Ear Infections, Soda Pop, Polio – PediaCast 265

Join Dr Mike in the PediaCast Studio this week for another Listener edition of our program. Topics include the great circumcision debate, teen problems, ear infections, soda pop, and polio.


  • Circumcision Debate

  • Care of the Uncircumcised Penis

  • Teen Problems

  • Ear Infections

  • Ear Tubes

  • Adenoids

  • Soda Pop & Behavior

  • Polio

  • Oral Polio Vaccine




Announcer: This is PediaCast.


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

Dr. Mike Patrick: Hello everyone and welcome once again to PediaCast. We are a pediatric podcast for moms and dads; this is Dr. Mike coming to from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. It is episode 265 for September 18, 2013. We're calling this one, Ear Infections, Soda Pop and Polio. I want to welcome everyone to the program; we do have a big listener show lined up for you today with lots of questions and some comments from your fellow audience members.


Don't forget, if you would like to chime in, stay tuned and I'll fill you in on getting in touch. It's a pretty easy thing to do. That way you can ask your question or share your comment. But first let's take a look at all of our listener generated topics this week, we have a number of them and more than we mention in the title of the program. So here is the full run down, the full list. First up it's got to be circumcision. Should you circumcise your new born infant? What are the risks? What are the benefits? And how do you take those through a risk/benefit filter? And what if you change your mind? Now of course we're only talking one direction here folks. Once it's off, it's off, but if you leave the fore skin on and decide to take it off down the road, what would prompt that decision, and how does that situation look in a risk/benefit filter? That's the particular question that our listener asks, so we will definitely address that. Plus, for those of you who decide not to take the fore skin off, we'll discuss care of the uncircumcised penis from the new born period through adulthood.


Good times should be a fairly frank discussion. Just warning you now because if you have little ears lurking around the corner, you may want to, kind of watch that. And then since we're dealing with boy private parts, we also have a listener who has a comment on girl private parts and more specifically period problems, so we'll quickly touch based on those. Next up after that, we'll get through our private parts discussion both the boys and the girls and then we're going to talk about ear infections, ear tubes, and adenoidectomy, which is getting your adenoids out. It's time for my yearly spill on ear infections the, who, what, when, where, why, and how, ear infections and their treatment. Seems like this comes up about this time of year, each year, once school gets started, the viruses start get spreading around and kids start having ear infections. Again, this year our discussion will be sparked off by a pair of listener questions. Two listener questions for the price of one, one big answer, so we'll talk ear infections.


Then we're going to talk soda pop after that. Another listener sent me an article which links soft drinks to aggressive behavior in kids. Could this be true? Your fellow listener has doubts; I'll deconstruct the study, show you its strengths and weaknesses and add my two cents for good measure. Then we're going to travel to the Middle East and answer a question from a mom in Israel, polio is making a comeback there. What exactly is polio? How does it make you sick? Is it really that dangerous? And what is the difference between the oral vaccine and the injectable vaccine, the actual shot? Is one better than the other? Does one pose dangers? What if your child already had the full set of injectable ones, and now health officials want your child to get an oral polio vaccine to boot? Does that sound right? We'll talk about it. And then at the end of the program from my final word this week, I have a family fun event to tell you about, it's a great kick off to fall if you live in Central Ohio. So be sure to stick around for those details at the end of the show.


Now, what if you have a question, or topic idea, or a comment? How can you participate in the show? Well it's an easy thing to do, just head over to pediacast.org and look for the contact link and write, just write in with your question, your topic idea, or your comment. I read all of those that come through and we'll try to get you on the program. If you haven't checked this out on iHeart Radio Talk, it's time to do so; really it's the easiest way to listen to the program. Just head over to iheart.com or you can download the iHeart radio app for iPhone, iPad, or android. Once you're there search for PediaCast and you'll be instantly connected with a convenient way to catch up on all of our latest episodes. If you found us on iHeart Radio Talk, maybe that's where you're listening right now. If that's the case, I would kindly encourage you to head over to pediacast.org, that's where you'll find the show notes, all the links we talked about on the program, and an archive of more than 250 episodes of more answers listener questions, news parents can use, and interviews of pediatric experts, and a host of valuable topics.


We also offer you single topic short format version of the program called PediaBytes. You can listen to those on iHeart Radio Talk. You can listen on the PediaBytes station, you can also incorporate them into your own custom talk radio station with other content providers of your choosing, and you can even add in your local news, weather and traffic into the mix. And, as if that weren't enough, PediaBytes are also included in the couple of pre-program stations on iHeart Radio Talk, namely the Parenthood, and Mom's Sippy Cup, so be sure to check all that out. One more thing before we get started, the information presented in this program is for general educational purposes only. We do not diagnose medical conditions, and we do not formulate treatment plans for specific individuals, because that would be practicing medicine in the form of a podcast, and that's not what we're about.


We just want to educate, and if you have concern about your particular child's health, share right in but make sure you're also calling your doctor and arranging for a face to face interview and hands on physical examination. Also, your use of this audio program is subject to the PediaCast terms of use agreement which you can find at pediacast.org. Alright, with all that in mind, let's take a quick break and I will be back with answers to your questions, right after this.



