Hand Gel Abuse, Reye’s Syndrome and Artificial Sweeteners – PediaCast 211

Join us in the PediaCast Studio as Dr Mike covers the latest pediatric news and answers listener questions. Topics this week include teens getting drunk from hand sanitizer, sippy cup dangers, a new use for an old antibiotic, math skills and medication errors, aspirin and Reye’s Syndrome, and an update on cell phones and driving. All this, plus kids with grey hair and a modern history of artificial sweeteners!


  • Hand Sanitizer Abuse

  • Baby Bottle, Pacifier and Sippy Cup Dangers

  • A New Use for an Old Antibiotic

  • Math Skills and Medication Errors

  • Cell Phones and Driving (an update)

  • Aspirin and Reye’s Syndrome

  • Grey Hair

  • Artificial Sweeteners


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 from the good folks at Nationwide Children's Hospital in Columbus, Ohio. This is Dr. Mike and it is episode 211, 2-1-1, for May 17th 2012. We're calling this one Hand Gel Abuse, Reye's Syndrome and Artificial Sweeteners.

Now, most of you will recognize that this is a news and listener episode of the program and of course we'll cover lots more topics than just those three. They're kind of a highlights there and we'll get to the full lineup in just a couple of moments.


We are in full swing here into a preparing for the opening of a new hospital on June 20th and as it turns out this is the Nation's largest pediatric expansion ever in the history of the United States. I mean, this is huge. So our new hospital is going to open on June 20th and when you look at all the new facilities that are going into this expansion project you were adding 2.1 million square feet to our existing facilities, so this is huge.

The new hospital tower, itself, is 12 stories tall and each floor is the size of a football field. I mean, it's colossal. And in fact, during our orientation they showed us the center elevators, they're calling that the 50-yard line because of the fact that each floor is 100 yards. So it's huge and to learn our way around it and how the facilities work, there's lots of really cool stuff for patients.

I mean, you hate to see a kid have to be hospitalized. You just hate it. And as a parent, you hate it and as medical professionals we don't like to see kids sick but sometimes they do have to spend a night in the hospital and I'm telling you if your kid has to spend in the hospital this is the place to do it because it's really cool. Lots of neat stuff and as you can imagine, we have to train everyone to know where things are and so there were lots of orientation stuff going on, lots of buzz, lots of excitement to get us ready for June 20th.

And one of the things, the emergency department is actually doubling in size and of course that's were I do some of my clinical time and we're doubling up to 70 beds in the emergency department, so a huge ER. And you know, when there's an emergency you don't want to be trying to figure out where things are located so we actually have scavenger hunts that are going on with the staff actually has to get a list of things and go find them fast. So just to get everybody on board or where things are located. It's exciting, really lot of buzz around this place over the new hospital opening and as we get closer to June 20th I'll share more of it with you.


Another cool thing that we have going on here at Nationwide Children's is a joint product and project from the Center for Healthy Weight and Nutrition here at Nationwide Children's and also the Pediatric Comprehensive Weight Management Center at the C.S. Mott Children's Hospital. Now, they're affiliated with the University of Michigan and of course here we house the Department of Pediatrics for the Ohio State University.

So here we have an Ohio State Michigan joint project, so we can work together with the State of North, just want to point that out. So this is a pretty cool project called Feeding Your Kids, it's a free 45-day text and email based program. So you basically sign up for it and for the next 45 days, you can either get them everyday or you can spread it out to 90 days and get it every other day. And you get text messages and email messages each day of the program that address the real life challenges of feeding today's kids and teenagers. And it's written from a parent's perspective aimed at other moms and dads and caregivers and really just dealing with feeding issues and toddlers up all the way through teenagers.


So it helps you make small changes overtime that add up to big results. So to sign up for that or to find out more information, there'll be a link in the Show Notes over at pediacast.org. Basically, you go to nationwidechildrens.org\feeding-your-kids or an easier way just go to pediacast.org look at the Show Notes for episode 211 and we'll have a link for you at that point so you can sign up for it.

OK. So what is the full lineup of today's show, hand sanitizer abuse, teens are getting drunk on hand sanitizer. So we're going to let the parents out there know exactly what kids are doing so you can be one step ahead of them.

A baby bottle, pacifier and sippy cup dangers, now we're not talking about plastic or the BPA content, which we're talked about before on this show. We're talking about trauma, so kids running around with the bottles, pacifiers and sippy cups in their mouths or holding on to them and exactly how many kids are injured because they are mobile with these things in their hand or in their mouth, we're going to talk about that.

Also a new use for an old antibiotic. Math skills and medication errors. The numbers are going to surprise you here just how many kids have a medication error because of poor math skills, so we're going to discuss that.

Also cell phones in driving, we've talked about this one before but there's a new study out and we'll have an update for you on the dangers of cell phone in driving. In this case, it's not even the act of using your cell phone when you drive, it's actually just anticipating that you're going to get a phone call or a text message can lead to more accidents. So we're going to talk about that.


Also Reye's syndrome, this comes from a listener question. You've probably been to the doctor before and your doctor's made a point of saying don't use aspirin for your kids at all, unless directed by a physician because they have something like Kawasaki disease; just don't use aspirin, use Tylenol or ibuprofen instead. So why is it that parents shouldn't give their kids aspirin? Well, the reason is Reye's syndrome, we're going to talk about exactly what that is, how we discovered it, when the recommendation not to use aspirin came along. Because a lot of parents out there that are my age remember taking the little orange chewable baby aspirin. It was like if you were sick it was a given you're going to get one these things and they tasted pretty yummy. So why don't we do that anymore? And we're going to talk about that.

Also, gray hair, why some kids have it? Is it a problem? Is it a concern if your child is getting gray hair as a child? We're going to discuss that and then finally we'll wrap up with artificial sweeteners. This one also coming from a listener who used the Skype line. What's with all the new artificial sweeteners including the new ones from the Stevia plant, which are reported as natural artificial sweeteners, although if it's natural should we really call it artificial? I'm not quite sure about that. So anyway, we're going to talk about aspartame and saccharin and sucralose and the new Stevia plant products and that's all coming up toward the end of the program.

