Tooth Decay, TV Viewing, and Teenage Driving – PediaCast 007

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  • Infant Night Waking
  • Baby-Bottle Tooth Decay
  • Importance of Milk
  • IV Catheter Study
  • TV Viewing Habits
  • Rubella (German Measles)
  • Teenage Driving
  • Proper Fit Of Football Helmets.





Dr. Mike Patrick: No, you don't have your wires crossed. You've got the right podcast. It's Dr. Mike Patrick, Jr. coming to you from Pediacast, a pediatric podcast for parents and we're coming to you from Birdhouse studio, like we do every week, only this is kind of a special Saturday as we get the kickoff to the college football season. Here in Ohio, college football is kind of like a religion you know. You go to church on Sunday, and you spend Saturday in the Horsehoe with a hundred and five thousand screaming rabid Buckeye fans, or you scream in your living room, or out of the sports bar. You folks who are in Texas and California and Florida, you know what I'm talking about.


My dad and I will be at the Horseshoe today, enjoying the cooler weather, you know breaking up the sweatshirts, watching the marching band, eating our hotdogs with the stadium mustard, you know, I don't think it gets any better than that. Well, okay. How about an undefeated season in the National Championship, I'll take that. And I'm not talking about the repeat of the Ohio State and Miami fiasco back in the 2003 either at the Fiesta Bowl, you remember that one? No, I'm talking about a convincing season this year. No, I hope. We'll see. [Laughs] We'll see.

Alright we have a lot of topics lined up this week for you here's the run down.

We're going to discuss infants waking up at night, baby bottle tooth decay, the importance of milk, IV catheters in the emergency department, ways you can make kids more comfortable when you're putting them in, TV viewing habits, rubella also known as German measles, teenage driving, and the proper fit of football helmets. So if you have any kids out there playing Pee Wee football, or highschool football, we're going to talk a little bit about what you can do to make sure their helmet's fitting snuggly which will help in terms of preventing concussions.


Also we have some Podsafe Music coming your way this week from We are going to be featuring Anne Farnsworth, and playing a couple of her tracks. She's a jazz pianist and vocalist and we'll have more from her coming up a little bit later on.

We also want to say congratulations to Holly, she was the winner of Disney's Lilo & Stitch DVD and her question is going to be coming up in the first segment of our program and we'll get to that right now.

We're going to talk about infants waking up at night. And here's Holly's question: When I stopped nursing my son and started formula, he began sleeping through the night better. Before three months, he only needed one feeding through the night, now he doesn't need a middle-of-the-night feeding, but he wants his pacifier back. We were getting up and giving it back to him but now we're letting him cry it out. He usually goes to bed between 8 PM and 9 PM, and now he's waking up 5 in the morning, eats and goes back to sleep.


Should we let him cry it out at 5 or go ahead and feed him, since he falls right back to sleep after the bottle.

Well that's a great question, Holly. And I'm going to expand the question a little bit and do just a general discussion of babies waking up in the middle of the night and what you do about it. And really you have to look at this depending on your child's age. The first sort of grouping that I like to use is between birth to around 4 months of age, and at that age, you know I think you can't really spoil them. You have to respond to their needs when they're real little like that. You want to make sure that they're comfortable, that they're not too hot, they're not too cold, they don't need to be changed, that they're not hungry. Basically whatever it is they need between birth and 4 months of age. You want to make sure that you're there to respond to their needs regardless of what time it is and how many times in the middle of the night. Also, if they're difficult to console, then you worry about them being in some pain and you want to take them to your doctor to have him looked at. I've seen kids as young as 2 or 3 weeks with ear infections.


Some kids, even if they're not spitting up can have some heart burn associated with acid reflux and there are some things you can do to help make them more comfortable. But they could also have meningitis or an infection or, you know, really, there's all sort of things that could go wrong in babies that can make them cry constantly. So if you have a baby that's difficult to console, you definitely want to talk to your doctor about that. And if they are difficult to console and if they have a fever at the same time and especially if they're less than two months older, you want to seek medical attention right away. That's not even something you wait till the next morning for.

So if you're meeting their needs between birth and 4 months over and over again during the middle of the night, you know three, four or five times in the night, you're not getting much sleep are you? Well, you know it's part of being a new parent, unfortunately. And believe me, it's only uphill from there. But no, it's great being a parent and there's so much rewards that you get out of it. But one of the disadvantages is, in the beginning you definitely get a lot of sleep.


Now once your baby gets to be about 4 months old or so, and it's arbitrary cutoff, there's not question about that, but you know I think it is a good arbitrary cutoff. You do want to follow those same guidelines in terms of making sure they don't need something. You know if they're too hot or too cold, or they need change or they really are hungry, you want to respond to those needs. But then once you have that need taken care of, it's time to go back to sleep. And so, now you're going to have to walk him little Joe to the real world, you know what I'm saying.

So if you know they don't need something and they're not in pain, they don't have an illness, then it is time to let him cry it out. And the best way to do that I think is first if they are waking up a lot in the middle of the night and crying and they don't really need anything, they just want you basically. The first thing to do is to make sure you put them to bed awake. If the last thing that they remember is being snuggled up against you and you're rocking them and their warm and toasty, and then they wake up in the middle of the night, the next thing they know they're in a bed by themselves, and it's kind of dark and it's quiet, of course they're going to cry and want you come pick them up again. So if you put them to bed awake, then at least when they wake up in the middle of the night, there's not really a shock, you know.


They're just, they were what they were when they went to sleep, and I think they're less likely to cry that way. Now if they're used to falling asleep in your arms, the first time that you put them down to bed awake, of course they're going to cry. And what you do for that is basically the same thing you do after crying in the middle of the night. And that's to let them cry for about 10 minutes or so, and then you peak your head in the door, it's all business, "Hey, we're letting you know that we're here, but we're not going to pick you up, it's to go to bed." You know, very business like, and then you leave and then let them cry for 15 minutes. And then after you have done that, you look back in, basically the same thing, don't pick them up and let them cry 20 minutes and then 25 then 30 then 35, making it a little bit longer each time. And probably the worst thing you can do is if you get to the point where they're crying 35 to 40 minutes at a stretch and you're going in there and you just can't take it anymore, and you're heart's breaking and you pick them up, I can guarantee you that what they've learned is that if they cry loud enough and long enough, you're going to pick them up and that's what they want and that's what they're trying to get.