Alright, we are back and first up is Constance in Dallas, Texas. Constance says, "Hi Dr. Mike, thank you for the great service, hi to all my friends who have kids about your show."

Dr. Mike Patrick: thank you.

Constance: "I think it's should be mandatory for all parents to listen before bringing their babies home."

Dr. Mike Patrick: OK that may be pushing it.

Constance: "My question is what is your take on circumcision? My older son was born in 2007, we did some research and followed guidelines at that time that suggested not circumcising new born boys. Fast forward, my son is going to attend first grade this fall, couple of weeks ago he woke up in the middle of the night crying about his penis hurting. Upon examination I found his penis was red and swollen, he wouldn't let me touch or examine it further. The next day I manage to pull his fore skin back with many tears and screams and lots of puss like secretion under the fore skin, just as I suspected. We cleaned it with soap and water and the inflammation subsided, from then on I always make sure he pulls back the foreskin and cleans it well. He does complain about the tightness of the foreskin, and it hurts to pull it back


"That episode may have been caused by lots of swimming in the hot summer days and excessive shedding of dead skin. So here's my question, should we consider circumcision now? An elderly friend suggested we have the procedure done at the end of fall semester for time to heal during that winter break, and less exposure to pool water. What do you think? And my younger son, two and a half now, should we consider circumcision for him too? Sincerely yours, Constance."

Dr. Mike Patrick: Well thank you for your question Constance. So, really we have a two part question here and actually I think you could extend that out to three parts. First, how should you care for the penis of an uncircumcised boy? Because you didn't exactly follow established care guidelines in your description, and in fact I think that some moms and dads were cringing as I read your message, maybe more than some. Not that we should blame you Constance because moms and dads don't have innate knowledge of these things, we're not born knowing how to take care of the uncircumcised penis.


And as you mentioned, babies don't come with instruction manuals, and PediaCast is not required listening, although I did like your idea regarding that, not sure it's practical or legal but I did like it. So we'll talk about caring for the uncircumcised penis in a moment. Next you ask specifically if your first grader son, and your two year old son, if they should be circumcised now as older boys. And I'm going to expand that question out to ask, should new born boys be circumcised? So, let's tackle these three things, I'm going to do it in reverse order. First, should new born boys be circumcised? Wow, that is a loaded question, and one that really doesn't have an absolute right or wrong answer. You really have to look at the pros and cons, consider your risk tolerance level because there are risks associated with circumcision as well as benefits, and there are risks associated with not circumcising, as well as benefits.


You have to take your family history into account, you have to take your world view into account which includes your religious, your ethnic, and your cultural, and your ethic biases. And when I run all the data points through my filter, I would choose to circumcise my son as a new born, that was my decision 16 years ago and that would remain my decision today. Now does that mean that any particular listener out there should make the same decision? No, you're going to put all those data points into your filter and come up with the decision that's right for your family, and I wouldn't fault you from making a different decision, really I wouldn't. OK, so what are these data points that I speak of? What are the risks and benefits of circumcision versus no circumcision in a new born? Well for the sake of time, and since some listeners will be more interested in this than others, I'm going to refer you to a couple of resources.


The first one is a blog post that I wrote last November for itriagehealth.com, and conveniently it's called "To Sirk or Not to Sirk", that is the question. And it really, I think does a nice job of highlighting the risks and benefits, and I'll include a link to that in the show notes for this episode 265 over at pediacast.org. Another good resource is PediaCast 228, and that one is from September 2012, one year ago, still current. And in that episode I run through the American Academy of Pediatrics policy statement on circumcision, and we talked about the trends in new born circumcision rates. So I think listening to that podcast will be helpful as well if you really want to dig deep and whether you should have your new born circumcised or not. And again I'll put a link in the show notes for this episode 265 over at pediacast.org so you can find these resources all in one convenient spot. And then finally, I'll put a link in the show notes to the actual American Academy of Pediatrics policy statement, because I think it does a nice job of outlining the risks and benefits.


And while the statement endorses the benefits justifying the risks from a medical stand point, in another word if you're just looking at the medical part of it, the AAP, and I would agree with this, says that they believe that the benefits outweigh the risks. But this policy statement doesn't just look at it from a medical standpoint, it does take religious, ethical, ethnic and cultural beliefs into account and it points out that the medical benefits alone may not justify the procedure when those other factors are considered by individual families. I think that's a well-rounded approach, and I'll include a link to that policy statement in the show notes again for this episode 265 over at pediacast.org. I hope these three resources help expecting moms out there who maybe struggling, and dads, maybe dads more so with making a decision.


OK, what about circumcision outside of the new born period, such as two year olds and first graders as is the case for Constance and her family? Well again, this is an individual family's decision, one that takes into account all the data points for new born circumcision and adds a couple additional ones. First, the risk is slightly greater because your child will need a sedation or anesthesia, and the procedure is less well tolerated by older boys and bigger penises. Now that doesn't mean things won't go well, but there is more potential for problems. The second consideration is the degree to which your child's uncircumcised penis is interfering with his quality of life. If the uncircumcised penis is a constant issue despite proper care, then for your family and your child in that situation, then that may be the right thing to do. On the other hand, if switching to proper foreskin care eliminates the problems, then you may want to hold off.