I want to remind you if there's a topic you' d like us to discuss just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or call the voice line at 347-404-KIDS, 347-404-K-I-D-S. So if you have a question or a topic suggestion please be sure to let us know.

I also 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. If you do have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. And with all that mind, we will be back and cover News Parents Can Use, right after this.



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

Los Angeles emergency departments are reporting a growing number of teen coming in drunk after drinking cheap liquid hand sanitizer. The hand sanitizers which contain over 60% ethyl alcohol and can make 120 proof liquid are becoming an increasingly popular route for getting drunk. According to the Los Angeles Times, six teens have been reportedly taken to emergency rooms in the San Fernando Valley and treated for alcohol poisoning after drinking the hand sanitizers. In some cases, salt was used to separate the alcohol so that it could be drunk straight like a shot. Learning how to distill this sanitizer's not difficult if you know how to look things up online.

Public health officials in the San Fernando Valley have been describing these cases as a possible trend nationally. A dangerous trend. And Dr. Cyrus Rangan, director of the Bureau of Toxicology and Environmental Assessment at the Los Angeles Department of Public Health told the L.A. Times, "All it takes is just a few swallows and you have a drunk teenager. There is no question that it is dangerous. And it's kind of scary the extent they'll go to distill the hand sanitizer in order to get a shot of what amounts to hard liquor."

Dr. Rangan is worried this behavior could turn into a national problem since hand sanitizers are readily available and relatively cheap, certainly within the budget of most teenagers. Intentional hand sanitizer consumption appears to be a new trend with virtually no cases reported in past years. Accidental ingestion by younger children is another hand sanitizer hazard but one that can be lessened by keeping the bottles away from little hands and using foam versions in the home rather than gel because it's more difficult to consume large volumes of the foam, unless of course they get the cap off.

Incidentally, it's also more difficult to distill foam sanitizers so this may be the better option to stock in your home if you're worried about teenage temptation. Dr. Rangan stresses the importance of parental awareness of just how much alcohol these products contain and you shouldn't overlook the small travel bottles either because even these contain enough alcohol to be dangerous.


So, it's one those things with something good you always have the potential for issues associated with it. I can remember and I'm sure a lot of healthcare providers out there my age or older will tell you that before hand sanitizers really came onto the scene and became an accepted substitution of using soap and water that when we had to wash with soap and water before and after every patient, especially in the winter time up in the north where it was dry outside, I mean, washing your hands with soap and water between every patient just would tear up your hands. Just dry them out, crack, you get little bleeding, it's not great although it's great for preventing the spread of an infection.

But when the alcohol based hand sanitizers came on to the market, it's really made a huge difference. And it doesn't dry out my hands even nearly as much, so you know, we gel as we go into a room, we gel when we come out of a room, so our hands are sanitized in between patients. And it's really made a big difference and so it's a great thing but when there's a great OK what's the downside and apparently this is one of the downsides.

So we talked about so-called synthetic marijuana a few weeks ago and how teens were lead that it's only incense. Well here's another potential hazard and unfortunately it's one you really can see catching on and I think we're going to hear more about this in the coming months. I did a quick Google search to see for myself exactly how easy it is to distill hand sanitizer gel to make pure 120 proof ethyl alcohol and let me just say it is remarkably easy.

Purell has began adding a chemical that provides a bitter unpleasant taste which remains even in the distilled product in an effort to eliminate abuse, but there are plenty of brands out there to choose from and some folks may not find the taste to be an obstacle, especially after you've had a couple of drinks, if you know what I'm saying. So parents be pro-active, know what your kids are doing, stay one step ahead of them and we're trying to be helpful in that regard here on our little program.


All right. Let's move to some news from my own backyard, a new study by researchers in the Center for Biobehavioral Health and the Center for Injury Research and Policy here at Nationwide Children's Hospital, exam in pediatric injuries associated with baby bottles, pacifiers and sippy cups. Researchers found that from 1991 to 2010 an estimated 45,398 children younger than three years of age were treated in U.S. emergency departments for injuries related to the use of these products.

This works out to an average of 2,270 injuries each year or one child treated in a hospital emergency department every four hours for injuries from these products. The study released online this week and slated for publication in the June 2012 print issue of Pediatrics, found that baby bottles accounted for 66% of injuries, followed by pacifiers at 20% and sippy cups at 14%. Body regions most commonly injured were the mouth – 71%; and head, face or neck – 20%. Most injuries were the result of falls while using the product – 86% – which suggest that children were walking or running with the products in their mouth at the time of the injury. "Two-thirds of injuries examined in our study were the one-year-old children who are just learning to walk and more prone to falls," said the study's co-author, Dr. Sarah Keim, PhD, MA, MS. "Having children sit down while drinking from baby bottles or sippy cups can help reduce the occurrence of these injuries."

Both the American Academy of Pediatrics and the American Academy of Pediatric Dentistry recommend that children be transitioned to regular, lidless cups at 12 months of age. The AAP also suggests parents try limiting pacifier use after six months of age because they might increase the risk of ear infections.

"These are products that almost everyone uses," noted study co-author, Lara McKenzie, PhD. "Educating parents and caregivers about the importance of transitioning their children away from these products at the ages recommended by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry could prevent up to 80% of the injuries related to baby bottles, pacifiers and sippy cups."

This is the first study to use a nationally representative sample to examine injuries associated with bottles, pacifiers and sippy cups that were treated in U.S. emergency departments. Data for this study were obtained from the National Electronic Injury Surveillance System, which is operated by the U.S. Consumer Product Safety Commission. This surveillance system provides information on consumer product-related and sports and recreation-related injuries treated in hospital emergency departments across the country.


So, I think the take-home here really is there's nothing magical or a design flaw with pacifiers, bottles and sippy cups. I mean, these just happen to be the things that 12-month olds are carrying and have in their mouths. So I really think the take-home here is that your kids, when they're learning to walk, when they're young, they really shouldn't have anything in their mouth and probably shouldn't have anything in their hand either when they're walking, cruising, crawling, toddling.

