Vaccines, ADHD, and Infant Feeding – PediaCast 003
- Vaccine Injection Techniques
- Vaccines To Prevent Obesity And Nicotine Addiction
- In-Depth Review Of ADHD
- Nighttime Infant Feeding
Announcer 1: This is PediaCast, Episode 3 for August 2nd, 2006.
Announcer 2: Hello, moms, dads, grandmoms and grandpas, aunts, uncles and anyone else who looks after kids. Welcome to this week’s episode of PediaCast, a pediatric podcast for parents. And now, direct from Birdhouse Studio, here is your host, Dr. Mike Patrick Jr!
Dr. Mike Patrick: Hi, everyone. This is Dr. Mike Patrick Jr coming to you from Birdhouse Studio and I'd like to welcome you to this week's edition of PediaCast, a pediatric podcast for parents.
We have a full show in line for you coming up in the News Segment. We're going to be talking about immunizations. Infants who are four to six months of age, they get lots of immunizations when they go in for their four-month and their sixth-month well checkups. And a recent study showed something simple that the nurse who gives the shots can do to decrease the pain that's associated with those injections. So we'll talk about that.
Also coming up in the News Segment, we're going to explore two new vaccines that are a little bit different. Most vaccines, we think of as treating — or actually preventing — infectious diseases where as these vaccines are aimed at preventing obesity and nicotine addiction or cigarette smoking. So we're going to talk about those two vaccines that are kind of on the horizon during the News Segment. And then, in our Feature Segment this week, we have a special for you on attention-deficit hyperactivity disorder or ADHD.
With school coming up here in two or three weeks for most kids, there was going to be a time when a lot of teachers are sending home notes to parents saying, "You know, I think you might want to take your child to see their pediatrician because I think they have ADHD."
So we're going to talk about what ADHD is all about. How do you diagnose it? What are the symptoms and the signs of it? How do you treat it? Why do you treat it? When do you treat it? Do you have to use medicine? Can you get away with not using medicine? How do the medicines work? How long do you have to treat them? Can teenagers and adults have ADHD and what do you do about that? So, it's all coming up in the Feature Segment. We're going to have an in-depth discussion of ADHD.
And then in our Mailbag Segment this week, Allison writes in and has a question about infant feeding in the middle of the night. What do you do to get them to sleep through the night? Is that something you have to do or is it okay to get up with them? And what if your family disagrees with what your pediatricians advises? What do you do about that? So that's all coming up in the Mailbag Segment.
So, stick around. We have a full show plan for you and we'll be right back with the news right after this.
Speaker 1:& We’re here discussing child development with some experts. Tell me the normal development of, say, a two-year old.
Speaker 2: My truck.
Speaker 1: So a child that age should know two to four-word phrases, good. And what about cognitive development?
Speaker 2: [Verbal Noise]
Speaker 1: Engaging in pretend play. I see. What of& social…
Speaker 2: Look, Anna.
Speaker 2: Being enthusiastic about the company of other children. All right, thank you.
Speaker 3: It’s time to change how we view a child’s growth. It’s not just physical. There are milestones your child should reach in how he plays, learn, speaks, and acts. A delay in any these areas could be a sign of a developmental problem, even autism. The good news is the earlier it’s recognized the more you can do to help your child reach his full potential.
Talk with a doctor. Visit cdc.gov/actearly or call 1-800-CDC-INFO. A message from the US Department of Health and Human Services Centers for Disease Control and Prevention.
Learn the signs, act early.
[End of Commercial]
Dr. Mike Patrick: All right, in our News Segment this week, we have several stories for you. The first one has to do with the infants getting immunizations and the pain that maybe associated with the ones that are given what we call IM, which is intramuscular. So these are the deep ones that go into the muscle that infants get when they come in for their well child checks.
Now, many health care professionals who give infant shots routinely pull back on the syringe plunger prior to giving the injection. And you've probably seen that done on television and maybe at your doctor's office, where they put the needle in and then they pull back and then they actually give the injection. Now, why do they pull back like that?
Well, the reasoning behind it is that you want this medicine to go into the muscle and you don't want it injected into a blood vessel. So, if the syringe, when you put it in, happens to enter a blood vessel and then you just give it, you maybe actually giving the injection into the bloodstream, which may not be a dangerous thing. It may decrease the effectiveness of the immunization. Because what you want is that what you're giving into the muscle to sort of leak out over a longer period of time so that the body is exposed and will make the antibodies against it. Whereas, if you direct it directly in to the bloodstream, your body might clear it out a little bit faster and you might not have as good of an immune response.
So, basically, when you're pulling back, you're making sure that you don't get blood because if you pull back on the syringe and your syringe fills with blood, you're probably in a blood vessel. Now, there is actually no scientific evidence to support the idea of an immunization needle fitting in to the lumen or the interior portion of a blood vessel to such a degree that you're going to inject all of that directly into the bloodstreams. So in other words, it's not like you're putting the shot into a place where you'd normally start an IV. This is a muscle that has some capillaries and some smaller of blood vessels running through it but nothing is so… It’s such a big blood vessel that you're going to be able to get that needle in to the lumen and inject all of it in there. It's very unlikely. In fact, it's so unlikely that the most recent guidelines from the American Academy of Pediatrics state that this practice may not be necessary.
Now, who cares? Well,& the Hospital For Sick Children in Toronto, Ontario did a study because they wanted to see if pulling back on the syringe actually made the shot more painful for kids. So what they did is they took 113 children who are four to six months old who were receiving their DPT-Hib vaccines. So, if you’re a parent with an infant at home, you've probably heard of that. The diphtheria, tetanus, pertussis — the A cellular 1 with the Hib in it — these are shots against a particular bacteria.
