Infant Formula, Asthma, and Infant Sleep – PediaCast 029

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  • RotaTeq vaccine and bowel obstruction
  • Preparing infant formula with water
  • Asthma questions
  • Infant sleep comments
  • Fluoride: When is it too much of a good thing?
  • Everything you wanted to know about BirdHouse Studio




Announcer This is PediaCast.




Announcer Hello moms, dads, grand moms, 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 Studios, here's your host Dr. Mike Patrick Jr.


Dr. Mike Patrick: Hello everyone and welcome to PediaCast, the pediatric podcast for parents. This is Dr. Mike coming to you from Birdhouse Studio and I would like to welcome everyone to the program: You found the best digital source of news parents can use, answers to your questions about child health issues, and the latest round up of research topics in the world of pediatric medicine.


Dr. Mike Patrick: If you're new to the program and listening at the website, be sure to subscribe to our feed by adding us to iTunes or any other pod catcher. That way you won't miss a single episode. And of course I warm welcome back to my loyal listeners. You folks are the ones that keep PediaCast alive and kicking. If you like to breathe more life into the program be sure to tell your friends, relatives, co-workers and neighbors about the show, or use an iTunes work wonders as to digs of each episode in the podcast section of, simply click on the dig us link at and once you're on the dig site be sure to dig each episode individually. Well, at least the ones that you think are worth digging, which of course we hope is all of them.


Dr. Mike Patrick: We have a full show lined up for you today and here's a run-down of the topics: In the News Parents can Use segment or Report on the Intussusception which is a form of bowel obstruction and the new rotavirus vaccine. Then we move on to listener questions and comment: What's on your mind? Well, we have questions regarding the preparation of infant formula with water: Is it important to boil the water or not? And albuterol; what role does it play in asthma therapy?


Dr. Mike Patrick: Plus we'll take comments about infant night time sleep issues from Catherine and Michelle, and then finally we'll wrap up the show by adding a topic to our research round-up. This week we'll discuss fluoride in water, when is it too much of a good thing? Now don't forget to if you'd like to join the conversation and want to contribute something to our Listeners' segment, it's an easy thing to do. Simply swing by the website at and click on the contact link. If you'd rather send an email, you can do that by writing to and if you want to leave a voice message, simply attach an audio file to your email or call the Skype line at 347-404-kids or keyword: pediacast, if you're a fellow Skype user.


Dr. Mike Patrick: Thanks go out to Dan and Carry over the baby time podcast. They recently interviewed me on their show. They're wonderful parents and have a great podcast. You can find it at, that's and of course we'll put a link to them on the show notes. Thanks also go out to my wife Karen, for taking over the blog. She's really kept it up to date, have been frequent posts and I think it's a great parenting supplement to the pediacast podcast. Pediascribe is the name of the blog and if you head over to and click on the pediascribe blog link, you'll find it there.


Dr. Mike Patrick: All right, before we get started, let me remind you that the information presented in pediacast is for educational purposes only. We do not diagnose medical conditions or formulate treatment plants for specific individuals. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination. Also, your use of this audio program is subject to pediacast terms of use agreement which you can find at! So with those ground rules in mind, we'll return with News Parents Can Use, right after this.




Dr. Mike Patrick: Ok. In our news parents can use segment this week, we have an item from the Department of Health and Human Services and their Centers for Disease Control and Prevention. This is Intussusception and the RotaTeq Vaccine. The Food and Drug Administration or FDA, has notified health care providers and consumers about reports of intussusception following administration of rotavirus live oral pentavalent vaccine with the trade name RotaTeq which is manufactured by Merck & Co. Inc. FDA has issued this notification to encourage the reporting of any additional cases of intussusception that may have occurred or will occur in the future after administration of RotaTeq.


& Dr. Mike Patrick: A number of intussusception cases reported to date, after RotaTeq administration does not exceed a number we would expect to occur without vaccination. Although the data we have received so far suggests that RotaTeq does not cause intussusception. It is possible that because of incomplete reporting of cases, some increase risk of intussusception associated with RotaTeq Vaccine could yet be found. Thus, the CDC and FDA are continuing to carefully monitor reports of possible adverse effects of the vaccine.



Dr. Mike Patrick: Now, here are some key facts from the Centers for Disease Control and Prevention: They're not surprised by the number of reported intussusception cases following RotaTeq vaccination. Intussusception, which is a form of bowel obstruction, occurs spontaneously in the absence of vaccination and there are a number of intussusception cases that occur every year in children in the age group recommended for RotaTeq which is 6 to 32 weeks of age, and they're not related to the vaccine. So you do have intussusception take place in kids who did not have the RotaTeq vaccine.