Basically, if they're in motion, their mouth and their hands really ought to be empty, I mean, that's my take-home for you and then interpret it as you will. It's not that the pacifier or the baby bottle or the sippy cup is inherently dangerous. It's just that's the object that most of them have and so regardless of what it is, keep their mouths clear, keep their hands empty when they're toddling around.

Another interesting study from my home institution concerns an antibiotic and I'm sure most of you will recognize amoxicillin combined clavulanic acid, better known as Augmentin as the brand name, but a lot of docs just call it Augmentin so I'm going to use that term. But this time around we are not using it to kill bacteria. As it turns out this common antibiotic may improve small bowel function in children experiencing motility disturbances, that's according to a study that will appear in the June print edition of the Journal of Pediatric Gastroenterology and Nutrition.

Augmentin is most commonly prescribed to treat or prevent infections caused by a bacteria, however, it is also been reported to increase small bowel motility in healthy individuals and has been used to treat bacterial overgrowth in patients with chronic diarrhea. Upper gastrointestinal symptoms such as nausea, vomiting, abdominal pain or early satiety, that means getting full fast, and abdominal distension are common in children despite the advances in the technology for diagnosing motility disorders there continues to be a lack of medications available for the treatment of upper gastrointestinal tract motor function.


"There is a significant for new drugs to treat upper gastrointestinal symptoms in children," said Dr. Carlo Di Lorenzo, MD, chief of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s and one of the study authors. “Currently used drugs are often only available on a restricted basis, have significant side effects or aren’t effective enough on the small and large intestine.”

To examine whether amoxicillin-clavulanate might serve as a new option for treating upper gastrointestinal tract motor function, investigators at Nationwide Children’s examined 20 patients who were scheduled to undergo antroduodenal manometry testing. So this is a testing movement and pressure in the small intestine. After catheter placement, the team monitored each child’s motility during fasting for at least three hours. The children then received one dose of Augmentin enterally, that means by mouth or through a feeding tube, either one hour before ingestion of a meal or one hour after the meal and then had motility monitored for one hour following.

The study showed Augmentin triggered groups of propagated contractions within the small intestine, similar to those observed during the duodenal phase III of the interdigestive motility process; or another way of putting it, following Augmentin, the small bowel moved food better. This response occurred in most of the study participants during the first 10-20 minutes and was most evident when Augmentin was given before the meal.

"Inducing a preprandial duodenal phase III may accelerate small bowel transit, influence the gut microbiome and play a role in preventing the development of small bowel bacterial overgrowth," said Dr. Di Lorenzo. Translation, the Augmentin may kill bad bacteria, promote healthy growth of food intestinal microorganisms and improve the forward flow of the stuff you've eaten.

Dr. Di Lorenzo says that Augmentin may be most effective in patients with alterations of duodenal phase III, chronic symptoms of intestinal pseudo-obstruction and those fed directly into the small bowel with gastrojejunal or nasojejunal feeding tubes. Boy, he is making me work today!

So it's most likely in help of one of the things Augmentin improves was broken in the first place and it's more likely to work in children fed with feeding tubes. Although Augmentin seems to mainly affect the small bowel, the mechanisms by which it works are not clear. Dr. Di Lorenzo also says that possible downsides of using amoxicillin-clavulanate as a prokinetic agent and this include the induction of bacterial resistance, especially from gram negative bacteria such as E.coli and Klebsiella and it may also cause Clostridium difficile induced colitis.

Still, he says further investigation of Augmentin’s long-term benefits in gastrointestinal clinical situations is worthwhile. And he says, "The scarcity of currently available therapeutic options may justify the use of Augmentin in selected patients with severe forms of small bowel dysmotility in whom other interventions have not been effective."


So this news story probably isn't of great interest to many of you, other that my seemingly amusing use of big words, but for others of you and you know who you are, it's very interesting and it's something you might want to discuss with your child's GI specialist at some point in the future if your kiddo is suffering from intestinal motility problems.

Also, I want to point out and just to be fair because if it we're coming from any other institution I would mention this and so if it's coming from my home institution I want to mention it as well. The study size is only 20 patients, so obviously there's going a need to be larger studies done with an increased sample and a well-done prospective study with the control group and then an experimental group to really see if this is an evidence based type of recommendation before it becomes a recommendation for everyone to use. But it's something on the horizon and there seems to be more and more kids being diagnosed with GI motility disorder, so I thought you'd be interested in hearing about it.


All right. Let's move on to one of my daughters least favorite subjects and that is math. Many parents cringe when their child asks for help with their math homework. Yeah, I've been there, especially when it's coming close to calculus, yeah, I've been there.

Our new research shows that poor math skills can cause another difficulty for caregivers and that is measuring the right amount of medicine. In fact, parents with math skills at the third grade level or below were five times more likely to measure the wrong dose of medication for their child that those with skills at the sixth grade level or higher. That's according to a study recently presents at the Pediatric Academic Societies annual meeting in Boston.

"Parents face many challenges as they seek to administer medications to their children in a safe and effective manner," said study co-author Dr. H. Shonna Yin, MD, MS, FAAP, assistant professor of pediatrics at New York University School of Medicine and Bellevue Hospital Center. She goes on to say, "Dosing liquid medications correctly can be especially confusing, as parents may need to understand numerical concepts such as how to convert between different units of measurement, like milliliters, teaspoons and tablespoons. Parents must also accurately use dosing cups, droppers and syringes, many of which vary in their measurement markings and the volumes that they hold."

Studies have shown that people with low reading skills are more likely to make mistakes in measuring the correct amount of medicine. Little research, however, had focused on whether low math skills contribute to dosing errors.

In this study, researchers looked at the relationship between both reading and math skills and medication dosing errors. Participants included 289 parents of children younger than 8 years of age who were prescribed a short course of liquid medication after being seen in a pediatric emergency department. Caregivers spoke either English or Spanish and were the primary person responsible for administering the medication. Caregivers were given three tests to assess their reading and math skills. Researchers also watched parents as they measured out a dose of the medication that had been prescribed for their child.