And so, they took a 113 kids, four to six months of age, who were getting this vaccine and they divided them into two groups. They had 57 of the kids were going to have the plunger pulled back like it's traditionally done and 56 of the kids were going to have no pulling back on the plunger. They were just going to put the needle in and basically give the shot.
So, then, the researchers video-taped the infants while they're getting their immunizations and they documented how long they cried and whether they cried or not, how long they cried and if they did cry; and then, also a pain score that was based on the infants’ physical response to the shots. And then, the groups, by the way, they were comparable so the groups who were going to have the syringe pulled back and the kids who they were just going to push the syringe in, they were comparable with regard to the age of the children in each group. So there were the same number of four-month old and the same number of six-month old, that sort of thing.
Also, whether they had been previously hospitalized before.
So, in other words, if they had a bad experience in the hospital and maybe more afraid of nurses and doctors even at that young of an age, you didn't want one group to be crying a little bit more because they've had some more bad experiences with the healthcare providers in the past.
Also, birth order was the same for both groups. The method that they were fed, whether they were breastfed, or bottle-fed and whether they had had some Tylenol given by the parent before they came in for the injections.
So all of those things were comparable between the two groups, so that, hopefully, the only true variable would be whether they pull back on the plunger or didn't pull back on the plunger.
OK, so what were the results? Well, the first interesting thing is how long it took the nurse to actually give the vaccine or the average time it took for the nurse to give the vaccines. So, from the time the needle went in, until the time the needle came back out. For the group where they pulled back on the syringe was 8.8 seconds and for the group where they just put it in and give the shot was 0.9 seconds. So 8.8 seconds versus 0.9 seconds.
So, right there, you know, I’m not sure why pulling back on the syringe took 8.8 seconds. That seems like an awful long time to me, personally. But, you can see there was definitely a difference between how long it took to give the shot which may have a lot to do with whether there’s a pain involved or not.
Now, in terms of the percentage of kids who cried in the group where they pulled back on the syringe before they gave the shot, 82.5% of the kids in that group actually did cry. And the ones who cried the average amount of crying time was 14.67 seconds.
Compare that to the group where they didn’t pull back, they just put the needle and push, and only 42% of the kids cried. So the majority of the kids didn’t even cried at all with that technique. And then, of the kids who did cry, they said that the range was from 0 to 58 seconds. And, actually, in the report of the study did not tell what the average time of crying was for that group. Actually, I think they said that the average ended up being zero because of the majority of them didn’t cry at all. So that was in a very good number.
In terms of the pain score, they also didn’t say in this study results what the highest number that you could get was. But the pain score in the group where you pulled back was 2.8 compared to 1.35 and the difference between those two was statistically significant.
So, the bottom line is that when the nurse pulls back on the syringe before they give the shot, it’s going to take longer to give, according to this study. There’s going to be increased number of kids who cry because of the shot. The ones who cry are going to cry longer and they’re going to have higher pain scores.
Now, before you get too upset at your doctor or nurse, this was a small study that was done in Canada. Just recently, it was presented at a Canadian Research Conference done just last month or actually two months ago now. It was in June of 2006. So it is an up-to-date study. But your doctor and nurse may not know about it. And I’ll tell you, in medicine, old habits die hard. So if you take a kind of an old crotchety nurse and tell him, "Hey, you’re not supposed to pull back on the syringe anymore," they’re going to sort you give you that eye above their glasses.
So, sometimes, it’s hard to get people to do things a little bit differently. But it’s important in medicine, that as we learn new things, to be open to changing the things that we do. And in the medical community, that’s definitely a hard thing when you’re used to doing something one way trying to change things and get it done a different way.
But, you know, as an advocate for your children, you can look up this study online. And I will try to find a link to it and put it on the Show Notes, so that maybe you could print off a copy and take it in to your doctor or nurse next time. Maybe,& it will make a little bit of a difference in their clinical practice and maybe, at your pediatrician's office, there will be fewer kids crying — infants, anyway, four to six months of age when they get their immunizations.
OK, another news items that we have for you, bird flu. Researchers, led by — let me make sure I get this name right for you — Tarrona Maines with the US Centers for Disease Control and Prevention, was looking at bird flu. And what they tried to do was despite multiple attempts, they were trying to make a more contagious form of the bird flu virus by combining it, the H5N1 virus – that’s the bird flu virus. They were trying to combine it with human influenza virus in such a way that they think might happen in nature which would make it possible for direct human to human transmission, which& then, of course, could result in a pandemic of this terrible bird flu.
So, right now, for the most part, you’re going to pick up bird flu if you’re in a close contact with the poultry and that’s mostly been seen in Asia and the other side of the world. But the theory is that if that virus can mutate in such a way that it’s able to transmit from person to person, then we can have some real problems. So, these researchers at the Central for Disease Control and Prevention tried to combine human virus or human influenza virus and the bird flu virus together to see if that really does happen or not.
Now, right there, makes you a little bit nervous, doesn't it?& & You can just imagine, in this lab, this thing that is feared that will be a global pandemic and they’re actually trying to do it in their lab. I’m not sure if that’s in Atlanta, Georgia or not.
To their credit, instead of using human subjects, they use parrots. They said that parrots were susceptible to the flu virus and has similar transmission mechanic. So they thought that if they were able to infect parrots with this virus and then see if the virus could infect from one parrot to another, then they'd be able to say, "Well, it’s likely this virus would also infect one human to another."