There actually is a third consideration, I just thought of this, what is your son want? If dad is circumcised, the brothers are or aren't, that may make a difference as well. Just another data point that you're got to have to consider in your risk-benefit filter as you come to this decision. These aren't easy decisions, talk to your son, and your family, and your doctor, juggle those risks and benefits, make a decision and then here I think is really important, you got to live with your decision, don't look back and second guess yourself because that's not good, it's going to interfere with the quality of your life. Just make the decision, put it all out there, make a list on paper if you need to, risks and benefits, medical, social, economic, and make your decision and go with it. Alright let's talk about care of the uncircumcised penis, if you care for it properly, you're going to have less chance that there's going to be problems.


During infancy, simply wash the penis and foreskin with soap and water during each bath, that's it, it's all you need to do, no need to retract the foreskin, just leave it alone, and if swelling, or redness, or tenderness, or drainage, or discharge occurs, see your doctor, pretty simple. During the toddler and childhood years, you can begin an attempt to retract the foreskin, but you want to do it gently, no forcing and if tears and screaming are involved, Constance, that's too much force, be gentle and realize this is going to take some time. Some boys will be able to fully retract the foreskin by kindergarten, but for others it's going to take longer, maybe not until puberty, and in the meantime during those years if swelling, or redness, or tenderness, or discharge occurs see your doctor, still pretty simple. Now once the foreskin can be fully retracted pass the head of the penis, and again this may not be until puberty, then your child or your teenager should gently retract the foreskin on a regular basis, clean beneath the foreskin with mild soap and water, rinse, dry, and pull the foreskin back over the head of the penis, again, pretty simple.


Now there are some issues you may run into, infection beneath the foreskin and infection of the penis itself, which may result in swelling, redness, pain, and or discharge, and you want to see your doctor for this because it's possible that an antibiotic might be required. We talked about the condition called phimosis, which is the inability to retract the foreskin, now that's OK in infants and children, in fact we would call that physiologic phimosis, it's phimosis that's normal at that age. However, if phimosis persists after puberty and into adulthood, then it can cause some problems like painful erection, sexual dysfunction, urinary retention, and the increase risk of some cancers. If your teenagers still isn't able to retract the foreskin, talk to your doctor.


Another condition, and this one is rare but even more worrisome is it something called paraphimosis, and paraphimosis is when the foreskin is retracted and then it get stock behind the glands, or behind the head of the penis, in other words, you can't pull the foreskin back over the head of the penis, and if this persist for several hours, it's possible to restrict blood flow to the tip of the penis which can lead to tissue death, or necrosis. Paraphimosis is a medical emergency, if the foreskin is retracted and won't go back, your child needs medical attention right away, not the next day, immediately. These are some of the issues we see with the uncircumcised penis, and if this become recurrent problems, then a circumcision maybe warranted in an older child, as always it's best to discuss the benefits and the risks of all this things with your child's doctor.

One last comment, I think this is really more just to provide little bit more understanding on your part as the parent with a child who has an uncircumcised penis. Just so you understand why it can take a while, ad why you really don't want to force that retraction before its ready to happen. The epithelium, the skin layers before the foreskin and the head of the penis, if you just think about the foreskin as it rest over the head of the penis, the foreskin itself has a bottom layer, and the head of the penis has a top layer and these are touching each other, and during infancy and childhood, these layers have a tendency to stick together and that's why retracting the foreskin is difficult, and if your force them apart before they're ready, they're going to tear away from each other which can lead to pain, bleeding, and scar tissue formation and it may ultimately cause the layers to stick together even more tightly as they scar together.


Now the good news is, with puberty the epithelium naturally changes from stick layers to smooth, slippery layers, so most of the time as puberty hits, the layers are going to separate on their own, funny how that works, the body does what it's supposed to do. I hope all that helps Constance, again check out the show notes, and the rest of you too especially those soon expecting baby boys, check out the show notes over at pediacast.org for this episode 265 for those resources I talked about that will help you in your decision making process. Alright, we talked about boys and their private parts; next up is a comment for the girls. This comes from Michelle in Indiana, "Hi Dr. Mike, just wanted to let you know your podcast on period problems was just what I'm looking for today. I have a 10 year old daughter and it's time to start discussing these items with her as this is right around the corner for us. A few of her friends have started their period already so I figured it was time to address it. I found it very informative and glad you chose a woman doctor to explain the facts as well. I found your podcast in iTunes one day just by clicking around and I am so glad I did.


At first I thought it was mostly subjects about babies and toddlers, I am glad however that in the most recent podcast you have addressed pre-teen and teen subjects as well, this has been wonderful. I also love that you have guest specialists on the show for specific topics, the nuts and bolts shows are some of your most interesting, great job on the podcast and keep them coming, thank you."