The study results revealed that nearly one in three parents had low reading skills, while 83% of parents had poor numeracy skills with 27% had skills at the third grade level or below. Observations showed 41% of parents made a dosing error.


I seriously need to pause and say that again, 41% of parents made a dosing error. That's crazy. I mean, that's just crazy. Parents' math scores, in particular, were associated with measuring mistakes, with parents who scored below the third grade level on math test having almost a five times increased odds of making a dosing error.

Dr. Yin concludes by saying, "Our study found that many parents have poor numeracy skills, placing them at a high risk for making dosing errors. These findings point to a need to examine whether strategies that specifically address parent math skills can help reduce medication errors in children. In addition, recognition of the importance of addressing math skills may be helpful for health care providers as they seek to improve their communication of medication instructions. For example, having providers review and give parents pictures of dosing instruments filled to the correct amount for that prescription may be beneficial."

So this is really important information for clinicians and I'm going to say, it's not just the doctors who are failing here, it's also the pharmacists, because we write out a prescription, this is how much we want the patient to give and granted we should have tools, pictures, the syringes, the cups, whatever, to make it quite clear exactly what we're giving. But ultimately, it is the pharmacist who says I'm going to dispense the medicine and I have provided any teaching that the parent needs. And so I really have to say that the pharmacists are also to blame if we're going to put blame somewhere on this, if parents aren't giving the right amount of medicine.

I mean, really it should be clear, hey, this is the cup, this is dropper, this is syringe that you're going to use, here's the line. I don't know if we need special droppers with the line marked in a different color for that particular medicine then it's an added issue because they're going to use that dropper for something else down the road and it's not necessarily the right dose for that one, I understand that.

So it's not perfect and I'm not placing all the blame on the pharmacist, don't get me wrong here. But I think all of us need to really look at this and figure out what we can do to make things better, because 41% of parents making dosing errors is just unacceptable. It's easy to whip out a prescription or just say hey, give them some Tylenol or Motrin as needed, but I guess we really need to do more than that. I need to do more than that. I think most of the doctors and nurses listening right now need to do more of that and I think pharmacists need to do more of that.

So I guess the next question is how do we improve this at the level of the medical visit and the pharmacy visit? Dr. Yin gave us some ideas but I'm sure some of you have others and be sure to share them and you can do that on the Show Notes blog over at pediacast.org for episode 211.


It's well known that using a cell phone while driving can lead to motor vehicle crashes and new research, this one also presented at the Pediatric Academic Societies annual meeting in Boston, shows that even anticipating calls or messages may distract drivers and increase the risk of a crash.

Dr. Jennifer M. Whitehill, PhD, a postdoctoral fellow at Harborview Injury Prevention and Research Center at the University of Washington, and her colleagues sought to determine whether compulsive cell phone use is associated with motor vehicle crashes.

They enlisted undergraduate students to complete the Cell Phone Overuse Scale (CPOS), a 24-item instrument that assesses four aspects of problematic cell phone use: 1) frequent anticipation of calls/messages; 2) interference with normal activities, impacting friends/family, we've all either seen that or been a part of that, someone's trying to talk to you and you're clicking away with your thumbs; 3) a strong emotional reaction to the cell phone and 4) recognizing problem use.

The 384 students also took an online anonymous survey that included questions about driving history, prior crashes while operating a vehicle, and items assessing risky behaviors and a psychological profile.

Another one of the study's author, Dr. Beth E. Ebel, MD, MSc, MPH, FAAP, says, "Young drivers continue to use cell phones in the car, despite the known risk of crash. We were interested to explore how cell phone use contributes to distracted driving and to begin to understand the relationship between the driver and the phone."

Results showed that for each 1 point increase on the Cell Phone Overuse Scale, there was an approximately a 1% increase in the number of previous motor vehicle crashes. And of the four dimensions of compulsive cell phone use, a higher level of call anticipation was most significantly associated with prior crashes.

Dr. Whitehill says, "We know it's important to prevent young drivers from taking their hands off the wheel and eyes off the road to use a cell phone. This study suggests that even thinking about cell phone calls and messages may be an additional source of distraction that could contribute to crashes."

So, I guess when it comes to using cell phones while you're driving the old adage proves true, "Don't even think about it." And on that note we conclude this week's News Parents Can Use. We're going to come back and answer your questions right after this.



All right. Welcome back to the program. It is time for our Answers to Listener Questions segment and you will recall a few shows ago, I put out a call for more listener questions because we are running a little low in the listener question piggy bank and of course you guys came through in large numbers and we are definitely reloaded. We won't get through all of them in this particular show but if you wrote in please be patient because we do have more News and Listeners shows, it's coming your way very soon and we are going to get to a lot of those.

If you haven't written and then you do have a question, please still write in, because if you have a great one that I think is really going to impact the audience and make a difference for people, we'll get to it. So please continue to send your questions in. But I did want to put out a thank you because I asked for more questions and you guys definitely responded.

All right. First up, we have Meg in Sewanee, Tennessee and Meg says, "Hi, Dr. Mike. Love your show. I'm a pre-med student and I'm planning on going into pediatrics and I just love listening to your podcast. I wanted to know if you could do a segment on Reye's syndrome and aspirin. I grew up referring to any pain reliever or anti-inflammatory drug as aspirin. And whenever I told my doctor I took aspirin even when I really meant ibuprofen or Tylenol they always got very stern with me. I know that taking aspirin can cause Reye's syndrome and I wondered if you could explain what that is and how aspirin causes it. I also want to know why it is so much more dangerous for kids. Thanks."


Thanks for your question, Meg. And I would encourage you that you're a pre-med student thinking about going into pediatrics and I would definitely encourage you to do it. This is absolutely a rewarding field, whether you're going to primary care pediatrics or then you go on to choose a sub-specialty within pediatrics, I really love it. And I certainly do not regret going into pediatrics in the least and I would encourage you to do that.