Incidentally, the findings on these were that they were not able to do it, basically. So, even when they combined in such a way that they thought would happen in nature, the human genes from the flu virus and the bird flu virus genes and combining them into a sort of hybrid virus, it did not pass easily from parrot to parrot. So, they think that it’s going to be a lot harder for a hybrid virus in nature to evolve that could infect human to human with this bird human flu virus hybrid.
Now, I’m not too reassured by the results of the study. First of all, it was done in parrots. And even though you can say that they're parrots, that their immune-response and susceptibility to flu virus is very similar to ours, the bottom line is they’re still parrots and they’re not humans. Hello? And then the other question is how safe is it to be mixed in this two in this age of bio-terrorism. I certainly hope that their laboratories are pretty secure.
OK, moving on, in the News Segment. There’s a new vaccine for obesity that’s being studied by researchers at the Scripps Institute in California and they have developed a vaccine that is targeted at Ghrelin. Ghrelin is a hormone discovered in 1999, so it’s a recent discovery that we thought controlled appetite in animals and humans.
So what researchers did was took two groups of rats. One group was given the Ghrelin vaccine and the other group was not. Both of these groups were given the same amount of food, so their total calories was the same for both groups. And what they found is that the group who had the vaccination against this Ghrelin hormone had less weigh gain and less fat storage than the unvaccinated group. Which would suggest that Ghrelin is probably involved in more than just appetite since both of these groups had the same amount of calories in but the vaccinated group had less weight gain and less fat storage.
So, the Ghrelin hormone must also be involved in metabolism. And so, it basically took these rats' metabolism and basically probably sped it up in order to burn up those extra calories. Whereas, the rats that had their normal amount of Ghrelin were slow metabolizers and then stored it.
So what that basically means? I’m sorry, I think I probably need to translate that a little bit. So, you got this Ghrelin hormone and in one group of rats, you’re going to let the Ghrelin hormone do its job. And as they eat, they store the fat from the energy that they don’t use, OK? So, they’re going to gain weight and they’re going to lay down more fat.
OK, so the group of rats who had this vaccine, their body made antibodies against Ghrelin. So it destroyed the hormone, Ghrelin, and without that hormone, these rats had less weight gain and less fat storage. So that tells you that their metabolism is sped up a little bit. And you know, we’ve always said that between folks who eat the same amount. You can have someone who’s skinny as a rail and someone who gains like crazy and we just say, "It’s a shame your metabolism is different."
But if Ghrelin is more active in the folks who are a little bit more prone to gaining weight when they eat the same amount of food than someone who doesn’t gain weight, if you could develop a vaccine against this hormone, you might be able to control their weight gain a little bit better.
Of course, this is a long way off from human studies and the researchers admit that there’s a lot about it that they don’t know. But it just shows you a different direction that vaccines are taking. Traditionally, we think of them as being targeted against infectious diseases, but here, we’re targeting it against one of your body’s own hormones.
Now, then you can open up the debate — is that really a safe thing? Are you better dealing with the obesity issue through diet and exercise? But there truly are some people who really do their best to diet and do a good job of really trying hard and exercising, and they’re still unable to lose weight or to be at the healthy weight level. And so, for some of these people, having a vaccine that could help them would probably be beneficial. But, certainly, this kind of thing never should be a substitute or proper balance diet in moderation and exercise. Those things are always going to be more important.
Now, along the lines of a vaccine being used for something other than an infection process, there’s also a new vaccine — and this one is a little bit further along in development –& that targets nicotine. So, this is kind of an interesting idea. If you inject a vaccine with the chemical that mimics nicotine and then your body makes antibodies against nicotine, the antibody nicotine complex. So an antibody is going to attach on to the nicotine because it’s trying to attack it because it thinks it's a foreign substance. It makes too big of a molecule to get in to the brain. And since the addictive properties of nicotine occur inside the brain, if the nicotine antibody complex stays inside the bloodstream and doesn’t make in to the brain, then you’re not going to have the high that you get from the nicotine and you’re not going to become addicted with nicotine.
Researchers right now are looking at using this vaccine in current smokers to basically help them kick the habit so that when they get off the band, when they jump off the wagon — that’s not the right term, is it — you know what I’m trying to say. When they fall off the wagon, there we go – I’m sorry. When they fall off the wagon and smoke again and they get that high, and then, they just relapse. So the thought is, if you vaccinate them against nicotine, then they won’t get that high and they'll be less likely to relapse if they pick up another cigarette down the road.
And then, there’s going to be less of an incentive to smoke if you’re not getting that buzz or that high or that increased energy, the drug effect basically of the nicotine.
So they’re talking about using it in current smokers to help them kick the habit. But my question is, if it turns out to really be safe and effective, is& this something that we should translate to children? We want to protect the kids against infectious diseases like diphtheria and tetanus, pertussis, measles and all those. Do we also want to protect kids against smoking? And one way that you might be able to do that is by having a vaccine against nicotine that would help kids not become addicted to cigarettes down the road and also not be able to get a buzz or high off of the nicotine in the future.
Now you could also argue — then, what are we going to do, have a vaccine against crack cocaine? And we’re going to have a vaccine against marijuana. Are we going to have some multi-vaccine against every single recreational drug known to man? And certainly that’s not going to be a practical thing and it’s probably more important to teach our children that smoking is bad and to make good choices and to hang out with friends who are going to make good choices and not encourage you to make bad choices.
So, you can argue at one way and say that we could protect our kids but it’s probably more important to instill them with a moral value. So that’s where I am on that one, anyway.