Dr. Mike Patrick: Well thank you for the nice comments Michelle. There is a lot of research and work that goes into this podcast to the tune of many hours each week, as you can imagine, so it is nice to hear that you actually help people. Teenage topics have always been included in PediaCast right from the beginning and I include topics pertaining to college aged students as well. The period problems podcast, which covered the normal menstrual cycle, because you have to understand normal to understand what goes wrong. We also talked about early or precautious puberty, to late puberty, irregular periods, heavy and long lasting periods, PMS the dreaded pre-menstrual syndrome, menstrual cramps, and other symptoms and the discussion of tampons versus pads, that was all PediaCast episode 253, and you can find it on iHeart Radio Talk, and over at pediacast.org.


To make it super easy, I'll put a link to it in the show notes for this episode 265. Other teen topics you might be interested in, PediaCast 201 health literacy, what teens and parents need to know, PediaCast 211 cell phones and driving, 221 was migraine headaches, 229 firearms safety and sudden death in college athletes, 232 we talked about video games and memory, 240 teenage suicide, 244 sports related knee injuries, 247 drinking milk in college, 249 all about eating disorders, and 250 preventing alcohol abuse in high school and college aged kids. And these are just 10 random examples in the past 65 episodes, there are 200 episodes prior to these which contained a multitude of teenage topics, so be sure to dive deep into the episode archive over at pediacast.org for even more adolescent topics.


Michelle, I also appreciate you mentioning that you found PediaCast in iTunes. Lots of listeners find this the same way and now that we're on iHeart Radio Talk, I think others will discover us there as well. We don't have a big advertising budget here on PediaCast; in fact we really don't have one at all. And what it boils down to is we rely on you, moms and dads spreading the word to her parents because it's confusing out there, there's lot of child health information on the internet, some of it good, much of it bad, a lot of it just wrong and there's sometimes even harmful information. We want PediaCast to be an evidence based information source you can trust. Sure I sometimes include opinion, but when that's the case, I'm clear to present it as opinion and include a rational which you may or may not agree with, that's up to you. But the bulk is evidence based and trustworthy, that say the opinion part's trustworthy too but that's little pride get in the way.


Bottom line, if you find a moment, please consider writing a quick review in iTunes and iHeart Radio Talk because a parent like Michelle, and like many of you read the reviews before they give us a listen. Someone came before you and wrote a review which you took to heart, gave us a try and now you're a regular listener. Please consider paying that forward for the parents yet to come. Alright let's move on to our next topic, this is going to be a two listener questions, and one discussion on ear infections. The first listener is Marcy in Bellmore, New York, she says, "Hi Dr. Mike, I love the podcast. My daughter is six years old and has suffered from a persistent runny nose and frequent ear infections since age three. We have taken her to three allergists who have not found anything she's allergic too, her ENT has suggested she have ear tube surgery along with an adenoidectomy."


"I have heard a lot about ear tube surgery but I have not heard anything about kids having their adenoids removed. I would appreciate it if you could talk about this on the podcast, thank you, Marcy."

Dr. Mike Patrick: Then we have Stephanie in Indiana, Stephanie says, "Dr. Mike, I have a two part question, my son is two years old and has a few ear infections already this year treated with antibiotics each time. When is it appropriate to consider ear tubes and what are the risks? Also I'm concern; all the antibiotics he's been taking might be adversely affecting the natural balance bacteria in his body. Should I be concern about this? Would taking prebiotics after an antibiotic treatment help, and how should he take them? Thank you for your advice, Stephanie."

Dr. Mike Patrick: Alright, I'm going to go off script for this one because this is a discussion that I've had many times in the examination room and one I could probably do in my sleep. In order to understand ear infections and their treatment, you really have to understand some anatomy and how most ear infections occur.

First of all you just have to close your eyes here and just picture if you will, you have the mouth and at the back of the throat we do have Eustachian tubes which is a little tube that connects the back of the throat to the middle ear space which is the space that is behind the ear drum in the ear. And the job of the Eustachian tube is to equalize the pressure on both sides of the eardrum. You want air pressure going into the ear canal on the outside part of the eardrum to be the same as the air pressure that is on the inside of the eardrum so the air that enters the mouth and goes up the Eustachian tube to ventilate that middle ear space, and you want the air pressure to be the same so that the eardrum can freely move, and you've experienced when the pressure is not equal on both sides of the eardrum when you go up and down in the airplane, or you go up and down in a car in the mountains.


When the air pressure changes on the outside of the eardrum but they hasn't had the chance to filter up the Eustachian tube to match the air pressure on the inside of the eardrum, you know what that feels like, when you have a pressure difference on your ear, so the Eustachian tube is important. Now you also have a lot of bacteria in your mouth, and those bacteria are actually important too, they serves some important roles, and in fact if you were to eliminate all of those bacteria, you have a nice place where yeast can start to grow and that's why babies get thrush because they don't have a lot of mouth bacteria yet. And so the mouth bacteria are important but we want to keep the mouth bacteria in the mouth, we don't want them going up the Eustachian tube into the middle ear space. And so the Eustachian tube has some little hair cells called cilia. Actually the cilia are the hair like projections that come out of these cells and they kind of beat back toward the mouth, so any bacteria that tries to make it up into the middle ear space up to Eustachian tube, the cilia are going to cause them to go back down to the mouth ok, there's going to be an obstacle.