So you're really not doing yourself a favor by doing that. Now I have to say I give this advice in the office a lot. It's been written about in lots of different books. I'm sure there's several people out there who would claim to be the original author of that kind of a plan. I don't claim to be the original author, but I do claim that it works well and I have a parent after parent who comes back after I explain that. So they tell me, "Hey, you know that worked great. It took about three or four nights. It was terrible for three or four nights." But once the baby has realized that you're not going to pick them up, the effort put into crying is just not worth it anymore. And they will learn to console themselves and go back to sleep.

Okay so what about night time feedings. Well, you have noticed that I said you want to meet their needs. You know, you want to make sure they're comfortable and they're not hungry. So I think if they're hungry, and they're waking up once or twice in the middle of the night and you give them a bottle and they go right back to sleep after you're done feeding them, and the whole thing lasts 15 minutes or so, I think you're better off doing that then letting them cry it out.


Babies, when they go through a big growth spurt have an increased need for calories, and sometimes they just can't get all those calories during the course of the day and I do need a night time feeding. And what you'll find is that as they through growth spurts, they'll need those feeding on and off. So they may need to sleep through the night for a while and then they'll get up for a while and then they'll be back at sleeping through the night for a while.

And I remember with my own kids, even up to about 15 to 18 months of age, there were still some periods of time, particularly during rapid growth, when it seemed like they were getting up once or twice in the middle of the night, but again, the whole thing lasted about 15 minutes and then everybody was back to sleep. So you're basically meeting a need for them and I think it's okay to do it. Now, if they're one to get up and eat four or five times in the middle of the night then you have to start asking yourself, are they really hungry or do they want you and because you put the bottle or the breast in their mouth, they quiet down. So there's too much of a good thing as well as not enough.

Also while we're talking about sleep with babies, make sure you never sleep with your baby. You know, you worry about rolling over on top of them.

If you're on the couch, they can fall off of the couch, if you fall asleep. Or they can get sandwiched between you and the couch. I've seen it happen more than once. I've seen babies coming basically dead in the emergency room, because a parent swore that they would not fall asleep with the baby on top of them, and yet they did fall asleep and rolled over on top of them and found the baby under and not breathing. So it's a bad idea to sleep with your baby. I just wanted to point that out.

Okay, we're going to go ahead and move on to another baby topic that kind of goes along with the feeding. This is baby bottle tooth-decay. You never want to put your baby to bed with a bottle, for a couple of reasons. If it's a milk bottle with either formula or breast milk, and that you do worry about the milk dripping to their teeth through the night. And milk is a great bacterial culture media so you have bacteria now growing on the teeth where the milk dripped. And eventually that causes tooth decay. And if it's a bottle of water, you're not going to have the tooth decay but they can choke on water. It's probably not a good idea to have them with any fluid unsupervised in their bed.


Binky or pacifier and milk, whatever it is you'd like to call it, that's fine to do. And actually I do recommend those because babies do have a need to suck even when they don't need the nutrition and they're not hungry and if you don't provide them with the binky or pacifier to suck on, they're probably going to find their thumb and down the road, it's a lot easier to get rid of the binky or pacifier than it is to get rid of their thumb, you know what I'm saying.

So binkies and pacifiers are fine. Bottles in the bed are not good, if you're getting up to feed in the middle of the night, they really have to be up and in your lap and eating that way.

Okay so how do you prevent a baby bottle caries and tooth decay in little babies. Well the first thing is, you know, you do want to keep the bottle out of the bed. We talked about that. But then when the first tooth erupts, you want to begin cleaning it with water or a small film of baby toothpaste in a soft brush. And then starting at around the age 6 months or so, we do start some fluoride supplementation.


So the reason for that is not for the teeth that are already in the mouth — if they have it first 2 to 6 months, some babies don't get the first tooth until they're closer to a year of age — but if they're getting their first tooth when they're 6 months old, we have a need for fluoride not just on that tooth that's coming through but also inside the body, because the adult teeth that are starting to form up above the baby teeth, and we want to get some fluoride to those as they're developing, which will make them nice and strong and cavity-resistant.

Now if you live in an area that puts fluoride in the tap water and you use that water to make up formula, then you're also set. If you formula-feed your baby, and you do not use the tap water, so you like use ready-to-feed, then you're going to need a multivitamin with some fluoride in it or if you breast feed, you only need to get a multivitamin with fluoride in it. Now they do have just fluoride vitamins, but I don't like to use those, because if the unforeseen happened and a younger child in the house were to drink a whole bottle of fluoride, that is bad news.


Whereas at least with the multivitamin, even though it has all those different things in there, they are all sort of dilute comparatively, whereas a bottle of just pure fluoride's going to be a little bit more dangerous to have around the house. So I think a multivitamin with fluoride is your best way to go.

Now, also another option is if you are making up formula bottles with water and you don't have fluoride in your tap water, because you have well water or you live in an area where they do not put fluoride in the city water supply, you can buy nursery water out there and then not have to do the fluoride multivitamin. The nursery water is basically bottled water that you buy that they've added fluoride to and that's safe to use starting at about 6 months of age and you can use that to make up baby bottles.

Now once kids are about a year old — ah — somewhere between 1 and 2, and it's going to depend on how your baby does with things in its mouth, whether it gags and chokes a lot and also how many teeth that they have. But somewhere between 1 and 2 years of age, they're going to want to switch from using water on the toothbrush or baby toothpaste to using a fluoride-containing toothpaste like Crest for Kids, that kind of thing.