Dr. Mike Patrick: In this week’s Feature Segment, we’re going to talk about ADHD or attention-deficit hyperactivity disorder. With it being the beginning of August, I thought with school right around the corner, it would be a good time to discuss this because they’re going to be plenty of kids that are certain back to school who, maybe last year, there were some questions about whether they had ADHD. Maybe, the decision whether to make the diagnosis and treat them was put off until the school year, sort of get them through the summer. And then, they're basically going to see how they do in the classroom this year and then try to make some decisions based on that.
First, I want to say — and this is probably the most important thing of this whole discussion to take home — and that is that not all behavioral problems and not all school performance problems are going to be caused by ADHD. So, there are lots of reasons why kids might misbehave or act out on their impulses or do poorly in school. Not everything is ADHD. And certainly, those kids are not going to benefit from the traditional ADHD kind of treatments if their problems are not from ADHD.
Now, on the other hand, just like anything in life, you can take the two extremes. There certainly are group of kids out there who definitely have ADHD and whose lives, and not just their lives but the lives of their entire family, can really just be absolutely turned around by addressing their ADHD and treating it. So, at the same time I want to say that not all behavioral problems and school problems are caused by ADHD, I also want to make the point that the people out there who say ADHD doesn’t exist and that no kids should be treated for ADHD, that’s baloney as well. So, I really think that you got to take the sort of middle of the road approach and realize that some of these kids do have ADHD while some of them do not.
So I guess the first big question with hyperactivity is which kids have ADHD and which kids don’t have it? And that’s a difficult question to address. As a pediatrician, you get comfortable with the diagnostic tools that you use, and certainly, just plain old observation is not going to be all that helpful. Because you’re in the exam room with the pediatrician when this comes up or anywhere from 10 to 20 minutes, maybe half an hour if it is a complex detailed examination.
But, for the most part, it’s a short amount of time and your observations of the child are kind of in a bit of, well, not so relaxed environment. Especially if they’re nervous and maybe they’re in trouble at school or at home. Or if it’s a younger child, they maybe all over the place because they’re acting out with quite a bit of energy because of their anxiety which is not always the case at home. So they may actually seem a little bit worse in the exam room when they do at home.
So, it can go either way. Sometimes they are quieter in exam room, sometimes they’re more active. And you really can’t get a good assessment of what’s going on.
The other thing, too, is you want to try to figure out that once they’re in school, is there a difference between the way that they’re acting and behaving and concentrating at home and at school? Because if they truly have a medical condition that’s causing these things, you would expect to have problems with the home and at school and not just in one location.
So the first thing that I’d like to do is to have a parent and the teacher fill out a Connor form. Now a Connor form is not perfect. It’s a set of questions for the parent and another set of questions for the teacher. I’d like to use the long Connor form. So there’s about, I think, 59 questions for the teacher and 80 questions for the parents. So, it’s a lot of questions. And they’re basically one-line statements and you have to circle whether you think that that statement describes your child on a scale of not at all to a whole bunch. I think it’s a scale like 1 to 5. And you basically circle which answer or you circle the number that best describes how much your child is described by that statement.
Now, the next important thing with this is when you score it, each of this question obviously is trying to get at a certain topic or a certain behavioral process. So in other words, you’re trying to figure out — are they hyperactive? Do they have attention problems? But then, with the long Connor form, it’s not just looking at those two things. It also looks at anxiety, anti-social behavior, obsessive compulsive tendencies, some things that go along with the depression. And then, it also looks at different types of ADHD. So, more of, like I said, the impulse problems — kids who are going to have more depression and emotional issues with their ADHD.
So it looks all these different sort of sub-categories and that’s what these questions are based on. They try to get, to show if there’s a problems in a certain category or not. So that you’re not only looking at ADHD, you’re also looking at other causes of behavioral issues like anxiety, depression, obsessive compulsive disorder and anti-social behavior, those kind of things.
Now, a lot of kids, just normally, are going to have some of these behaviors to an extent. So really what you want to do is try to figure out how your child is different than sort of the average or normal child of the same sex and the same age. So when these Connor forms are scored, your child’s answers are going to be compared to a large group of children that are of the same sex and the same age.
So if a certain behavior is typical for, let’s say, a 10-year old boy, it’s not really going to show on the Connor form. Because when you do the graph at the end and you come up with a series of circles that are on a graph that looks like a growth chart, you basically have a 50th percentile, and then it goes on up there to above the 95th percentile. So, if a behavior is normal for 10-year old boy, even if it’s a hyperactive behavior, it is going to show up on this Connor form as being normal. So only behaviors that are outside of the realm of normal for your child’s age and their sex is going to show up on this form.& So I think that’s nice.
And then, by doing one with the teacher and one with the parent, you’re able to confirm to see if you have the same sort of pattern both at home and at school. So looking at that, if you have significant responses in the hyperactivity column and the attention column and that’s both at home and at school, then you have a pretty good idea that you’re dealing with ADHD.
Now a lot of times, before you get started in any kind of treatment or addressing the problem, you’re going to see a high anxiety mark. And you might even see an elevation in the depression kind of scores. A lot of that is because these kids really are trying hard in school. They’re trying hard to be good at home and to please their parents. And because they’re not able to do it and they’re getting in trouble and they’re failing at school, that sets up quite a bit of anxiety in their lives and can even go on to some depression things.
And what we find is, if you address the ADHD, a lot of times the anxiety and depression go away on their own and don’t necessarily have to be treated by themselves. In other cases, you do have to treat them and but that’s a little bit more of a complicated issue that we can discuss at another time.
So let’s say your child has issue that the teachers brought up and I think maybe there’s a degree of ADHD. Your pediatrician has you fill out a couple of this forms, one for the parent and one for school. And let’s say that the pattern on the Connor form does look like it’s ADHD, both at home and at school, and you think that this child would benefit from some medicine. Well, before we get to the medicine part, it really helps to understand exactly what we think is going on in the brain with ADHD so that you can understand what medicines are available and exactly why they work.