Dr. Mike Patrick: The number of intussusception cases reported to date after RotaTeq administration is consistent with the number of cases we expected to see based on background rates in unvaccinated children. These cases where detected through routine monitoring of a new vaccine using the Vaccine Adverse Event Reporting System, or VAERS. This routine monitoring is done to ensure the safety of all vaccines. We're closely monitoring VAERS reports with this vaccine as we would with any newly licensed vaccine. However, we are aware of past issues, with rotavirus vaccine and intussusception, and therefore we will continue to closely watch for cases of intussusception following rotavirus vaccination. This notice does not mean there is a problem with the RotaTeq vaccine. CDC is not changing its policy at this time. CDC continues to support the Advisory Committee and Immunization Practices or ACIP. Their recommendation for routine immunization of all US infants with three doses of RotaTeq administered orally at ages 2,4, and 6 months. CDC and FDA encourages all health care providers and other individuals, including moms and dads, to report any cases of intussusception or other severe adverse events to the vaccine adverse event reporting system, that's a mouthful, and you can easily report events online at and I hope you'll link to that in the show notes if you want to report an adverse event.


Dr. Mike Patrick: Now, let's talk a little bit about RotaTeq and intussusception. So first, what is rotavirus which is what RotaTeq is protecting you against? A rotavirus is a virus that causes severe diarrhea, vomiting, fever and dehydration on infants and young children. In fact, it's the leading cause of gastroenteritis in infants and children around the world. Each year in the United States, rotavirus is responsible for more than 400,000 doctor visits, more than 200,000 emergency room visits, 55,000 to 70,000 hospitalizations, and between 20 and 60 deaths. Now, if you look in developing countries, rotavirus is actually a major cause of childhood death, estimated to cause more than half a million deaths each year in children less than 5 years of age. It's usually from dehydration and the inaccessibility of IV fluids for kids who are dehydrated.


Dr. Mike Patrick: So, what is the RotaTeq Vaccine? The RotaTeq vaccine is the only vaccine approved in the United States for prevention of rotavirus disease. It was licensed in 2006 and RotaTeq is really the best way to protect your child against rotavirus disease and studies indicate that RotaTeq will prevent about 74% of all rotavirus cases and about 98% of the most severe cases including 96% of cases that require hospitalization. Now, is this the same vaccine for rotavirus that was taken off the market because of problems? No. This is not the same vaccine in 1999. Rota shield which was a different rotavirus vaccine was what's drawn from the market after it was found to be associated with the type of bowel obstruction called intussusception.


Dr. Mike Patrick: Now what is Intussusception? I think one leads to another. Intussusception is a serious life threatening condition that occurs when the intestine or bowel becomes blocked. One portion of the intestine basically telescopes into a nearby portion causing the obstruction and this leads to inflammation, swelling, and eventually decreased blood flow. With prompt detection and treatment, almost all patients fully recover although persons of any age can get intussusception that is most common among infants in their first year of life each year approximately 1,400 US infants less than 12 months of age are hospitalized for intussusception and these cases of course occur every year even in years when there is no rotavirus vaccine being given in the United States.


Dr. Mike Patrick: Has the association between the new RotaTeq vaccine and intussusception been studied in clinical trials? The answer to that question is yes, the risk of intussusception for RotaTeq was evaluated prior to the licensure and a large clinical study involving more than 70,000 children. In that study, there was no association found between RotaTeq and intussusception. Now that the vaccine is being broadly administered, CDC and FDA continue to monitor RotaTeq for problems in those who receive the vaccine.


Dr. Mike Patrick: How are the CDC and FDA monitoring RotaTeq safety? Well, following licensure and general use of RotaTeq and other vaccines in the United States, safety is closely monitored by the FDA and CDC through the Vaccine Adverse Event Reporting System, and these agencies monitor and evaluate all reports of intussusception and other side effects reported to them. In addition, CDC is conducting a large study to rapidly detect any association between RotaTeq and intussusception as well as other potential adverse events through its vaccine safety data link. That data link evaluates vaccine safety in approximately 90,000 infants born each year. Merck & Co., the vaccine's manufacturer will conduct a separate post licensure study of approximately 44,000 children.


Dr. Mike Patrick: Are all adverse events reported to the government that's caused by vaccines? Well, the answer to that is no. It's important to realize that many adverse events reported to the government may not be caused by vaccines because reports to the government can be submitted by anyone including of course health care providers, also patients and family members. Because of this, the Vaccine Adverse Event Reporting System is subject to several limitations including inaccurate reporting and incomplete information. VAERS receives reports of many events that occur after immunization and some of these events may occur coincidentally, following vaccination while others may actually be caused by the vaccination. The fact that an adverse event occurred following immunization is not conclusive evidence that the event was caused by the vaccine. Factors such as medical history and other medications taken near the time of the vaccination must be examined to determine if they could have been the cause of the adverse event.