Now, when you get a virus like in the winter, you got a viral upper respiratory tract infection. The virus can infect those cilia cells and the cilia don't work right, so now mouth bacteria are able to go up the Eustachian tube and into the middle ear space. Now combine that with a bunch of mucus production and you can have mucus whether it's from a virus, or whether it's from allergies, but that mucus can clog the Eustachian tubes, so now any bacteria that had gone up there into the middle ear space can't get back down to the mouth because there's mucus in the way. And then we add a third factor, and that is just the anatomy of the Eustachian tube that you're born with. Some people are born with long, rigid, skinny Eustachian tubes and others are born with short, wide, floppy Eustachian tubes, and the short, wide floppy ones have a tendency to flop close and all that mucus can make the edges stick together, so now you just got a Eustachian tube that is sealed close with mouth bacteria trapped.


Other kids have a longer, rigid Eustachian tube that's not floppy and doesn't tend to close like that, and they get less ear infections and kids with the short, floppy wide Eustachian tubes. Now the good news is, as their head grows the Eustachian tubes that are short, wide, and floppy have a tendency to become longer and more rigid and less prone to collapsing, and then as kids get older too, they get less viral upper respiratory infections or their allergies have now been diagnosed and are treated, and so they kind of outgrow their tendencies to get ear infections based on all of this different factors. Once you have an ear infection, how do you treat it? I should mention too, so the mouth bacteria you got up there into the middle ear space, they reproduce and overwhelmed the space and can't get back down to the mouth, and so the body's immune system kicks in since white blood cells tend to kill all those bacteria that aren't supposed to be there, and you get puss and pressure, and the eardrum becomes inflamed and bulging, now you get the ear infection.


OK, so we have the ear infection, how do you treat it? Well, some ear infections are actually caused by the virus itself and not bacteria, although it's difficult to tell if it's bacterial or viral unless you'd still a whole in the eardrum and drain the fluid and culture it and see what's growing. We don't really do that anymore although back in the day, doctors did do that but not anymore. We know that it could be virus, we could sort of assume that it's bacterial and where we are right now with treatment in older kids, so might too an older in the otherwise healthy kid if they have symptoms of an ear infection, and it's just been a dare too. You may want to give it a dare too, to see if the symptoms started to just go away on their own.


The body's immune system can take care of the ear infections and so it does make some sense to give it little time and see if your body's going to take care of it. If your body is not taking care of the ear infection and you're really getting sicker and more pain, and you've got a high fever, or if it's a younger kid who's a little bit more prone to some complications from ear infections like a bone infection behind the ear called mastoiditis or even meningitis from the ear infection. For those younger kids, two and under, we're more likely to just treat them right out of the gate with the antibiotics. The first decision you have to make is, are you going to use an antibiotic? If you are going to use the antibiotic, you have several choices and we're not going to talk about that, I would go with what your doctor wants to do in terms of the guidance there. If you have lots of ear infections and you're using lots of antibiotics and it is becoming a recurrent thing, one option that you have is ear tube surgery. And the way the ear tubes work is, it's a little piece of plastic with a hole in the middle that goes through the eardrum.


And the idea is this, if your Eustachian tube is not working to ventilate the middle ear space, then you can use a hole that goes through the eardrum to ventilate that space. Any bacteria that are trapped in the middle ear and can't got out because the Eustachian tube is blocked, they have an exit route, and they can go through that hole into the ear canal and become skin bacteria, and it's OK to have skin bacteria, the immune system doesn't really respond to that being a problem as long as they're on the surface of the skin and don't invade into the skin, it's basically that tube provides an exit route. If you do end up with an ear infection, it also provides drainage for the puss to come out and makes it a little bit easier to treat the ear infection just with some antibiotic ear drops rather than having to do and oral antibiotic and subject all of your bacteria in your body to death, death by antibiotic.


So that's how ear tubes work, just simple ear tube usually last about 18 months and then they fall out, and there are types of ear tubes that can last longer. There are complications that you can get from ear tube surgery, you have to have anesthesia, there can be complications with that, we worry about bleeding, we worry about a surgical associated in infection, there's also the cost to consider. The surgery itself is probably safer than the car trip to get to the surgical center, it's probably more risk of being in a car accident than actually having something going wrong with the surgical procedure, but it's still possible, so you got to look at it again from a risk/benefit kind of thing. A post operatively, sometimes the ear tubes, when they fall out, sometime the hole doesn't close up on its own and then you can make your way into the teenage years and still have a chronic perforated eardrum from the tube that was there, and that may actually require a surgical procedure to patch up that hole, that's a possible complication of ear tube surgery as well.


What about adenoidectomy? Why would you take adenoids out? Well sometimes adenoids get big and push on the Eustachian tube and so it causes compression of the Eustachian tube which then again, they don't work right, so the idea is, if you have very large adenoids that are compressing the Eustachian tube closed by taking out the adenoids, you make it more likely at the Eustachian tube will stay open and then you ventilate through the eardrum and that hopefully will help the ear infections go away. So big, long discussion there in ear infections, thank you for the questions Marcy and Stephanie, I hope that helped. Let me glance up here real quick and just make sure that I did answer you wanted to know about adenoids and how ear tubes work, we talked about that, no I did miss something, see I'm glad I went back up. What about the probiotics, if you're using the antibiotics to treat ear infections? Probiotics may be helpful if, and really there's a studies that you could pull up that show that prebiotics are good and there are studies that show that they really don't make much of a difference.