And I think the easiest way to explain this is you have to realize that the brain is actually a bunch of connections. So there’s a bunch of a nerve fibers that make up the brain and there’s just millions of connections. And then, the other thing you have to understand is that each area of the brain is going to be dealing with the specific task.
So just to sort of oversimplify things a little bit, if you look at it that way, that there’s a bunch of connections and there’s different areas that control different things. OK, so if there’s a bunch of connections, obviously the brain has to communicate across this connection. So if you think of it as the nerves being two pieces of string, they don’t quite touch, okay? There’s going to be a little bit of gap between. That’s called the synapse and the way that the brain communicates with itself is that it sense out a chemical signal from one nerve to the other. That’s how it talks.
And, what we think basically happens in ADHD is that there is a tendency for the brain to start using these neurotransmitters or chemical messengers between the gaps and the nerves that make up the brain, and there is a tendency for the body, once you start communicating, to basically get rid of that neurotransmitter or messenger chemical a little bit early.
So, the prime example with ADHD is going to be dopamine and norepinephrine. Those are just the chemical names of the neurotransmitters or chemical messengers that are in that space between nerve cells and the brain. So, just to give a sort of a classroom example of this, let’s say that your child is working on a math problem. So the math part of the brain is working on the math problem and it’s relying on communication between nerves and the nerves are communicating by way of a chemical, a neurotransmitter. So they’re working on the math problem, they’ve got enough neurotransmitter, things are going well. And after two or three minutes, the body says, "Hey, I don’t want this neurotransmitter here anymore" and it starts to take it away. Well, now those nerves can’t communicate effectively.
And in the classroom, what happens is, your child who is working on the math problem, they got started on it. They got a really good start, but now they start drifting off and thinking about something else. Why are they thinking about something else? It’s because their math center is no longer communicating with itself and now the brain doesn’t just go idle.
So let’s say there’s a noise out in the hallway, well, the pathway in the brain that handles noises in the hallway takes over and it’s got plenty of neurotransmitter. And so, they look out in the hallway or they kind of stretch their neck a little bit trying to see out the door or looking out the window or looking at the kid two rows over who dropped the pencil on the floor. Because that curiosity pathway is firing and the math pathway completely is out of neurotransmitter at this point.
Well, now, the teacher says, "Hey, what are you doing? Get back to work." And your child looks down, sees the math problem. Well, now, the brain is going to have a whole new set of neurotransmitter that gets excreted into that space between the nerve cells. And what do you know we’re working on that math problem but the problem is now you have to start all over again.
So the child partially completed the math problem and didn’t get all the way through it, was distracted. But the distraction was really the extinction of the math pathway and the taking over of what’s going on the hallway& pathway. And now that the math pathway is starting up again, you basically have to start the math problem all over again.
So, you have a kid who does really well in the beginning of the math problem but they have to keep restarting it over and over and over again. And if you could find a way to increase the amount of that neurotransmitter or help the body hang on to it so that you didn’t get rid of it quite so fast, then you’re going to be able to not extinguish that math pathway and then the hey-what’s-going-on-out-in-the-hallway-pathway is not going to have a chance to exert itself and sort of take over.
So that’s what we’re trying to do here, is basically have more of that neurotransmitter or chemical messenger between the gaps and the nerves so the brain can continue to communicate with itself and whatever pathway it is that’s firing can continue to fire and do its job until you basically the child is done with the math problem. Now, of course, I’m just using math as an example. It could be the reading pathway, it could be the concentrating on the quiz pathway or a test or whatever.
Now, if you look at it this way, that some people’s brains get rid of the neurotransmitter quicker than others, is this really a disease? My personal opinion on this is it’s probably not a disease in terms of the body dysfunctioning. It probably is more that genetically speaking, some people are able to have a neurotransmitter last a long time between the cells communicating. And then, other people, based on your family history, you’re going to have cells that tend to get rid of the neurotransmitter a little bit faster.
I think it’s probably more of a genetic difference. Now, the problem is that in today’s society, we demand that you’re able to pay attention to something for a prolonged period time, and for a math pathway or a driving pathway or reading pathway, to be able to keep firing for a long time and to concentrate. And so, you sort of become a misfit in our society if you’re not able to do that. Not because there’s anything wrong disease-wise, but because the way that your brain is, you’re just not able to concentrate over long periods of time.
Now that’s not necessary a problem if you’re doing something that requires short bouts of attention. So from a pediatrician standpoint, I could probably function at my job pretty well with ADHD. Because I’m in an exam room talking about ADHD for a few minutes and then I’m in another exam room with a different family looking in someone’s ear and trying to decide if they have an ear infection or not. And then, I’ve got a kid with the sore throat, and then a well child checkup and I have to talk about immunizations. So I’m going from one thing to another and that makes it a lot easier if I had ADHD because my pathway of talking about shots is only going to last a few minutes and then my pathway looking at an ear is only going to last a few minutes. And then, my pathway of charting is only going to last a few minutes.
On the other hand, if I’m an accountant and I have to set and work on someone’s tax form for an hour, I’m going to go bonkers because my working-on-a-tax-form pathway is just going to get exhausted and run out of neurotransmitter. Even as an adult, I’m going to have a tendency not to do well as an accountant.& Well, as adults we do have some choice in what job we end up doing. I chose to go to medical school and to be a pediatrician and accountants choose to be accountant. So, to some degree, our career choice is based on our brain chemistry.