And when you're looking for a great medical school, I would say hey, take a look at Ohio State, they've got a really cool curriculum out there. It's really unique and integrates the basic sciences and the clinical sciences and so definitely check them out, even if you're from Tennessee. And when you're looking for a Pediatric Residency Program, there's no place better, in my humble opinion, than the Nationwide Children's Hospital.

OK. So, this is advice about aspirin that many parents have heard, don't give your kids aspirin; use Tylenol or ibuprofen instead and in general it is absolutely good advice. Now, there may be cases when a physician instructs a parent to give their child aspirin, for example, a pediatric cardiologist may tell you to do that if they suspect that your kid is suffering from Kawasaki disease and back in episode 203 we talked about Kawasaki disease. But these situations are rare and really we only use aspirin in kids if the benefits of using it clearly outweigh the risk. Certainly, giving your kids aspirin is not something you should do on your own, only with directions from and supervision by a physician.

So what's up with this risk? Isn't there a product out there called baby aspirin? The orange-flavored chewables that many of us remember taking as kids, made popular by such brands as Bayer and St. Joseph and either you loved them or you hated them. And those of you in your late 30s and 40s know what I'm talking about. I used to call them googoos as a young child, I don't know why and I'm kind of embarrassed that I just told you that actually.


But you know, when I was sick and mom was getting out the bottle, I'd say googoo, probably because I thought they were yummy and I was trying to say good, good. I mean, it was definitely tasty in my opinion, orange-flavored candy-like medicine, which of course is a Poison Center's nightmare. You've got pills that are chewable and taste good. All right, but I digress.

The orange-flavored chewables are still out there but they are not called baby aspirin anymore because they aren't for routine uses in babies or children or teenagers, they're only for adult use now. So again, what exactly is the risk? Well, as Meg mentioned, the risk is something called Reye's syndrome so let's talk about it.

Back in the early 1960s, a physician by the name of Dr. R. Douglas Reye, that's why it's called Reye's syndrome, published a study in The Lancet Medical Journal that first described a seemingly new set of unexplained symptoms. So what happened? Well, the symptoms went like this — these kids had this syndrome that became, called Reye's syndrome, first they would have high fever, vomiting and sometimes a rash would be present, then they would progress into liver inflammation; they would have then get some mild liver dysfunction and some brain inflammation or encephalitis, which would cause behavioral changes and confusion.

This would then turn into what he called stage three where they would have worsening brain and liver inflammation. The liver would still be mild problems but it became bad news for the brain because the brain you remember it's enclosed in a hard skull, it doesn't have a lot of space to expand and so it the brain swells you get increase pressure on the brain and that causes cerebral edema, swelling of the brain that chokes off its own blood supply and so the brain is swelling the pressure, itself, cuts off return of blood, which causes even more swelling. So it's basically a vicious cycle of more and more swelling and then that leads to loss of consciousness and ultimately coma and then death.


And then stage four, we would see worsening brain and liver inflammation and now at this point the liver problem is beginning to get worse and you'd also get some kidney inflammation at this point. And then deepening unconsciousness or coma and then finally, stage five, which would happen rapidly is that now you'd have seizures, respiratory arrest, your liver and kidneys are in failure and you'd get a high ammonia level and then finally death.

Now, if you go back to stage one, high fever, vomiting and a rash, a lot of kids had that. So this was a common viral presentation but so why was it that some kids would just have the high fever, vomiting, rash and then get better but other kids would progress down this pathway to Reye's syndrome and at that time no one really knew why this would happen to some kids but most kids it wouldn't happen with.

And most kids, by the way, in the 1960s who had this progression ended up dying. And ultimately, it really did progress all the way to death. And while Dr. Reye outlined the progression of symptoms which defined the syndrome, still nobody really knew what caused it or how they could prevent it. I just seemed to happen at random to some kids with no clear way to predict who would get it and who wouldn't. And in fact, it took them about 20 years to determine that the culprit was a combination of a viral infection treated with aspirin.

So why did it take so long to figure this out? Well, tons of kids had viral infections and tons of kids took baby aspirin but only a few cases of Reye's syndrome popped up here and there. So it wasn't one of those things where oh yeah, every kid who had a virus and they took aspirin this happened to them. It was sporadic and so no one really looked at aspirin as being part of the cause because so many kids took aspirin and most kids who had a fever and vomiting and might get a rash did not go into Reye's syndrome.


So what really led to identifying the association was when Tylenol and ibuprofen entered the market. So kids treated with these products they did notice now where much less likely to develop Reye's syndrome compared to those who are taking aspirin. So now that Tylenol and ibuprofen are an option, now you can start to say, hey, wait a minute, kids who take Tylenol and ibuprofen this is not happening, it's only in the kids, even though it's sporadic and not all kids taking aspirin get it, it's always in the aspirin kids. So now we've got to look could aspirin be an issue?

We also got better at identifying viruses and we began to see that kids with chickenpox and influenza-like viruses were also more common to get Reye's syndrome. So if it was a kid who took aspirin and they had chickenpox or an influenza-like virus, those were much more likely to then go down that Reye's syndrome, cascade to those stages and then ultimately ended up dying.

By the early 1980s, the association was pretty clear and the warnings began to appear on aspirin bottles saying that it was not safe to give kids aspirin if they had a current viral infection. It wasn't an outright ban at that point. Doctors didn't say don't do it, it was just if your kid has a viral infection you might not want to use aspirin; go with the Tylenol or with ibuprofen instead. But it still wasn't like really you had to do this. And the reason for that is because there was a lot of push back and the use of aspirin in kids was very popular and most families would say, hey, my grandparents had aspirin, my parents had aspirin, I had aspirin as a kid, I'm going to give my kids aspirin because this is all nonsense.

So it appeared to be safe and it really took a while for parents to switch over to using Tylenol and ibuprofen instead of aspirin and so it wasn't an overnight ban kind of thing. Moms still used it for pain, but then it became more and more acceptable, OK, if you kid's in pain use the aspirin, if they have an illness with the fever don't use the aspirin. And especially, if they have chickenpox, don't use the aspirin.