It seems the consensus that their most likely be helpful and a who takes antibiotic and then has some chronic diarrhea from the antibiotic, that even the diarrhea is still there even after the antibiotic has stopped. And in those kids, taking a probiotic maybe helpful to repopulate the normal flora in the intestinal tract which will help that diarrhea to go away. And if you have a kid who want to get antibiotics, they are prone to this happening every time, then it may be a good idea to go ahead and put them on the probiotic as long as the probiotic that's not killed by the particular bacteria that you're on, then that may help to prevent the diarrhea from happening in the first place, although it's not a 100% works from some kids doesn't seem to work for others. Your best bet really is to talk to your regular doctor about this and look at your kids' specific situation to see if it's something that may be helpful or not. Alright, there I think we got all the questions taken care of there and I'm sure that next year we'll have more listeners about this time the school gets started and the ear infections start up, we'll have more listeners writing in and we'll cover ear infections again at that point.


Let's move on to Jamie in San Diego, California, Jamie says, "A friend of my wife posted an article on Facebook and I wanted to get your opinion. The article states that drinking soda is linked to behavioural problems in kids. I admit I give my five year old a cup of soda now and then but usually only non-caffeinated root beer or orange pop. To me the study lacks details, does not specify if the kids were given caffeinated or non-caffeinated soda, and makes no mention of socio economic background that might contribute to aggressive behavior. I just think there is not enough evidence to make the assumption the authors are making, I would like to know your thoughts."

Dr. Mike Patrick: Thank you for submitting this story Jamie, and for those of you interested in reading the article Jamie is referring to, and it's a news article not a journal article, I'll include a link to it in the show notes for episode 265 over at pediacast.org.


Let's talk about the basics of this study first and then I'll give you my opinion. This is a collaborative study that was done by the Mailman Scholl of Public Health at Colombia University, The University of Vermont, and Harvard School of Public Health. It was published in the journal of pediatrics August 2013; this is a fairly new study that was published. And if you would like to see the journal article, I'll put a link to the pub med entry for this journal article over at pediacast.org episode 265 in the show notes. You'll be able to see the actual journal article if you're interested, and you'll also be able to see the media story so the new story that the news reporter was able to get from this article, and we'll see if they match up, we'll see how well they reported their job of analyzing the study.


The question before the researchers was this, among five year old children is increasing consumption of soda pop associated with an increased incidence of aggressive behavior, withdraw behavior, and attention problems. Researchers sampled 2929 mother/child pairs from the fragile families in child wellbeing study. All of these children were five years old, 52% were boys, 51% were African-American, 28% were Hispanic, and 21% were white Caucasian. Now mothers were asked on a typical day how many servings of soda does your child drink? And this resulted in five groups of kids, those with zero servings per day, those with one serving per day, those with two servings per day, those with three servings per day, and those with four or more servings of soda per day.


Researchers also collect the data on TV viewing, how many hours per day, candy and other sweets consumption on a per day basis, and fruit juice consumption each day. They were also asked about some social risk factors such as maternal depression, intimate partner violence. Between mother and her intimate partner if she had one, was there any violence between the two? And then also, paternal incarceration is dad in jail? And then they assess each child's behavior by asking the mothers to complete the child behavior checklist based on their child's behavior during the previous two months, and the child behavior checklist is a valid and reliable age standardized tool that measures aggressive behavior, attention problems, and withdrawal behavior. OK, what did they find?


Well first how many of the 2929 children fit in the each of those five soda consumption groups? Well zero servings per day was 57% I think that's great, OK and by the way, occasional soda drinkers were included in the zero servings per day. Most of these kids were not drinking soda, 57% one serving per day, 25% two servings per day, 10% three servings per day, 4% and four or more servings per day was another 4% of the total kids. Do we see a difference in behaviors among these different groups based on their soda consumption? After adjusting the five groups for differences in socio demographic information, such as maternal depression, partner violence, incarcerated fathers compared to those who drink zero servings per day, aggressive behavior did increase in a statistically significant and those dependent fashion. Just to give you an example, the numbers won't really mean much to you, I think they're just really helpful for comparison, the raw aggressions scores.


This is just the raw score on aggression that each child of the group had for the zero servings per day, the average raw aggression score was 56.2, one serving per day it went up to 57.2, two servings per day, 58.4, three servings per day 58.7, and four or more servings per day 62. It went from 56.2 at zero servings a day to 62.0 with four or more servings per day, and with each serving, that aggression score went up a little bit more. Again that score mean much to you except for comparison. But these increases were statistically significant and these numbers held true when TV viewing, candy and or sweet consumption, and fruit juice consumption were factored in.


What about attention problems, will these results mirrored the aggression scores with a statistically significant those dependent rise and attention problems as the number of soda servings per day increased? And then with regard to withdrawal behaviors and this is the tendency to avoid unfamiliar people, places, or situations. Here, researchers only found the statistically significant increase in those who consume four or more soda servings per day compared to those who drank no soda. In order to have the withdrawal behavior, you really have to drink a lot of soda for the un-association to be seen there. The authors conclude by saying, "We know an association between soda consumption and negative behavior among very young children. Future studies should explore potential mechanisms that could explain this association."