Now, the tube will say to use a pea-sized amount. Since we're doing a fluoride supplement either through water or through multivitamin fluoride drops, I think it's best that you use even a smaller amount than a pea-size amount. Just a real thin film of the toothpaste and do that once or twice a day and that'll help. But they're going swallow some of it. But the less that you use probably the better. But you do want to get a little bit of fluoride on the teeth on a daily basis once they're somewhere between 1 and 2 years of age.

Now, an up and coming thing that you're going to hear about are these fluoride varnishings. Most of the welfare agencies and state Medicaid will pay for this in most states and private health insurance, from what I understand they're not paying for it yet. But they're probably will in the future. Even if they don't pay for it, you ought to look into it. It only costs about $20 per application.


You start it about 6 months of age or when they get their first tooth, or if they are a late bloomer and they get their first tooth closer to a year of age, then that's when you start. And you can repeat it at 6-month intervals until they are about age 3. And then once they're 3, we recommend that they see the dentist anyways so you can ask them how to continue with the dental care from that point on.

Now this fluoride vanishes are pretty easy to do. Basically, it's a special chemical that is brushed on to the teeth, once every six months and it can be done at your dentists. Health departments will do it. And more and more pediatricians are learning how to do it as well. We're just starting doing that in our office. In fact someone from the state health department is coming to a meeting at our place next week, to give us instructions on exactly the right technique for doing it.

Now a study showed that kids who did not have this varnish done were twice as likely to develop cavities compared to kids who had the varnish done once a year, and four times more likely to get cavities in later childhood than kids who had the varnish done as an infant every six months.


And it is recommended to do these fluoride varnishings from the American Dental Association. When we look at a study like this, you know, I always like to play devil advocate to these studies. You do have to ask yourself, and I will be the first to admit this, that if you any kid who is getting the fluoride varnish done, are those parents more likely to not put them to bed with a bottle and to be brushing their teeth a couple of times a day with a fluoride toothpaste, and practicing good mouth hygiene. Whereas the kids who did not have the varnish done, what was their oral health like at home, or were they able to make the two groups that had the fluoride varnish done pretty equal to the kind of oral care that they had at home and from that study I wasn't able to tell if that was true or not.

So you always have to think about those other kind of variables that can affect your study outcome. Now there's a couple of links in the show notes you might be interested in. One is the American Dental Association's policy on fluoride and fluoridation. It has sensible information in it, and it dispels many of the theories and myths that are related to fluoride these days. So I encourage you [15:50 to go to our] show notes and check that out.


Our show notes by the way can be found at www.pediascribe/podcast and there's also another link in the show notes to some more information on that study that supports fluoride varnish in reducing cavities in early childhood. So I encourage you to check that out as well.

Once again, first trip to the dentist — now according to the American Academy of Pediatrics and the American Dental Association they both recommend that you take your baby to the dentist for the very first time when the first tooth erupts. Now, a more practical advice is probably to go for the first time just with mom and dad at age 2 so that the child can get used to the dentist and someone kind of shining a light on the mouth. And then, going for their first real appointment with the cleaning and all that business at about age 3. Now why is that more practical advice? Well I think for the most part, in most cities and towns, the dental community is not set up to see an influx of babies and really young toddlers. You know, they are overwhelmed and overworked as it is.


I know of my dentist that takes months to get in to see him for a cleaning, and if you added all those babies to that population, there just probably is not enough dentists around to handle it. Now if you live in a larger city and you have some pediatric dental groups where they just take care of kids, you may have a different situation and by all means, take them to the dentist for the first time after their first tooth erupts. But it is going to be kind of difficult to get in in most places, and your best bet is just to have your pediatrician or family doctor. You know, every time you go on for a well checkup, take a good look in the mouth, take a good look at the teeth and if you can find someone to do the fluoride varnish starting at 6 months or when the first tooth appears, I think you'll be in pretty good shape with that.

Okay so we're going to sum up here real quickly. No bottles in bed, brush with water or a film of baby toothpaste when the first teeth appear and then switch to a fluoride toothpaste, just a film of it, some time between 1 and 2 years of age, depending on your child. Consider the fluoride varnish every six months beginning when the first tooth erupts or at age 6 months, that's when you start. And ideally see a dentist at that point, but more realistically, do it when they're about 3 years old, unless there's a problem before that.

Okay, if you have a baby question and you'd like us to address it on the show, you can get ahold of us by emailing or going to and clicking on the contact link — you can get to us that way. We also have a phone-in line 347-404-KIDS, and you can leave us a voice mail that way.

Alright we're going to move on to our first music segment. This is by Anne Farnsworth, and it's from the Podsafe Music Network which you can find at Anne is a jazz pianist and vocalist who lives in Los Angeles. She divides her time between performing and, teaching and journalism. She's actually toured exclusively on her own in the United States and abroad and she has also appeared with Harry "Sweets" Edison, Johnny Griffin and Herbie Hancock so here's Anne Farnsworth with a track she calls, "Coolage."




Dr. Mike Patrick: Alright, welcome back to the program, we're going to talk about milk now. We're talking now out of the infant period and in the more toddler childhood and then even into the teenage years, the importance of milk. Cow's milk is an important dietary component for kids. It's relatively inexpensive source of protein and calcium. It also contains vitamins A, B12, D, has potassium, phosphorus, niacin and riboflavin. So it's loaded with nutrients.

Also the fat that is in the whole milk is important for rapid growth especially rapid brain growth between birth to about 2 years of age. And the other nice thing about cow's milk is most kids tolerate the taste. So that's how it sort of came to be, plus I'm sure there's little political pressure from the farmers too [Laughs]. You know what I'm saying. Then continue on with the cow's milk over the other animal's milk.

Now, the basic recommendation with regard to milk is that, from birth until 12 months of age, breast milk is going to be best. There's definitely an advantage to having human milk as opposed to cow's milk. But sometimes that's not possible either because of mom not making enough milk or the baby not nursing very well, or jobs get in the way. And certainly there are too many things in life to feel guilty about, that if you are not able to breast feed, using formula is fine and you want to pick a cow's milk formula to start with. And examples of that would be Similac and Enfamil and then there's also other store brands.