So slowly, over the next 10 years or so, through the 1980s, it became more and more on topic of just stop using the aspirin, stop using the aspirin. So as this sort of caught on with the family and with practitioners out there, it really became more OK, now we're going to actually put a label on the aspirin saying don't do this and the messaging from the medical community became more consistently, don't do it.

But that was a process and it really did take some time to get to the point where we were saying, "no aspirin for kids and taking baby aspirin off the shelves as something that's marketed toward giving to children." Now, even though we had this association and we really knew that it was a true and the recommendation came out not to give the aspirin, we still didn't really know the mechanism. So what pathological process was at play?

And in terms of absolute certainty, we still don't know exactly, even today, what's happening. But we do have a pretty good idea and it took some time for this to happen too. It took a very long time for us to kind of get to the point where, in fact, when I was in medical school, it was we don't know. We don't know, we just don't do it but we don't know what the mechanism is. But here in the last five to ten years we do have a pretty good theory and that theory is that some people are born with an inherited condition known as a fatty acid oxidation disorder. And this means that they're either missing or they have a defective enzyme in their cells which makes it difficult to break down fatty acids.


And under normal conditions when you just have a few fatty acids that need to be broken down, there are alternate pathways that can do that, so pathways that don't involve their missing or defective enzyme. So on a normal circumstance it's really not a big deal because whenever they're missing or defective enzyme is they have other enzymes that can do the job. They're not necessarily the enzyme of choice but they can break down fatty acids.

However, under the stress of illness and particularly with chickenpox and influenza-like viruses, more fatty acids are produced as a by-product of having the infection and fighting the infection. And so now, you have a big load of fatty acids that you need to break down and you have a missing or a defective enzyme to do that and so the alternate pathway can't keep up. And then what we think is that aspirin actually blocks that alternate pathway, so that now not only do you have a big build-up of fatty acids and a defective enzyme for breaking them down but now with the aspirin you have basically eliminated the alternate pathway. And so you're going to get a build-up of these fatty acids that your body can't handle and your body has to do something with them.

And that's why it happens sporadically because if you were born fine, without an enzyme problem to begin with, it wasn't an issue. You can use the aspirin to break down the alternate pathway but your primary pathway still works fine and so it's not going to be a problem. It's just these folks who are born with this issue who would have a problem when they got the virus or they had the aspirin. And because it didn't really show up as an issue until they have the viral illness and had the aspirin, you couldn't really identify which people would have this issue and which wouldn't.


And so, ultimately, you get a massive build-up of fatty acids in the blood and in an effort to get rid of them the body starts storing them. And guess where, in the brain and in the liver and the kidneys. And these organs don't like them being there and so inflammation and swelling and dysfunction result which finally lead to liver failure, kidney failure, brain failure and death. So, if this is the case at this point, why not test everyone for fatty acid oxidation disorders and only have those people avoid aspirin?

Well, testing everyone of course would be expensive and there are accepted alternatives to aspirin now like Tylenol and ibuprofen, which don't block fatty acid metabolism. Now, if you have a family history of someone with the Reye's syndrome that could be a reason for testing of you could also just make doubly sure that you're avoiding aspirin. Actually, there have been cases of Reye's syndrome in the absence of a known fatty acid oxidation disorder, so there may be other enzymes and pathways that we don't know about which means a negative screening test for a fatty acid oxidation disorder could give you a false sense of security if there are other mechanisms that could lead down that Reye's syndrome pathway that we just don't know about yet.

So there you have it, many people today are walking around with undiagnosed, generally mild, metabolic disorders but when you give them a severe viral infection or you add aspirin on top of that, bam!, they could start down that Reye's syndrome pathway. And that, Meg, is the story behind Reye's syndrome. I hope that was helpful for you.

And by the way, Meg, I mentioned that we have a great residency program, we do have a show coming up down the road this summer where we're going to have the director of our Pediatric Residency Program and one of our first year residents come into the studio and talk a little bit about what goes into training a pediatrician and I think you'll find that show particularly interesting. So look for that, Meg, in the coming weeks.


All right, let's move on to Lisa in Southern California and Lisa says, "Dear Dr. Mike, I love listening to your show and I have a question for you. My five-year-old son has had a third gray hair. Now I have some, I'm in my late 30s, my husband used to have quite a few gray hairs when he was in his 20s but has less of them now, which we kind of explain with his current sedentary lifestyle." So he sits on the couch and the gray goes away. All right. I'm sorry. Lisa goes on to say, "My son is out in the sun a lot and swims at least once a week, although indoors. He's also a picky eater except for red meat, he does eat those and he's a smart kid. Is this a fluke or should I be concerned? Thanks, Lisa."

Well thanks for the question, Lisa. First, smartness is not associated with gray hair and neither is lack of physical activity, otherwise we'd have millions of gray haired kids out there because there is a lot of kids who are smart and there's a lot kids who lack in the physical activity department. What actually causes gray hair is a decreased amount of a pigment called melanin, they get incorporated into the hair as it's made in the hair follicle. So then the question becomes what causes a decrease in the pigment melanin as hair is getting made?

Well, the most common reason is just normal aging, they just happens. But what about when it happens early? Well there are genetic patterns of early graying, meaning this phenomenon tends to run in families and is nothing to worry about. So if a mom and dad both had some gray hairs early and grandparents had gray hairs early and now your child has some gray hairs early it's a family pattern, it's probably nothing to worry about.

Then having said that, there are some disease processes that can result in the emergence of gray hair but the good news is they're not common. In fact, they're pretty rare, but it's still possible and some examples of those include a condition called alopecia areata, which we have talked about on this show before. It's an inherited auto-immune disorder, so your immune system attacks the hair follicle and that results in hair loss and it can also result in some pigment changes because of what the immune system is doing and hair can initially grow back kind of gray in this order after it's fallen out.

But eventually, there usually is recovery of the original color. So with alopecia areata, often times you'll have hair that falls out in patches and then those patches come back gray but then the color comes back. So it's not really what you're describing. It's not a strand here and there. It's a pretty particular pattern that's fairly easy to recognize on the part of your doctor, he should be able to recognize that.