Dr. Mike Patrick: Now, does the available data since RotaTeq has been on the market indicate that the vaccine is associated with intussusception? And the answer to that is no. Since its licensure on February 3, 2006 until January 31, 2007, CDC and FDA, through the VAERS, the Vaccine Adverse Event Reporting System, have received 28 reports of intussusception 0 to 73 days following RotaTeq vaccination. Half of these cases, 14, occurred within 21 days following vaccination. A number of intussusception cases reported the day after RotaTeq administration does not exceed the number we would expect to occur without vaccination. Although the data we have received so far suggests that RotaTeq does not cause intussusception, it is possible that because of incomplete reporting of cases to VAERS, another factor is some increase risk of intussusception associated with RotaTeq vaccination could yet be found. Thus, CDC and FDA are continuing to carefully monitor reports of possible adverse effects of the vaccine.


Dr. Mike Patrick: Have the recommendations regarding RotaTeq vaccination changed? No. This particular notice from the CDC does not mean there is a problem with the vaccine. The Advisory Committee and Immunization Practices has not made any changes as of today, February 25, 2007, to the RotaTeq vaccinations guidelines and CDC is not changing its policy at this time. The ACIP or Advisory Committee on Immunization Practices recommends routine immunization of all US infants with three doses of RotaTeq administered orally at ages 2,4, and 6 months. It is important to remember that the known benefits of the vaccine in preventing rotavirus disease, the cause of one of our most common potentially severe childhood illnesses far out way any known risks today. Ok, so that wraps up News Parents Can Use. We'll be back with your questions after this short break.




Dr. Mike Patrick: Welcome back to the program! Up first in our listeners' segment is Chris from Maryland. "Dear Dr. Mike, I am the father of a three year old and a new born. I enjoy your podcast very much and eagerly await each new one. Now that our younger son is transitioning to formula, my question is about how to best make a formula? We use powdered formula mix, and the side of the package contains an advisory that if we do not use cold boiled water and boil our bottles and utensils, we could be putting our child at risk. We did this with our first son until my wife nearly burned the house down when she forgot about bottles boiling in a pot on the stove. Now we either warm filtered refrigerator water up in the microwave after of course carefully testing it to ensure it's not too hot, or use a warm tap water. Can you help explain what the risks are, and what those risks are based on? Naturally, if we suspect any water sources being suspect we wouldn't use it. But in our area, drinking water is considered safe. Thanks in advance, Chris"


Dr. Mike Patrick: Ok. Well, thanks for writing into the program Chris. Let's start by taking a look at the potential dangers of water. In a fairly short order I would say but it comes up with five potential problems, and the first is bacteria. And Children less than 6 months and especially those less than 2 months are more susceptible to bacterial blood infections which can then lead to meningitis and significant bacterial exposure on water can lead to this type of infection. The most common culprits here are what are called the coliform bacteria and this includes E. coli. These bacteria primarily come from animal and human waste and from septic systems and they can move through the ground and in depth in the water supply.


Dr. Mike Patrick: The second potential dangers are protozoan organisms. Protozoan, if you remember back from high school biology, they're single celled organisms that are a little bit larger and more complex than bacteria. Two common examples would be giardia and cryptosporidium and these usually cause severe prolonged diarrhea which can lead easily to dehydration. A third problem is nitrates. These occur when nitrogen in the soil combines with oxygenated water. Oxygenated water is liquid water with oxygen gas dissolved in and then the nitrogen usually comes from ammonia which in turn comes from fertilizers or septic systems, and the resulting nitrates are dangerous because they can get into the blood and turn hemoglobin and red blood cells into something called a methemoglobin. Methemoglobin doesn't combine with oxygen very well, so the red blood cells don't carry as much oxygen as they should and a cellular suffocation a result, so the cells aren't getting the oxygen that they need. Hemoglobin carrying oxygen is what gives blood its red appearance. With methemoglobinemia, as a condition from exposure to nitrates is called, the blood turns of a chocolate color and then fair skin people will turn from a pinkish tone to a dull gray or even a blue tone and this is called the blue baby syndrome. And when methemoglobinemia gets this bad, it's deadly if it's not recognized and treated promptly.