Now kids don’t have that choice. Kids have to go to school and be in a classroom. Or more and more people are homeschooling but that’s a different topic entirely. But most kids don’t have a choice and they have to go to school and they have to function in an environment that demands that they pay attention for a longer period of time.
So you have a kid who maybe better, as a pediatrician running from room to room and they’re being forced to be an accountant. And my analogy there is just they're being forced to sit and concentrate for a longer period of time and that may not be how they brain works the best.
So for these kids you have to do something for them. And unfortunately, the public school system is oftentimes not quite flexible enough to say, "Well, we’ll let you work on one math problem at a time and then do something a little bit different in between to rejuvenate your math pathway." You’ve got to sit there and work on Math for 40 minutes, by golly, and that’s just the way that it is. And so you have to try to figure out a way to help these kids to function in the classroom.
So what do the medicines that we used for ADHD do? Well, it’s pretty simple really. These medicines act on the synapse or the junction — the space between the nerves that’s communicating with one another — and that chemical messenger, that neurotransmitter. These medicines help your body hang on to them longer. So they don’t provide more neurotransmitter and they don’t make you make new neurotransmitter, a new chemical. They just help you hold on to what’s already there so that your body doesn’t get rid of that chemical quite so fast so that more of the chemical is available for continued communication between those cells.
So, the neurotransmitter that most of the ADHD medicines that we use today work on is dopamine. And so you have Ritalin, the long acting Ritalins, Concerta, Adderall, Adderall XR, Metadate, a whole slew of these medicines that act on dopamine reuptake inhibitor. That’s what they are. They're sort of dopamine reuptake inhibitors. So that they’re helping you to have more dopamine or more of that chemical, but in the space where the two nerves are going to talk to one another within a certain pathway of the brain. And that’s how they help.
Now, why are they controlled substances? The reason for that, anyone get addicted to them. If you have a normal amount of neurotransmitter to begin with and you take one of these medications, then what’s going to happen is your body is going to hang on to that neurotransmitter, that chemical, and now you’re going to have an excess. So instead of normal amount, you’re going to have more of it and that does give you euphoria or a high. And then, your body can get use to needing that increased amount, so that when you start to take it away, even a normal amount, your body is going to crave more and you can become addicted to it.
But if you take a kid or an adult who really has ADHD — that’s really what they have — and they really do have a decrease amount of this chemical or neurotransmitter on their brain, by giving them these medicines, you’re just raising the total amount of the neurotransmitter up to normal. And so, they really are not at any risk of being addicted to them or having a high or euphoria from them. But that’s the reason they’re controlled substances, because they have a street value. Because people can take them and basically get a buzz off of them if they don’t have ADHD. If they have ADHD, they’re not going to get a buzz off of them. And so, they probably have a street value for those folks, too, because they’re just trying to get their disease under control and be able to function. But we’ll get with more of that in a minute.
So that’s how those medicines work. Now, there’s also a medicine out there called Strattera which is not a controlled substance and it does not work on the dopamine chemical pathway. It works on the norepinephrine chemical pathway which tends to not produce euphoria or high when it’s there in excess. And so, the Strattera is not a controlled substance.
Strattera definitely has its place in the market but there’s also a lot of kids that Strattera just does not work for very well, especially the younger kids who have a lot of hyperactivity component to it. You find just through sort of trial and error that the stimulant medications — the Adderall, Concerta, Ritalins& — the ones that work on the dopamine pathway, tend to work a lot better for those kids and the Strattera works a little bit better for teenagers.
But that’s a generalization and for a lot of people, you just have to sort of try one, try the other and figure out what works best based on the chemical pathways that are most affected in an individual person’s brain.
So that’s how those medicines work. Now, understanding that that’s how the medicines work sort to lead you to another point. And that’s that it’s not just kids who are affected by these chemical issues in the brain in terms of there being a decrease& in the amount of neurotransmitters, but adults are affected by this, as well. And a lot of adults have learned that if they drink coffee or soda or tea, they get some caffeine and what do you know, caffeine has the same effects that Adderall, Concerta, Ritalin, all those medicines have. It also helps your body or your brain not to get rid of those neurotransmitters quite so fast.
So caffeine is a way for people, adults with ADHD, sort of self-medicate themselves. And I always find it kind of funny. A lot of times, as a pediatrician, these kids — especially the ones who have behavioral problems whether it’s ADHD or not ADHD — a lot of times they come from single parent homes. And they’re with their mom, they’re having behavioral problems during the week and school problems and then they go see their dad on the weekend or every other weekend and their dads quite a bit upset that mom wants to put them on medicine. And so, you have dad come in, you talk to him and you find out, oh, dad drinks three cups of coffee during the course of a morning, and then has a can of Coke during the afternoon and then a Mountain Dew in the evening. Well, the dads got ADHD too. He’s just treating himself with caffeine and then expecting his child to be able to perform at school and to behave himself at home without the benefit of a chemical helper when he’s doing it himself.
So, that’s why a lot of people are addicted to caffeine. I shouldn’t say addicted, that’s probably the bad term to use. Not truly physically addicted to it, but they rely on caffeine to help them out with their ADHD problems. And that’s why, well, that’s the reason.
Now, those medicines do have some other side effects that are important considerations. One, they do tend to decrease appetite a little bit. So, with kids that are on ADHD medicines, we do like to see him about every three months. If we’re changing the dose, we tend to see him back a month later to see how it’s going. But once they're on a stable dose of medicine that’s working pretty well for him, then, we have him come back about every three months.
And one of the things we check is their weight. We want to know how they’re eating. Now, a lot times their appetite decreases and that’s actually ends up being OK. They don’t lose weight because their activity level also decreases a little bit. So they’re not eating. They don’t have as many calories in but they don’t have quite as many calories out either, so it’s sort of a balance.