Let's talk about this. To their credit, the authors are kind enough to identify some of the study's short comings, they admit that this is an association, they do not claim that soda is causing the behaviors and that's an important distinction and one the authors are quick to point out, so kudos to them. The mainstream press switches out the word association for linked; they say soda is linked to aggressive behavior. It's a synonym, but in my mind, saying linked implies a cause, whereas association, which is the word the study uses, association could mean something else like bad parenting or neglect which could cause both rising soda consumption and a rise in aggressive behavior. I'm not saying bad parenting or neglect is the cause; there are other possibilities as well.


My point is, that a third unidentified causative factor maybe in play, on the other hand, maybe the soda is the cause but this study was not designed to elicit a causal relationship. Another limitation of this study and by the authors' own admission, data obtained on the number of soda servings, and the results of the behavioural survey are based on parent memory which may be subjective rather than objective. A prospective study with investigators controlling the number of servings of soda per day for each group and directly observing behavior that would be more reliable. Third, serving size was not defined, was each serving a Dixie cup, an eight ounce glass, a 20 ounce bottle, or a two litre? We don't know. Forth, and here's one that Jamie pointed out, we don't know what type of soft drink the children consumed, were they caffeinated or non-caffeinated? Sugar sweetened or artificially sweetened? Was it a cola or non-cola?


And finally the sample is not representative of all US children. The authors used the fragile families and child wellbeing study which is made up of 5000 children born in 20 large US urban areas between 1998 and 2000, three quarters of whom were born to unmarried parents and all of whom are considered fragile due to a high risk of family breakups and lives lived in poverty. Another point now in 2013 these kids are actually 13-15 years old, the researchers did not use current data, they mind the child wellbeing study and use data that was actually collected 8-10 years ago. Bottom line, what can we say about this study? Well we can say that 8-10 years ago in socially fragile five year olds who lived in urban areas, there was an association, not a cause or a link in my mind but an association between aggressive behavior and increasing amounts of soda consumption.


That's really all we can say, and to their credit that's all the authors of this study is saying. The problem here is really not the researchers; the problem is the media twisting the study to create an eye catching headline, "Drinking soda linked to behavioural problems in kids", is that what you get out of this? It's not exactly what I get out of it. What's the bottom line for parents? Don't let your kids drink soda every day; it's not good for them. The occasional soda is fine for special days, maybe with a burger or a pizza once a week, I mean you kind of have a little fun living now and then right? But their main stay should be low fat milk and water. I don't need this study to give you that advice, I know it's true and I suspect you know it's true and if press, I could find the evidence to back that up, that's the bottom line. One other bottom line, like Jamie, it's good to be skeptical of the media spin placed upon well intentioned scientific studies.


Let's move on to our final listener question this week, this one comes from Rose in Israel, "Dear Dr. Mike, traces of polio virus have recently been found in the sewage of south Israel. As a result it is now required that children receive oral polio vaccine. The regular vaccination plan had required them to receive Injected Polio Vaccine, so they are already protected against polio. The reasoning for the newly required oral polio vaccine is quote, "To give further protection to the child vaccinated and his family", this sounds suspicious to many mom in Israel. Could you please explain the logic behind the vaccine, and the risk versus benefit analysis, thank you for your great podcast, Rose."

Dr. Mike Patrick: It's a great question Rose and the sure answer is, if I were in your shoes I would give my child the OPV if local health officials are advising it.


And this should not raise suspicions at all but I do think your local health officials could spend a bit more time explaining so I don't have to do it for them. Here's the deal, polio is caused by a virus that spreads primarily through the fecal oral route. What that means is the virus is in the intestine, you poop it out, kids scratch their butt, wipe their butts and the virus is on their fingers, they don't wash well and they touch a door knob, and then you come along and touch the door knob and then you catch fingers in your mouth, and so it spreads fecal oral route, and there's a lot of viruses that spread that way, polio is one of them. Once it is in the intestinal tract, the polio virus may enter the blood stream and cause flu like symptoms, fever, aches, and if this happens then there is the possibility of it causing meningitis, paralysis, and death, it has the potential to be a life altering or life threatening infection.


Now the oral polio vaccine is a live virus vaccine given orally, it strongly stimulates the immune system in the location where the polio virus will first be encountered in the intestine. The resulting immunity has a good chance of eliminating the virus before it ever even enters the blood stream, it's a really good vaccine most people have a really good immune response to it. But there's a problem, rarely the live virus oral vaccine actually causes polio in the United States when the oral polio vaccine was widely used. Pretty much every kid was getting the oral polio vaccine. About two to four cases for every one million babies vaccinated would get polio disease from the oral vaccine. That's a pretty low risk, two to four cases for every one million.