Carnation has one. You know, Walmart, you know what I'm saying. They've all got their own formula now. So, you want to use a cow's milk based formula until about 12 months of age. And then starting a year of age, then you're going to switch to cow's milk, and you want to use vitamin D whole milk which is actually 3% milk fat. So whole milk until about they are 2 years old. And then once they're 2, you switch them either to 1%, 2% or skim milk depending on their growth or their family history. Now, what I mean by that is if you have a kid that's obese, you know, really overweight for their age, you'd probably going to want to get them on skim milk pretty quickly after age 2. And if you have a kid who is a little bit underweight, then you might want to keep them either a whole milk for a little bit longer or 2%. But most kids, 1% to 2% milk's going to be good starting at age 2.

Toddlers are going to need, during that time in between they're two and about 5 years old, they need two or three 8-ounce servings of 1% or 2% milk.


And then you switch to skim milk for most kids somewhere between late toddlerhood and then the school age — you know, 4 or 5 years of age is good. Closer down the age 2 though, the skim milk, again if they're overweight.

Teenagers should also be drinking milk, and skim milk is going to be the best for them. And three or four 8-ounce servings of skim milk will definitely meet their protein and calcium needs. So that's where you want to target, somewhere between three or four 8-ounce servings of milk a day for teenagers, particularly in girls. There have been studies that have shown, the more milk the teenage girls drink, the less chances that they'll have of developing osteoporosis later in life and then having broken hips when they fall down. So with the amount of milk that you drink as a teenager, really does have an impact later in life. Now there are some exceptions to drinking a lot of milk. If you have what's called a "hypercalcuria," what that means is too much calcium in the urine — breaking that word down a little bit.


And there are some folks who actually get some blood in their urine if they have too much calcium. Most of these kids are picked up during a well check up exam. They just have a microscopic amount of blood in the urine. And that's one of the reasons that we do a urinalysis when you come in for a well checkup — looking for that.

And one of the things that can cause microscopic amounts of blood in the urine is as diet just got a little bit too much calcium in it for that child, then you have to put on a little bit of a lower-calcium diet. Also if you there's strong family history of calcium kidney stones in the family, especially in folks under the same sex as your child, then you worry a little about getting too much calcium and then causing kidney stones. Kidney stones are rare in children but not unheard of so it's still a possibility and something to think about. Also you don't want to overdo milk. I would limit consumption really at any age to somewhere between 20 and 30 ounces a day. You don't want to go too much more than 30 ounces a day, because that can actually cause some problems. Now, speaking of problems what are some potential issues with milk?

Well, you can have some sensitivity to the cow's milk protein in the intestinal wall and you can get some bleeding from the intestine, and if that happens over a long period of time, it can result in iron deficiency anemia, and again that's usually likely secondary to an allergic reaction to the milk protein in the intestinal wall.

In infants, you may even see some blood in their stool, when that happens and you want to switch them to soy — well of course you want to let your doctor know. But what your doctor is going to probably do is switch him to a soy formula and then if that doesn't work, switch him to formula, like Nutramigen or Alimentum which is basically like a pre-digestive formula that is very gentle.

If they do have this kind of allergic reaction in the intestine and have some blood in their stools in infant, and you switch him to soy milk or to one of these other formulas, you're still going to see blood for a week or so, and that's because the inflammation that that cow's milk protein caused the allergic reaction inside their intestine. It takes some time for that to heal, and even when you switch to a different formula, you're going to still have some consequences from that cow's milk protein that' still happening in the intestines.

So if you switch them to soy formula because they have blood in their stool at your doctor's request, again because there are other things that can cause blood in the stool that are much more serious so you want to make sure you let your doctor know about that.

Now if they switch you to a soy formula, you're still going to see blood for a few days and that's normal. Okay, infants who are switched to cow's milk prior to 12 months of age, are at high risk for severe anemia and that's because the pure cow's milk protein as opposed to the diluted form of cow's milk protein that's available in those cow milk-based formulas like Similac and Enfamil, there's a lot more of it in plain cow's milk. And so these kids can have a higher risk for developing bleeding in the intestines, especially microscopic amounts. They can be there for months and you never really know it's there. And so over that time period they're losing a lot of blood and become very anemic. And so some kids if they're switched to cow's milk at 6 months of age, which used to be the recommendation to do that.

You would have several kids — if you took like a hundred kids, you might have two or three of them who become very anemic, I mean really low red blood cells in their blood, and so, they have to have some medical intervention. And so by switching, by keeping everyone on formula until they're 12 months of age, you pretty much eliminate the kids who are going to get severe anemia from the cow's milk protein.

Another problem with milk that's a potential issue is lactose intolerance. Lactose is a sugar, and you need a special enzyme in your intestine to break it down called lactase. And some people don't have that enzyme. And so, plain milk can cause some lactose intolerance which we see as diarrhea, bloating, abdominal cramping, sometimes vomiting with it. And then another problem with milk is about 1% of the population has a true milk allergy across the whole body, not just in the intestine or wall but actually an allergic reaction throughout the body from the cow's milk protein, and this can cause a rash, hives, wheezing, any milder forms of nasal congestion.

So those folks are definitely going to need to switch over to a soy product. Now, these problems whether it be lactose intolerance, food allergies or the bleeding from the intestine, a lot of babies who have that will outgrow those issues as kids. So talk to your doctor about when would be a good time to retest them for milk allergies or to go ahead and do a trial of milk and see what happens.

Some other potential problems: some kids just refuse to drink the milk because of the taste, especially when you first switch him from formula over to milk, some kids will really have a strong reaction to not wanting to drink the milk and there are some things you can do for that. Probably your best bet is to put some flavoring in the milk whether it be like strawberry, chocolate or vanilla, a couple of teaspoonfuls, mix it around and it sweetens it a little bit. And a lot of times then babies will take it much easier if it has a bit of a sweeter flavor to it. Then what you can do is over the course of a month or so, is just slowly decrease the amount of the additive that you're putting in it and sort of wean them off of it, so that after a month or so they're on just milk without the flavoring in it.