Other kids, their appetite doesn’t seem to be affected much at all by it. And then, there are other kids who are definitely more affected and start to lose weight and we have to make some adjustments in the medicine or try different kind of medicine or different strategy. For instance, taking a break from the medicine in the weekends and really letting them eat quite a bit of food to make up for the fact that they’re not eating as much during the course of the week and they’re able to maintain their body weight that way. So sometimes that becomes a bit of an issue.
Another issue is one that we really don’t see very often. But these medicines do have the potential to elevate blood pressure. So one of the things we do when we check them every three months is to check their blood pressure and make sure that that’s okay. I have to tell you, in 10 years of clinical practice, I have not had to stop these medications very many times because of elevated blood pressure. It’s pretty unusual to see high blood pressure because of these medicines. But it is something that you have to keep in mind and, certainly, something that we& check when you come in for the medicine re-checks.
A question that often comes up is do this cause heart problems. And there had been some kids with the sudden cardiac death who were on Adderall here recently in the news and, yeah, from time to time you hear the same sort of thing when Ritalin was given, regular Ritalin, before the long acting methylphenidates came out like Concerta and Metadate. So obviously that’s going to scare parents, "Hey, is there a potential that my child could have sudden cardiac death from a medication?" That’s certainly a scary thing.
In Canada, about a year, year-and-a-half ago or so, they actually took Adderall off the market for a while because of this fear that it was associated with sudden cardiac death. But they've since reinstated it and put it back on the market. And what they found basically is that so many kids are taking these medicines. You’re going to have a number of kids who have underlying heart problems, anyway. And if you look at the total number of kids who have heart problems in the general population and who have suddenly cardiac death because of their underlying heart problem, and then you look at the group of kids who are on Adderall, there was really no difference between a group of kids on Adderall and a group of kids not on Adderall in terms of the numbers that we’re having sudden cardiac death.
So, well, you can say is that the kids who had sudden cardiac death that were on the Adderall probably wouldn’t had to happen anyway, because the number of kids on Adderall who have sudden cardiac death is no higher than it is in the general population of kids who are not in Adderall. So I hope that make sense. And, certainly, if kids on Adderall were three or four times as likely to have sudden cardiac death as kids who weren’t on Adderall, then you have to stop and think about it a little bit. But when you have a group of kids on these medicines and these adverse outcome is no higher than in the general population of kids who are on these medicines, then you can say, well, just by chance those kids probably would have had that problem, anyway.
And, when you look at it, too, so many kids' lives are really changed by these kind of medicines. Kids who really have trouble in school, they couldn’t keep themselves out of trouble. And then, they go on to succeed and be on the honor roll and to do well in school and then have much more of a potential to go on to college and have a good paying job and have a family rather than being in jail. So you have to look at the benefit of these two, that even if these things did cause a very slight elevation on the risk of sudden cardiac death — which I don’t believe that they do and there’s not been any studies that have shown that they do — but even if they did to a tiny degree, you might be able to tolerate it when you look at the number of kids who truly are helped by it.
Now obviously, the parent of the child who died from sudden cardiac death, it’s just a terrible thing. And it is and my heart goes out to him. I feel terrible for him. But if you’re looking out from a public health standpoint at the greater good, then you have to say, "Well, is the small amount of risk worth the benefit that you get?" And for some things, it is, and I think probably for the ADHD medicines if that’s the case.
OK, wrapping up our talk of ADHD, the next question becomes when do you stop treating ADHD? And what I’d like to do is, there’s going to be a subset of kids who just in their early childhood have some attention problems and impulse control problems that are helped by these medicines and they’re going to outgrow the need to use them. So I think it’s a good idea, every couple of years, if you think your child is maturing and might not need it, try them off of it in the summer time and see how they do. If they seem to do well, try them in the beginning of the school year and see how they’re able to perform in the classroom without the medicine. But I wouldn’t let them go too long. Maybe, to the first parent-teacher conference in late September early October or something like that, if they’re starting to have problems, I’ll get them right back on the medicine. I wouldn’t let them get too far behind in school. But it may be worth allowing them to try without the medicine to see how they do.
Now, that’s from a practical standpoint and because that’s what parents are hoping for. From a realistic standpoint, most of these kids to be honest with you are not able to stop the medicine. And the reason is because their brain is just built in such a way that we’ve just described and it’s going to be like that throughout their teenage years and on into adulthood. And, as I said, there are plenty of adults out there who treat themselves for ADHD with medicines like caffeine. And so, there’s a lot of ADHD out there, and teenagers and adults, as well.
And it is becoming more and more recognized and treated and that’s a good thing. The reason it’s a good thing is because there had been several studies that show that teenagers who have ADHD that is untreated have a much higher chance of being involved in a fatal car accident. They have a higher chance of being alcohol users, drug users, committing crimes, being in juvenile detention homes. So these kids who have impulse control problems and attention problems are much more likely get into trouble and if you treat them with appropriate medicines and get their ADHD& under control, they make better decisions and they’re less likely to be involved in car accidents and do alcohol drugs and steal, those kind of anti-social sort of behaviors.
Now, as adults who have untreated ADHD, we also have some studies that show that they have a higher rate of divorce, a higher rate of gambling, drug-use and also being imprisoned. So again you can make a case for treating adults with ADHD with these medications as well.
OK, so that wraps up our discussion of attention-deficit hyperactivity disorder. It went about half an hour, which is a little bit on the long side. Sorry, I apologize for that, but see, you get me talking about something and it’s nice to be honest with you, to be able to talk about something for half an hour without knowing that the waiting room is full of patients and that the nurse is going to be knocking on the door saying, "Hey, get yourself in gear."