That's an acceptable risk for my personal risk tolerance if there is wild polio virus in the community that is threatening my child. In the United States back in the 1990's we virtually eliminated wild polio virus, even though the incidence of vaccine acquired polio was two to four cases per one million babies, that was actually a higher number that the number of kids getting wild polio virus. More kids in the United States where should be getting polio from the vaccine than from the real deal, of course again it's only two to four cases per one million but the point where the vaccine's causing more disease than the wild disease then you got to do something about it and you have a couple of choices. You could stop vaccinating against polio altogether but that would result in an unvaccinated population who would be in real trouble if wild polio virus returned to the community. Another choice that you have is to switch to the IPV which is a killed virus and has a 0% chance of causing polio disease.


There's another problem, compared to the oral polio vaccine the immunity that you get from the injected polio vaccine is puny, it's not even nearly as good and it produces little immunity in the gut so the virus has a better chance of getting into the blood stream where it might evade the puny immunity provided by the injected polio vaccine. Still, given the fact that more children in the US were getting polio disease from the oral vaccine, and then we're getting it from the wild polio virus and given the fact that we didn't want a completely unprotected population, we switched over to IPV and I think that was the right thing to do. It offers some protection if wild polio virus returns to the community but once we see significant wild polio virus has returned to the community.


It's out there and it may be out there right around the corner from my house, then we have to ask ourselves, is that protection from IPV really enough, or would you rather have the much better immunity at the point where the virus enters the body? Is it worth the two to four chances in a million that that oral polio vaccine will actually cause polio? Well for me, from my risk tolerance level and in the light of local health officials advising it, would I give my child the oral polio vaccine in that situation even if they have had their full series of IPV? Absolutely, but you have to decide for yourself first. I will say this, shame on your local health officials for not explaining their rationale; do you really think parents are not able to understand? I guess you just have to explain it to your fellow Israeli moms Rose or send them in my direction, PediaCast episode 265 we'll let them listen to this section of it and then they can understand as well. It's on my iHeart Radio Talk, and iTunes, and at pediacast.org, 265.


That wraps up our listener edition of PediaCast, don't forget again if you have a topic in mind, you have a question for me or a comment that you would like to make, just head over to pediacast.org, click on the contact link and let me know what you have on your mind and we'll try to get it on the show for you. We are going to take a quick break and I will be back with a final word right after this.



Dr. Mike Patrick: Alright, my final word this week pertains to those living in Central Ohio in relates to a family fun event coming up in just 10 days. The fifth annual Twig Pumpkin Palooza benefiting the rehabilitation unit at Nationwide Children's Hospital will be held form 10 a.m. to 4 p.m. on Saturday, September 38, 2013 at Lynd Fruit Farm in Pataskala. The event will feature a day long autumn festival fit for the entire family with the backdrop of a beautiful country setting; Pumpkin Palooza will feature food, hay rides, bounce houses, games, crafts, a pumpkin patch corn maze and more. I mean seriously, it is fall in Central Ohio right there in the nutshell. Admission to Pumpkin Palooza is free with tickets sold for activities and food.


Three different passes are offered, the toddler fun pass for ages three and younger, it's 11$, the kids' fun pass, ages 4 to 12 at 16$, and the adult fun pass, 13 years and older is 15$. You can buy your passes at the gate and remember, proceeds benefit the rehabilitation unit at Nationwide Children's. Pumpkin Palooza passes, you can purchase them in advance by visiting nationwidechildrens.org\pumpkin Palooza, and I'll put a link to that in case you can't spell it in the show notes for this episode 265 over at pediacast.org. Pumpkin Palooza, food, hay rides, bounce houses, games, crafts, a pumpkin patch, corn maze and more. Lynd Fruit farm at Pataskala, Saturday, September 28 just 10 days away, 10 a.m. to 4 p.m. You can kick off fall before the Buckeyes kick off to Wisconsin later that night at 8 p.m. to be exact in the shoe, so you at the best of both worlds all in one day, and that's my final word.


I want to thank all of you for taking time out of your day to make PediaCast a part of it, we really appreciate your support and for listening. Don't forget PediaCast and our single topic short format program, PediaBytes are both available on iHeart Radio Talk which you'll find on the web at iheart.com and the iHeart Radio app for mobile devices. Reviews and comments on iHeart Radio Talk and in iTunes would be most helpful as I had mentioned earlier in the show. Also links mentions, shares, re-tweets, re-pens, all that stuff sharing it on your social media sites is helpful. PediaCast is on Facebook, Twitter, Google Plus and Pinterest and be sure to tell your family, friends, neighbors and co-workers about the program, also probably most important, tell your child's doctor so that they know that there is an evidence based pediatric podcast aimed at moms and dads but we don't dumb things down, we really go into detail in a way that you can understand, just let them know that and in that way they can share the show with their other patients and we do have posters available under the resources tab at pediacast.org.


You can also get in touch with me as I mentioned at pediacast.org, just click the contact link says, "Contact Dr. Mike", you can't miss it. You can ask questions; provide comments and suggestions of topic. We also have a link to connect with a pediatric specialist from Nationwide Children's just that to help you out with referrals and appointments. That wraps up our time today, thank you again for stopping by and in until next time, this is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids, so long everybody.


Announcer: This program is a production of Nationwide Children's, thank you for listening. Well see you next time on PediaCast.




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