The problem with the flavoring is you are adding a lot of sugar to the milk, and then that can cause some issues with the teeth. So if you are adding a flavoring, you're going to want to make sure that you're really taking care of those teeth, getting the fluoride varnishings that we talked about earlier and brushing their teeth a couple of times a day depending on how old they are, either with water and baby toothpaste or with fluoride toothpaste.

Also, another issue with milk is some parents have concerns about the hormones that are given to cows who are at dairies and then those hormones getting into the milk. And then also there have been some studies that have suggested a link to diabetes with milk ingestion. Subsequent studies with that did not show a link to diabetes with milk, so that's pretty low risk and most experts would agree that there's not really much of a risk there at all. And the hormones in the milk, those studies have shown, there's really not much of an issue there either.

And certainly, the benefits that you get from milk far outweigh any potential problems with hormones in the milk or any possible link to diabetes. Now too much milk is an issue and we talked about hat a little bit, if you get too much milk, it can cause some of those milk protein reactions in the gut that can lead to iron deficiency anemia. Also obesity can result from too much milk, especially if you keep your kids on the whole milk a little bit too long and not switching down to 2% and then 1% and skim milk. And we talked about some people are sensitive to the calcium and you can get blood in the urine, which can contribute to iron deficiency anemia, and also the formation of calcium kidney stones. So those are all things to think about with too much milk. Too little milk can also be an issue, because if you're not getting enough milk, you're not getting enough calcium and vitamin D and then that can result in decreased bone mineralization which ultimately leads to a disease called rickets, which is from decreased amounts of vitamin D in the body, along with decreased calcium, and you get pretty soft, brittle bones that bend easily and bow, and that's called rickets.

So you want to avoid that by drinking enough milk. Now alternatives, again, if it's an infant, and they are having a problem with the cow's milk-based formulas, you can switch to soy-based formula or Alimentum and Nutramigen, and there's the pre-digested ones. We talked about adding flavoring in, if taste is an issue. Also you can look for calcium fortified soy or rice milk for the older kids. Also, if they are not big milk drinkers, so there's an issue with it. More and more foods these days are calcium fortified. But you do want to look and make sure that the manufacturer of the food is also adding vitamin D along with the calcium because calcium gets absorbed better when the vitamin D is around. So you want to make sure, and I did notice that some of these orange juices have the extra calcium, just within the last year, so I've noticed that they are adding vitamin D along with the calcium so they've gotten the message that you have to have that. If you're doing a calcium-fortified food that does not have vitamin D in it, you can get around it by giving them a daily dose of a multivitamin that has vitamin D and then at about the same time that they're eating the calcium-fortified food.

Now what about a natural source of calcium. Great sources of calcium are broccoli and kale. Yeah, good luck [Laughs] at least in my house. And then you can talk to your doctor about other calcium supplements. If you are interested in taking a pediatric milk quiz, and you can see what you learned from this segment, and also it has some other questions in it that we didn't cover, so you will learn some more information. We have a link for you in the show notes to a quiz you can take online to test your knowledge of milk and kids. So that's the pediatric milk quiz and again you'll find that in the show notes.

Okay moving on to our next topic, this is Dr. Mike Patrick Jr., Pediacast, the pediatric podcast for parents, episode number 7. Our next topic is IV insertions and kids in the emergency department. This is an interesting one. You know, a study was done at the Washington University School of Medicine and it looked at child positioning during IV catheter insertion.


It looked at kids that were being held by their parents while the nurse put the IV in, versus laying down flat on the gurney or cart and being held down and the IV catheter going in that way. And the researches wanted to look at three things. They wanted to find out, in which position was the child more comfortable and have less stress, and you can bet you knew which one they thought the position that would be. Number 2, is there any difference in nurse performance and this is a big question because, sure kids can be more comfortable in their parents' arms but if it's taking five sticks to get the IV in as opposed to one or two, you know is it worth it? And then three, how well were the parents satisfied. There may be the parents that didn't want to hold them. Maybe the parents wanted them laying down on the bed. So, the researchers wanted to find out in what positions were the kids comfortable, in what position did the nurse do better, and which did the parents prefer.

Now, what they did is they took 118 patients in a pediatric emergency department.

They were all between the ages of 9 months and 4 years and they all needed IV access for one reason or another, most of them dehydration, needing some IV fluids. They were randomized in two groups, one group with the parents holding them while the IV went in, and the other group what we call "supine" or laying on their back. And then observers were blinded to the study design and reviewed a video tape of the procedure and they scored it according to a set procedural behavioral waiting scale. And these scores were obtained during the prep for the IV, the actual procedure and then during clean up. And then they also used the 5-point visual analog scale to measure parental and nurse satisfaction. And all these children did have at least one parent present in the room during the procedure.

Now in terms of the results, you know, you probably expect this. The scores in terms of the stress on the kids was lower for the parent-held group both during the preparation, during the actual procedure and then also during the clean up phase. So the kids definitely preferred being in the parents' arms during this process.

In terms of parent satisfaction, that was highest where the parent-held group. So the parents didn't mind holding their kids during the procedure, and they seem to be more satisfied being able to hold them during the time the nurse is putting the IV in as opposed to them being held down on their back on the cart. Now nurse satisfaction was a lower for the parent-held group. So the nurses were frustrated, didn't want the parents holding them, just felt that they had better control of the kids who were lying on their back on the gurneys.

But, here's the thing, the number of IV attempts was no different between the two groups. So even though the nurses didn't like doing it, they still did their job well. And all of these statistics I mentioned were statistically significant.

So, kids have less stress when they're held by their parents. The parents like it better that way. The nurses didn't like it but they still did their job well. I think this is important because we do really need to be more consumer-oriented in healthcare. You know, people have choices on where they want to go, and you know the days of just sort of blind routine protocol are ending.