Some other diseases that can cause some gray hair and usually it's not just one gray hair here and there, so this is going to be more in patches, widespread kind of graying and the things that can do that include vitamin B12 deficiency, abnormal thyroid function, pigment disorder known is vitiligo, some neural diseases like tuberous sclerosis and neurofibromatosis and Wallenberg's syndrome, these are all things that can cause the emergence of gray hair.

Usually not like one strand at a time or here and there sporadic, but more patchy, full graying that can happen. But these things are rare and it's far more likely, Lisa, that your child is simply following the family pattern. Still it's worth to mention to your doctor the next time you're in for a check. I hope that helps and as always thanks for the question.

All right. Finally, up in our Listeners segment, we are going to head over to the Skype line.

Rebecca: Hi, Dr. Mike. This is Rebecca from Kingsley Center Academy. I was just listening to episode 200 and I have heard some of that baby-led weaning in the past and I thought it was interesting, but I just wanted to ask you to address one part of the study about the puree that you give to infants. You noted that it was sweetened puree and combinations like lasagna was what the parents were feeding those babies. Wouldn't it be important to consider the fact that some parents are doing 100% fruit or vegetable purees to start with? These are things that are not sweetened and also maybe if your cooking helps fully and feeding your baby the things that you're cooking so you know what's in it, wouldn't it not make a difference? Also, I was curious about some of the non-sugar all-natural sweeteners that are available now like Truvia and ones from the Stevia plant, not sure if I'm saying that right or not. What do you think about those and if there's any research available to share how safe all of these are. Are they really better for you than sugar, they don't use any fake sweeteners like aspartame or NeutraSweet, those things at our home? But I just want to know your thoughts on it. Thanks again for making PediaCast. Have a great day!


Dr. Mike Patrick: All right. So, Rebecca near Chattanooga, Tennessee, apparently it's our Tennessee show, we have Meg and Rebecca from Tennessee today. It's a great state; we just had a family vacation out in the Smokies recently which I'd talk about on the show. So, a little loving to Tennessee here with Meg and Rebecca. So Rebecca has some comments concerning baby lead weaning and there are points that are well-taken, Rebecca. Lots of parents are pureeing food from the kitchen in their natural form and with great success, so I think those are definitely good points.

What about artificial sweeteners and in particular newer ones from the Stevia plant would seem appealing because they're labeled "natural". Are they safe and are they better than sugar? So let's first talk about sugar, itself. As a sweetener, sugar has a pretty good safety record. I mean, it's safe to say that sugar has been used for an extremely long time. And it taste great, in fact, it's our gold standard when we want to sweeten something. When we're looking at sweeteners we say, hey, how does that relate to sugar because sugar is kind of our basis for understanding what sweetness is because it's been used for such a long time and it's such a part of pretty much every culture in the world, probably since the beginning of time.

So if you do use something different you're going to compare the taste to sugar. So why not just use sugar? Well, the problem with sugar of course is that it's full of calories. One teaspoon of table sugar contains close to 20 calories, so in a can of regular soda it has the equivalent of seven teaspoons of sugar, so you got 140 calories and that adds up if you are consuming lots of things with sugar in them.


Well, back in the 1960s, people began to realize that they didn't look so great in their swimsuits if the drank a lot of soda and the soda companies didn't want to lose sales so the race was on to find a low calorie sweetener. So it was really the cola wars that sort of stimulated the discovery of artificial sweeteners in the first place. Tab was one of the first diet colas on the market made by the Coca-Cola Company and it was originally sweetened with cyclamates and saccharin.

Well, cyclamates didn't last long. There was a 1969 study that linked it to bladder cancer in rats and the FDA was still reeling from the whole thalidomide debacle where there were birth defects associated with the drug that they had too quickly approved for use. And so when the study in the late 60s came out that cyclamates were related to bladder cancer in rats, it was like the FDA we're not going there again, let's just ban its use.

And so then, diet colas became just sweetened with saccharin, saccharin alone. And that really saccharin at that point became king of the artificial sweetener. Studies initially found that this also could cause bladder cancer in rats and so there was a little bit of the FDA saying, oh, should we ban this, should we ban this. But then what they found was that number one, it took a huge amount of saccharine to cause bladder cancer in rats, way more than people are being exposed to even if they drink a lot of diet cola; and the other thing is that the mechanism by which saccharin was found the cause of bladder cancer in rats appeared to not be a mechanism in humans. So humans, they didn't have the mechanism in place to even do this.


So you can imagine the soda industry lobbyist just going nuts about this and saccharin did win a stay of execution. But the FDA did insist on putting a warning label on any product containing saccharin, which of course had a tendency to decrease sales. Now, as it turns out saccharin has been shown to be safe for human consumption in multiple well-done studies since that time and the FDA has removed it from its list of potentially harmful substances; warning labels are no longer required.

But the image damage was done and the soda industry had trouble selling their diet sodas that contain saccharin and so the race was on to find another low cal sweetener with a safer brand image. Incidentally, saccharin also has a bitter aftertaste which sort of defeats the whole sweetening deal. It tastes sweet, oh bitter, oh sweet, no now it's bitter. So it wasn't the ideal artificial sweetener.

So what came next was aspartame and aspartame like saccharin is not a natural occurring chemical, that's made in a lab, just like saccharin was. So that's bad rep number one, people don't like that. I mean, never mind that sugar is as much a chemical as any other substance, including artificial sweeteners. It's a chemical, it's got atoms, you can draw the chemical equation of what it looks like. It's a chemical but the fact goes if said chemical occurs in nature I'm going to trust it more. Of course, this doesn't mean all-naturally occurring chemicals are safe, right?

I mean, here's a list of naturally occurring chemicals for you, cyclopeptides, monomethylhydrazine, muscarine, coprine and ibotenic acid and these are all naturally occurring ingredients of poisonous mushrooms. So I know I kind of digress here a little bit, it seems to be a theme for this show but just because something occurs naturally doesn't mean that it's safe. And just because something is made in a lab doesn't necessarily mean it's dangerous but we do have those ideas in our mind, I understand that.