So this is nice. And if there are topics that you would like me to discuss, I’m happy to do so. Just give me email at email@example.com and let me know what your question is. Or you can go to the website at www.pediascribe.com/podcast and click on the Contact link and shoot me an email that way or message that way and we’ll try to answer some of your questions and have some more discussions in the course of this podcasts.
Also, I’m going to be getting a Skype line here soon. So, hopefully by next week, I’ll have the phone number for you to call if you’d rather phone in your question or comment to the Skype line. We'd be able to do that way, as well. So that’s something to look forward to.
OK. And we’re going to take a little bit of a break here and when we come back, we’re going to go to the Listener Mailbag. That’s next here on PediaCast.
All right, in our Mailbag Section this week, we have a question from Allison. And I want to thank Allison for writing in to us here at PediaCast. She says, "Dear Dr. Mike, I have a question about my baby. He is two months old and is completely breastfed. Because of that he gets up every three hours overnight to eat. My family, mother, mother-in-law and sisters are all urging me to start him on cereal to fill him up so he sleeps through the night. My pediatrician says not to do that and to wait until he’s four months old before we start cereal. I’m a stay-at-home mom and don’t mind getting up with him at night, so that’s not an issue. Should I start him on cereal and what do I tell my family? Thanks — Allison."
All right, Allison, thanks for your question. And if any of you out there have a question you’d like to ask me and hear addressed during our Mailbag Section, please write in to firstname.lastname@example.org or you can go to our website at www.pediascribe.com/podcast and click on the Contact link and send us your question that way. And here in the future, we hope to have our Skype line up and running with the phone number that you can call in and leave your message that way, too.
OK, so to Allison’s question — first, Allison, I think that you probably, to some degree, answered the question yourself when you say that you’re stay-at-home mom and you don’t mind getting up at night, so that’s not an issue. Well, if it’s not an issue for you, it shouldn’t be an issue for your family. And in no uncertain terms this I’d tell them, this is your baby, this is what you want to do, this is what your pediatrician wants you to do, and they need to mind their own business with regard to this. I know that’s kind of a hard stance to take but it’s not going to be the first time that people are telling you what to do with regard to how to raise your children and you really have to research it to yourself, make some decisions yourself and then, stand by those decisions.
Now, are there certain circumstances where a two-month old, where you would want to put some cereal in the bottle for him during the night? And, I guess, I should differentiate that here real quick. You didn’t say but I’m assuming that what your family is asking you to do is put the cereal in the bottle. Certainly, a two month old, I would not feed with a spoon. You'll definitely run the risk of him choking and then aspirating or sucking food down into their lungs, because they don’t have a good swallow reflex with solid food quite yet. So, certainly, you don’t want to feed him with a spoon, a cereal, in a two-month old.
Now, the question of putting the cereal in the bottle is a little bit a different one. And certainly, there are two-month old babies out there who their pediatricians tell them to put some cereal in the bottle especially if they have reflux –& gastroesophageal reflux — where they’re spitting up a lot, they’re spitting up at night, maybe gagging and chocking on it. And so, for those babies, thickening their formula or breast milk, expressed breast milk with a little bit of cereal, may help them to not spit up so much, to not be as fuzzy and to sleep better through the night.
So it’s certainly is something that can be done but it’s not something that has to be done in a baby who’s only problem is that they won’t sleep through the night. And if you are OK getting up with him every three hours at night time, then I would just stick with that and do that. Because, really, what your baby is telling you is that they need to eat every three hours. And, really, the best thing is to adjust to their schedule and feed on demand when they need to eat at such a young age.
Now, there are certainly are going to be circumstances when parents are working. Maybe mom goes back to work when the baby is two months old, she has to function during the day or she’s not able to take naps during the day and she’s just completely exhausted. And you’ve got to feel for those moms and understand that there are certain family circumstances which may make it definitely beneficial for the family as a whole unit for the baby to be sleeping through the night. And for those kids, at two months, you could argue that a little bit of cereal in the bottles, especially at night time to help them get through the night sleeping, is not necessarily a bad thing and you really have to look at the context.
And I think for you, Allison, if you’re willing to get up in the middle of the night two or three times to feed your baby, it doesn’t matter what your family says. I would definitely stick with that.
I also should mention, this is kind of a funny story. When we’re talking about putting cereal in the bottle, we are talking about rice cereal that are the little flakes made for babies. For those of you who maybe listening to this without kids out there, I do remember a story from a few years back where I was talking about to a family about putting cereal in the bottle. And the dad said, "You mean Rice Krispies?" No, we’re not putting Rice Krispies in the bottle, folks. We’re talking about baby cereal.
OK. So thanks, Allison, for your question. And again, if any of you out there have question you’d like me to address, let me know.
That wraps up this week’s edition of PediaCast and I’d like to thank all of you for tuning in. Next week, on Wednesday, we’ll have another show for you. So we look forward to that in the iTunes Music Store. You can also catch us on our website, www.pediascribe.com/podcast.
And as always, your feedback is appreciated. Particularly, since this is a new program, I really want this PediaCast to go in the direction where you, the listener, wants it to go. So let me know, what things you like, what you don’t like, what you would like to see changed, what you would like to see us keep. Because in the end, we want to do what’s right for the listener and really make& this into something that you look forward to hearing every week and something that’s a good source of communication between a pediatrician and parents.
All right. So, once again, thanks for listening. And until next week, this is Dr. Mike Patrick Jr saying, so long, everybody!