And just because nurses don't want to do it a certain way. If they can still do their job well, and the consumer is happier and the kids are less stressed, then I think that nurses have to stop looking out for themselves and doing what's right for the kids. And so if you are a nurse out there, and you were one of them that took part in this study and you still did your job well, but you didn't like it that the kids were held by their parents, you know, what I say is that, get over it [Laughs].

Alright, we're going to move on in the program — media viewing habits. This is another study that was recently done. That's "Updated Statistics on TV Watching Habits for Kids in the United States." This is a survey that was conducted by the Center for Healthier Children, Families and Communities at the Davis Geffen School of Medicine at UCLA Los Angeles. So it's a telephone survey that was conducted in English and Spanish and it looked at the media habits. So this is watching television, DVDs, videos, basically media where you have no interaction with it of over 69,000 children who are between the ages of 6 and 17 years of age.

And the basic statistics were this: there was no daily media used in about 8% of the kids, less than one hour in 16% of the kids, one to two hours in 59% of the kids, and 3 or more hours in 17% of the kids. Now, I don't know about you but I was actually a little bit surprised by these numbers. I thought that the three or more hours would actually be higher than 17%. But the most of these kids were watching about an hour or two of television or movies a day. And that actually I think I don't have old numbers but it seems to me that that might be a little bit improved as before. Now I don't know if this study took into account computer time and video game town. Because if it did take these into account then these are actually amazing numbers. But I suspect that did not take those things into account and that may explain why they only spent one to two hours watching TV, because they spent the rest of their time playing video games or on the internet. [Laughs]

So what were some factors associated with more media exposure. Well male sex — so these are all things that my kids watch or kids who have these factors are more likely to watch more media TV, DVDs, videos — male sex, black and hispanic race, lower family income, actually fewer children in the house, if there are less than four kids in the house they are more likely to watch more TV, more kids in the house less TV. Poor child health status, poor mental health status on the part of a parent, or non-participation in school clubs, sports and exercises. So all those are factors that led to kids watching more TV. And the author's conclusion was that decreased TV viewing is associated with increased health efforts which is — wait a minute, I'm sorry.[Laughs] Let me start that all over again.


Decreased TV viewing is associated with better health. And of course that's no surprise, really. And so the authors think that we should have some efforts to decrease TV viewing and in order to do that, well we have to target are the boys, the blacks and hispanics, families with low income, families with less than four kids in the house and non-participators in the school activities.

So those are the folks that are watching the most TV. So those are the ones that you have to target. Now my thoughts on this, you know, we really aren't getting anything too new out of this study other than some updated demographics. I mean, let's face it, low income kids who aren't participating in school, who have poor health, are more likely to watch TV. And why? Well these kids have fewer options on what they can do, they have less encouragement at home, diminished parent involvement. And it's just somewhat easy for them just to sit in front of the TV all day. So they are the ones who are set in the home watching TV and many of these low income families even though they're low income they do consider TV and their cable a necessity.

And they may have trouble affording clothes or an oil change for the car, even cough medicine for their kids, but by golly, they're paying the cable bill and you know to some degree you can't blame them because it's really their only source of entertainment, besides drugs and alcohol. And of course it's just getting overused by these kids.

So if you want to make an impact on these kids' lives, what do we have to do. Well, we have tog offer more opportunities to be active and to get them involved. And often that means getting around their parents, because the parents, for the most part, of these children, they kind of like the fact that their kids are sitting in front of the TV for 5 hours a day because that means they're out of their hair. So some of us have to step in the community and provide other things that these kids can do, and you know, government subsidies are not the answer. The kids need to have the opportunities to be involved in activities and extra money from the government does not provide that. You know it helps them to feed the kids and themselves, but we still need some outreach through churches.


Just to give you an example, the church that we go to. It's a large suburban type church that has lots of the middleclass and wealthy folks in it. Our church is adopted, or really more than adopted, kind of taking over an intercity church so that we have three actual buildings, three different campuses that incorporate the same Lutheran church that I go too. And this other intercity church that basically we took over the mortgage payments of that church and it's just very involved in that intercity community. So you have basically the suburbs reaching out to the intercity and giving these kids a chance to have some opportunities that break their cycle of poverty. And I think that personal involvement in your community is really much better than any government subsidy can do because you're showing these kids that someone cares about them and wants to get them involved, as opposed to a lot of their parents who just want them to sit in front of the TV and stay out of their hair.


Now obviously, that's not — you know I'm making some gross generalizations there and there are plenty of low-income parents who want their kids to be involved and do everything they can for their kids and they're in the situation that they're in to a large degree out of their control so please don't think I'm saying that all low-income parents are lazy, they just want their kids to sit in front of the TV all day. That's not true. But I think what is true is a higher percentage of them are like that compared to other socio-economic groups and the best way to help break the cycle of poverty of these kids' lives is to get involved and to offer them opportunities that their parents aren't able to offer them or don't want to offer them. Okay so that's my two cents. Before we move on to our next segment, we do have a message from Whitney over at the LD Podcast.


Whitney Hoffman: Do you know a child with a learning disability or do you know a child that is struggling in school?
The LD Podcast may be for you. Our podcast is for parents, by parents of children with learning disabilities. We've struggled to find any resources we need to help our children and you know hard it can be. But fear no more. No longer will you have to shock parents at PTA meetings and in couple ones to get the advice you need. You can find it here, 24 hours a day, 7 days a week when it's convenient for you. Our weekly podcast cover a variety of subjects including ADHD, dyslexia, autism spectrum disorders and understanding the nuts and bolts of standardized testing, labels, individualized education plans and the information you need to get your child the help they need. Our podcast is available through iTunes and through our website, Come by and check us out.


[Marching band and crowd shouting]

Dr. Mike Patrick: Okay college football Saturday. Welcome back to the program. This is Pediacast episode no. 7, it's a pediatric podcast for parents. I'm Dr. Mike Patrick Jr., coming to you form Bird House Studio.