So back to aspartame, it's actually still going strong, Equal and NutraSweet are both made of aspartame. The FDA considers it safe. There are anecdotal tales of side effects, my wife swears she gets a migraine whenever she drinks something with lots aspartame in it, but no studies have shown a significant problem. And aspartame is widely used today, but again, it is artificial because it's made in lab.

Well then sucralose comes along and sucralose as their slogan goes made from sugar so it taste like sugar, still made in a lab, not naturally occurring. Basically what they do is three chloride molecules replaced three hydroxil groups on the chemical sucrose. So it taste very much like sugar without an aftertaste associated with it but the addition of this chloride atoms actually makes sucralose an organochloride. So if you look at the sucralose molecule, and this is Splenda by the way, Splenda is the sucralose name brand, and if you look at the molecule, itself, once you replaced the hydroxil groups of sucrose with these chlorides, you have a molecule known as an organochloride. And organochlorides are used to make such things as vinyl, solvents and pesticides.


Now, that does not mean that sucralose can be used in making vinyl, solvents or pesticides but here comes the bad press, hey, this is an organochloride; pesticides are made of organochlorides, not made of sucralose but you get the bad press in there and the buzz on the Internet and we can't use this. Now the FDA has deemed sucralose safe and acceptable but you know, again, the bad press and blogs are out there that hey, your soda's being sweetened with a component of pesticide.

But there's another big problem that sucralose has and that is that it is patented in the United States by one company and marketed as Splenda. So the Cola companies can't use it unless they buy it which they don't want to do. So now the Cola companies want to develop and patent, because that was such a good idea, their own artificial sweetener which they don't have to buy, which then they can claim is the best.

And in the process of doing this in walks the Stevia plant with its low calorie, naturally-occurring sweet chemical component called rebaudio-side A or Reb A, that's the chemical name. Well, the soda companies, they were all over this. And they each have been coming up with their own proprietary patented way of extracting Reb A from the Stevia plant to use in its commercial product. That way, they have their own product, they don't have to buy it from someone else and it comes from a plant so they can say this is naturally-occurring sweetener, not an artificial sweetener. So this is like a win-win kind of discovery for the cola companies.


For Coca-Cola, their product that they have from this is called Truvia and for Pepsi Cola, it's called PureVia, got to love this. The FDA says purified Reb A is safe and it is approved for use in the U.S. so it is starting to show up all over the place. So Coca-Cola can market Truvia, which then other companies can buy it to use it as a naturally-occurring alternative to sugar, might be a better way to put it.

However, there is one controversy that remains; the FDA did deny approval for another Stevia plant-derived product in the 1990s because it was linked to cancers and infertility at lab animals. But that was a different substance. It was a different component of the Stevia plant. It wasn't Reb A and Reb A the FDA says is safe. So, there you have it, a short history on the artificial sweetener and the cola wars.

So the question then becomes should you use this for your kids? I really can't answer that, I mean, the FDA says it's safe, it's showing up everywhere. It's probably safe. Time is going to let us know for sure. What I do know this though, sugar has been around for a long, long, long, long, long, long time and if you really want to sweeten something and yet limit calories in a healthy way, my suggestion would be to eat a well-balanced diet, including lots of fruits and vegetables and when it comes to artificial or naturally-occurring sweeteners, one work seems wise and that word would be moderation.

All right. I hope that helps, Rebecca and as always thanks for calling and thanks for using the Skype line.


I want to remind you that if there is a topic you'd like us to talk about or you have a question for us on the show, even though I did get a lot of questions recently, please send them in, I read every question. And if you have a great one we'll put it on the show. You just head over to pediacast.org and click on the Contact link. You can also email pediacast@gmail.com or again call the voice line at 347-404-KIDS. 347-404-K-I-D-S. And we will be back to wrap up the show, right after this.

All right. We are back to wrap up the show and I want to thank all of you for taking part in PediaCast and for making us a part of your week. We really do appreciate that. And also I want to remind you that again, I've been kind of pushing that we just got a lot of questions but I love hearing from you. And if you do have a question or comment, please don't hesitate to write in or call the Skype line, we'd really appreciate it.

Also, I want to mention one more time, Feeding Your Kids, the joint project between Nationwide Children's Hospital and our Center for Healthy Weight and Nutrition and the C.S. Mott Children's Hospital of the University of Michigan and their Pediatric Comprehensive Weight Management Center, it's a free 45-day text and email based program with lots of helpful hands written from a parent's perspective aimed at parents and caregivers of how to improve the nutrition and ease of feeding your toddlers through your teenagers to help you make small changes overtime that can add up to big results.


So head on over to nationwidechildrens.org\feeding-your-kids or an easier way just head over to pediacast.org, click on the Show Notes for episode 211 and we'll have link for you to that. So make sure you check that out. It's a really cool and free program that you can use.

Also, I want to remind you if you have not written a review on iTunes, we'd really appreciate you doing so. iTunes reviews help get us in front of more moms and dads' eyes and so just the more reviews that we get, the more they highlight PediaCast in the iTunes store and the more people who see it and find out that it exists, so we really appreciate you doing that.

Also, be sure to join our community by liking PediaCast on Facebook, following us on Twitter and tweeting with hashtag #pediacast. You can also hang out with us oven on Google+, we're there as well. And be sure to swing by the Show Notes at pediacast.org to add your comments on today's show.


We'll also appreciate you telling your family, friends and neighbors about PediaCast and don't forget to talk us up with your child's doctor at your next well check-up or your sick office visit. Just let them know hey, we got this great podcast we found that deals with evidence-based pediatric topics, it's great for parents, it's great for clinicians as well, hey doc, you might even learn a thing or two on the latest research in pediatrics if you take a listen to the program.

And we do have posters you can download and hang up. You can find them under the Resources tab at pediacast.org. All right. One more time on the contact information, pediacast.org, Contact link, pediacast@gmail.com or 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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