So is changing daycare centers if your child seems sick all the time might help? And again, it might not, because even in the best environments and the strictest policies and the most conscientious workers exposures are still going to happen. And as I've said before in this show, if your child doesn't get exposed and sick in daycare it's going to happen. It's going to happen when they go to school. If it doesn't happen when they go to school or if they're home-schooled it's going to happen when they're in the workplace, especially if kids are present, but even if they're not once kids start school and start giving their germs to each other then parents get sick and then it goes in to the workplace.

And when folks are training to be pediatricians or they're new pediatric nurses, we're sick all the time. But after a few years we finally have been exposed to the majority of the viruses in our community then we start getting sick less often. Then you move to Florida and you get exposed to their strains and then you start getting sick again quite often and then you develop immunity against those.


So even adults get sick when they come across a new virus. So let's get back to your question, Jess. How often is too often? Well that depends on what illnesses you're talking about. The ones you've described the viral upper respiratory infections, pink eye, stomach viruses that cause brief vomiting and diarrhea, hand-foot-mouth disease, these types of viral infection really are pretty harmless.

There are exceptions but in general they're fairly harmless. There are many strains of viruses that cause these diseases so your child can get them often and in fact, they're likely to get sick with every exposure to a new strain and that might be one right after another in the wrong or right daycare environment.

On the other hand, we don't want your child getting dangerous viral infections, so things like measles, mumps, rubella, chicken pox and that's why we immunize against those particular illnesses. We also don't want your child getting some potentially deadly bacterial infections, things like pertussis or whooping cough, diphtheria, hemopholys, pneumococcus, meningococcus and again that's why we immunize against those things. With those illnesses one time is too many and so vaccines are important.

But what about run-of-the-mill bacterial infections, things like ear infections, sinus infections, pneumonia, skin infections or cellulitis or abscesses or MRSA. Some kids get these things recurrently and the cause of getting those recurrently might be a problem with your child's immune system and it might not, but it could.

And so it is important you see your doctor not only for treatment of the infection but also to see if there could be a reason your child keeps getting those types of infections. Another concerning recurrent infection in kids is going to be yeast or fungal infections, especially in the mouth or recurrent shingle, also known as herpes zoster. If these infections are happening frequently it could represent an immune system problem.


On the other hand, recurrent viral infections like the ones you're describing, Jess, are really expected in a daycare setting. They kind of go along with the territory. But how many is too many? Well that depends on you and your family's tolerance for your child being sick all the time and it also depends on what other options that you have.

But keep in mind if you don't get those viruses now, your child's likely going to get them later and that's just how our immune system works. You have to get the illness or be vaccinated to be protected later.

In the end, talk to your doctor, some recurrent illness patterns aren't concerning but are expected, while other recurrent illness patterns could mean something is wrong with your child. And that's why we say if you have a concern about your child see your doctor for a face-to-face interview and hands-on physical examination.

All right. I hope that helps, Jess. I know it's frustrating. Other parents out there with kids the same age as yours know your frustration and frustration is part of parenthood. It's what you signed up for. And as they get older, frequent illness will be less of an issue, but trust me other frustration will take its place.

All right. That wraps up our listeners segment for this show. We're going to wrap up the show, right after this.



All right. We are back a little over on time, I apologize for that. I want to remind you that the Pediatric Health Library is brand new here at Nationwide Children's Hospital. It's online and it's really easy and we'll put a link in the Show Notes for you. It's a great resource and I encourage you to check that out.

I want to thank each and everyone of you for taking time to make PediaCast a part of your day. We really appreciate it. As always, iTunes reviews are helpful as our links on your webpages and mentions in your blogs, on Facebook, in your Tweets and on Google+. Be sure to join our community by liking PediaCast on Facebook. You can follow us on Twitter, make sure you tweet with hashtag #pediacast and hang out with us over on Google+. Also be sure to swing by the Show Notes at to add your comments on today's show.

We also appreciate you telling your family, friends and neighbors about the program. And don't forget to talk us up with your child's doctor at your next well check-up or sick office visit. We also have posters you can download and hang up wherever moms and dads hang-out. And you can find them under the Resources tab at

Again, if you want to get a hold of us or if you have a topic idea, just go to, click on the Contact link, if you have a question and want to get yours answered on the program. You could email or call the voice line at 347-404-KIDS. That's 347-404- K-I-D-S.

And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody!


Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

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