Last week covered mumps and before that we covered measles, so I thought we'd round out the MMR vacccine and cover rubella this week, also known as German Measles. Now, Germany doesn't have anything to do with these measles. The word "German" comes from the Latin word germanes which means "similar." So this is a rash that is similar to the real measles but it's caused by a different virus, and there's some also many other differences. It doesn't last as long. Sometimes it's called 3-day measles, so it doesn't last nearly as long with regular measles. It's not as severe and there are fewer complications associated with it. Now, like measles and mumps, rubella is caused by a virus. It's incubation period is two to three weeks.


And its symptoms are a non-distinctive rash that usually starts on the face and covers the body within 24 hours. You got some enlarged lymph nodes at the back of the neck, mild fever. The symptoms, again, only last about three or four days. Complications are rare. And the symptoms are so non-distinctive but it usually just gets diagnosed as a virus, pretty non-specific. And many of these go really undiagnosed and the way that you finally figure out there's rubella going around the community is if there's a bunch of it happening like in a school or in one particular neighborhood then someone gets the idea to test for rubella and it shows up positive in the context of an epidemic.

Treatment is just like any other virus. You treat the fever and the aches with a Tylenol or a Motrin. We don't use aspirin in kids anymore because of the fear of Reye's syndrome, which is a complication you can get with some viruses particularly chicken pox, which causes liver and brain disease. So no aspirin in kids, unless your doctor tells you. There are some heart conditions where you have to have aspirin but for the most part, your typical kid, no aspirin — just Tylenol and Motrin


So okay, if it only lasts 3 or 4 days, complications are rare, it's a non-specific rash, why do we even vaccinate against it, right? That's the question you were thinking, I hope it was. If that was the question you were thinking, then you're doing your job as a parent because it always important to ask why. Well, the problem with rubella is that if a fetus gets rubella, it very commonly leads to severe birth defects, fetal death and miscarriage. And kids that survive the fetal rubella, they are often born blind, deaf, they can have heart defects and severe mental retardation. So really we immunize the population against rubella to protect unborn babies. Now, non-pregnant women who are diagnosed with rubella, which they're unlikely to be diagnosed with, unless they're part of an epidemic. But if you do know that you have rubella, you should avoid getting pregnant for at least three months after the infection has resolved in case any of that virus is still in your body.


If a pregnant woman is exposed to rubella then she should go see her OB GYN. Mom and the baby are probably going to be okay with the exposure, because hopefully mom had the MMR and still has good protective antibodies against rubella, but if mom did not have the MMR or the vaccine failed or the immunity has worn off, then there is some risk. And so what your doctor would do is some blood test to see if you still have protective antibodies against rubella.

If your child has rubella, you should definitely keep them away from pregnant women for a while. But it is safe for a child who's mom is pregnant to have their MMR vaccine. So even though the MMR is a live viral vaccine, and there is rubella virus in the vaccine, it is a type of virus that is not very contagious at all and it is safe for a child to get an MMR vaccine if you are pregnant. It may not be safe if there's someone with chemotherapy in the house, you want to talk to their cancer doctor about whether kids who are in that house should have an MMR vaccine or not.


That's kind of controversial and it depends on which cancer doctor that you talked to.

Okay, so that's rubella in a nutshell. And not as much to say about that one. because as a disease in kids it's really not that bad. it's the unborn babies that we want to protect against rubella because it can just be a disaster for them.

Okay we're going to go ahead and move on to some teenage topics. The first one is teenage drivers. The problem is the traffic crashes is the leading cause of death in teenagers. And more than 6,000 young people who are between the ages of 15 and 20 die each year in car accidents and thousands more of them are injured, and the 16-year-old drivers are 20 times more likely to have a motor vehicle accident than experienced drivers. But why is that? Well, a few reasons. One is lack of experience. Driving experience leads to better judgment in situations that demand a specific driver response to avoid an accident. So example, if you are driving long and you hit a patch of ice, you know, as an experience driver, you know you let off the accelerator, you don't slam on the breaks and you just keep going straight and hope you don't slide.


But if you are a teenage driver and you realized that you are on ice, your instinct may be to actually put on the brake which we all know is not the right thing to do. You're going to skid. So that's just an example of where lack of experience can lead to problems on the road.

Another problem of course is risk-taking and impulsiveness, and this is worse with uncontrolled ADHD. And these kids are more likely to drive fast and be influenced by peers with the use of drugs and alcohol during driving and also not using safety belt. So, teens also do more night driving too which is another one of the risk factors. And that requires more experience in judgment. And so since these kids are driving around at night, they're more likely to be involved in car accidents because of their lack of experience and poor judgment. So what can we do? Well, the US Department of Transportation is now recommending a graduated licensing program and this spreads driver's education over three stages, and each stage increases driving privileges as the kids get more experienced and has shown to have better judgment and more responsibility.


So an example would be a learner's permit at 6 months of age. And this is something where they can only drive with a parent in the car or an approved, responsible adult. And then after they had done that for six months, having a provisional license for a full 12 months, and that is where — it depends, it's different from state to state, but it could be having an adult in the car with them or certain hours that they can drive, so they can only drive during the day or they can only be driving to school or to work and not just out driving around. And after you've had the provisional driver's license for 12 months, then they can graduate that to the full driver's license, with all the responsibilities that go along with it and the time when they're showing good judgment. And then along with this graduated licensing, driver's education classes both in the classroom and on the road go alongside it.


Now at the present time, only 12 states have a graduated licensing program with all three of those stages, but I think more will come because studies have shown that states that have these graduated licensing systems in place are beginning to show that they have fewer teenage car accidents in those states.

Now, we also have to combat drug and alcohol use in teenagers who are driving. Actually, another recent survey showed that 10% of drivers under the age of 21 who are stopped routinely at sobriety checkpoints are shown to have had recent alcohol consumption. And this goes along with risk-taking and peer pressure types of problems. And so, part of that graduated licensing program, especially during the provisional license period, when they might be driving by themselves but having some restrictions associated with it, is that if you do find a teenager who's drinking and driving during that time period is to have zero tolerance laws in effect and what this does is it decreases the allowable blood alcohol limit for teenagers down from .05 down to .02.


So basically any drinking at all in a teenager would become illegal. And intoxicated drivers, even at .02 who are under the age of 21, these zero tolerance laws dictate that they have their license completely suspended for one year. No driving to school. No driving to work. Nothing. They can not drive for a whole year if they are less than 21 and they have been shown to have even a tiny amount of alcohol and then drive with it. Now, after these types of laws went into effect in Maryland, for example, with the three stages and with the zero tolerance for alcohol. Alcohol related teenage crashes actually decrease by 11%. Now whether that was just a year to year fluctuations is yet to be determined. But it certainly makes sense that we'd have decreased teen car accidents. Also, we need increased seatbelt education. Ten- to twenty-year-olds are the lowest users of seatbelts among any age group.


Ten- to twenty-year-olds only use seatbelts about 35% of the time across the country. So safety belt education is still an important part of this. Now if your state is not one of the 12 states that has that three-step program, you know, as a parent, you could require it for your teenagers. I mean there's nothing stopping you from saying, "During the first six months of your driver's license, you can only drive with me, or mom or dad. And then for a year after that, we're going to let you have a provisional license. You can only drive to school, you can only drive to work, or you can only drive when a responsible adult that we know is in the car and then a year of that, if you have been shown to have good judgment, and you're gaining your experience, then we'll let you drive wherever you want. So even though your state has no requirement, your house can require. And if you want more specific information on what this graduated licensing program is all about, because each of these stages, there's more information about what goes into each stage, and you can find that at the US Department of Transportation National Highway Safety Administration's website.


And of course I put a link to the show notes in there for you. So if you go to you can look in the show notes and there'll be a link to US Department of Transportation and the part of their website that describes these three step program for graduated licensing.

Alright we're going to move on to our last topic of this week's Pediacast and that's football helmet use. I think it's a good topic with the football season getting started. You know parents assume that the football helmet is going to protect their child from head injury. Well the New York Times recently reported a study that's due out this fall in the publication Medicine and Science in Sports and Exercise, and this study showed that football helmets are often ineffective in high school students because they do not fit properly.

And this study suggests that thousands of needless concussions occur each year in high school football players because of a poor fitting helmet.


And that coaching staffs in high schools have poor education regarding what goes into making sure that a football fits appropriately.

Now Dr. Eugene Hong of the Drexel College of Medicine, he recommends a 10-step fitting process for high schools. And this is the process that's currently used in collegiate and professional football organizations. The biggest problem with the fit, then in other words of these 10 steps, the ones that were being followed the least were to make sure that the face mask was a proper distance away from the nose. Now what they found is that too many high school students, the face mask is too close to the nose. And then also that the chin straps do not fit properly. So just as a helmet, when you are riding a bike, has to be on just right in order to work properly. Same thing is true for a football helmet. You're going to have those chin straps on correctly and you also want to make sure that the face mask is a certain distance away from the tip of the nose.


And then the other thing is that the helmet fit should be re-evaluated regularly throughout the season because of many changing factors that can influence a proper fit, which includes the player growing, and also collisions and wear and tear on the helmet can cause the fit to change over time. So you do want to have frequent re-fittings to make sure that those 10 points are being met.

Now rather than read all 10 points, because you're not going to remember all of them. Rather than reading them here, there is a link in the show notes. If you go to, in the show notes, we do have a link to more information about getting a proper fit for a football helmet and it has all 10 of the factors that you need to make sure that your football helmet fits right so that you can avoid getting that concussion.

Okay well that really concludes this week's edition of Pediacast. We're right close to the magic hour mark that I'm trying to keep these podcasts at. It's so easy for me, by the way, to go off on tangents, talk about these things because I don't have the pressure of being out of the exam room or knowing that I have a waiting room-ful of patients. So this is very nice, being able to explain things at a little bit more leisure pace.

Again if you have a question that you would like us to address here on Pediacast, just send us an email at podcast@ or you can go to www. and use the contact link and send us a message that way. Or you can also use our phone-in line 347-404-KIDS, and then if you call that number and leave us some voice feedback, we can answer your questions that way as well.

I also want to put a little bit of a plug in. You've heard me talk about Pediascribe, you know our email is and I talked about the show notes being a www.

What is Pediascribe? Well, my whole venture into online media actually began with Pediascribe back around April or so. And I began doing a weekly column there. That is kind of in the pattern or format of a newspaper column about 500 to 800 words on a specific topic. But I'll be honest, I've kind of let it slack a little bit instead of doing a weekly one, it's been every other week for a couple of weeks now, and most of that's because of this podcast. It just takes so much energy and effort to put one of these things together and promote it that Pediascribe kind of slacked off a little bit.

So what I would do is actually, at least for the winter, because we get so busy during the winter, which gives me even less free time, what I may do for the winter is actually switch that over from being a weekly column to being more for a daily blog. So with having a paragraph each day and then trying to get some interaction among parents on that site. So you may want to check it out. And again at www.


And I have one other project that I want to mention, only because a lot of parents also have this interest and that's in Disney and I also write a weekly column called Mouse Matters which you can find at So you want to go there and take a look at Mouse Matters. Again, and that also is about a 500-word weekly column that comes out, so you may want to check that out.

If you haven't left us some feedback, and not only questions, we also encourage you to let us know what you think of the program, things we can do to improve it, you can use any of our contact ways to get in touch with us for that. Also if you want to leave us some feedback in the iTunes Music Store, that would be appreciated. And we're also on Podcast Pickle, you can find us that way as well.

Alright we're going to leave you with one more song. This is also Anne Farnsworth and she calls this one, "Saturday Morning" which is appropriate since I'm recording this on a Saturday morning. You can find out more about Anne at music.podshow .com, the Podsafe Music Network.


You can go to our home page and click on the link in the show notes, and that will also take you to Anne's page, there at

So we leave you with that, and until next week. This is Dr. Mike Patrick saying, so long everybody.


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