Dr. Mike Patrick: An interesting side note, methemoglobinemia, (laughs) I even trip up over the word, methemoglobinemia is treated with an IV injection of methylene blue which is a common dye, but methylene blue works by converting Methemoglobin back to hemoglobin which then can carry oxygen and it's life threatening, or I'm sorry, that would be life saving to give methylene blue to someone who has methemoglobinemia. This is one of those illnesses that you know, maybe they've done like on House. You know the show House? I'm not a big watcher of that show but I've seen a couple episodes. They always come up with crazy scenarios. This would be a good one for them to write about because basically you're just, you're using your tap water that has tons of nitrates and the next thing you know over time it builds up in the baby's body and they start to look a gray color, when they draw blood to do labs in the emergency room, the blood is a chocolate color and then to save the baby's life the doctors putting deep indigo blue dye in their body through an IV. And this is all true.


Dr. Mike Patrick: So why are nitrates more dangerous for infants compared to adults? The same process of course would happen in everybody but the significant thing is how much hemoglobin to Methemoglobin conversion takes place in relationship to the total blood volume and since babies have less blood volume, it takes less nitrates and less conversion from hemoglobin to Methemoglobin to create a major problem. Issue number four comes from fluoride and we're going to talk a little bit more about fluoride in the research round up segment coming up in a little while. Infants over 6 months old need a little bit of fluoride for healthy adult tooth development, which is taking place above the infant teeth even if the infant teeth haven't popped through yet, but too much fluoride can cause fluorosis. These results to permanent tooth staining and in extreme cases can lead to bone mineralization problems as well and also kidney and liver problems too, if water doesn't have enough fluoride in it, so too low of fluoride, then soft cavity prone adult teeth may result. If there's too much fluoride then fluorosis can occur. So you want the fluoride level somewhere in the middle and again we will talk more about that a little bit later on the program in our research round up.


Dr. Mike Patrick: And then finally, the fifth one I came up with is lead. May be a problem if your water reaches the faucet through old, corroding plumbing materials, then lead can get into the water and significant lead exposure results in a variety of health problems including delays in physical and mental development and deficits in learning and attention. Ok. So what does all this mean? That depends on what kind of water you use municipal water in your local town, well water or bottled water. Let's choose city water first. With municipal water, you're paying to have this stuff taken care of for you, so the water should be free of bacteria and protozoan organisms and the level of nitrates will be safe, and they test these things daily but you won't need to pay attention to your local news because that's where you'd get warnings for boil alerts because a bacteria, like it's common after a water main breaker repair or also notification of high nitrate levels. Incidentally, boiling water only kills bacteria or protozoan organisms. It doesn't help with nitrates at all. In fact, boiling will actually make things worse because you'll lose some of the water to steam, making the concentration of the nitrates even higher. You should also be aware of fluoride in your city water. Most cities add the right amount but some locations do not add extra fluoride and some locations have too much natural fluoride. So you want to call your water department to see if they add fluoride, or to ask them how much fluoride is in your water and again later on the show will talk more about fluoride issues. If they don't put any fluoride in the water and your water has low fluoride, you can ask your doctor about fluoride supplementation in the form of medication for infants older than 6 months or you can get your water from a friend or relative who has a city water where they do put fluoride in or buy bottled water that has fluoride added in. Also, if you have a house that's less than 20 years old, lead shouldn't be a problem but if your house is older than that then it's not a bad idea to call your local health department, have them test the water for lead. Of course if they find it, you're looking at a big bill for plumbing replacement but your home will be safer because of the work. Bottom line for city water, you know it's going to be safe. There's no need to boil water that's city water as long as you pay attention to boil alerts and nitrate warnings and as long as you don't have the lead problem with your home's plumbing. How about bottled water? This water comes from the municipal supply and it's also tested by the company that produces the product, so you can assume it's safe too and boiling is not required. If you're buying bottled water, consider one that has a bit of fluoride added into it, again if your infant's older than 6 months, otherwise ask your doctor about fluoride supplementation. Ok. Under well water, is it safe? Honestly, here's where you might run into some problems. If you have a young baby, either use bottled water or take some steps to make sure your supply is safe. Take a sample to your local health department; have them test it for organisms, nitrates, fluoride and lead. If they find organisms, they usually give the instructions for bleaching the well and retesting the water, it's a fairly straight forward process that usually works.


Dr. Mike Patrick: If they find a nitrate that's more of a problem because you can't get those out. Nitrates can fluctuate with the time and year depending on the agriculture near areas. Just because there are low nitrates now doesn't mean that they'll be low in 3 or 4 months. so if you test your water every 3 or 4 months for a year or two, and the nitrates stay low then that's comforting and you may not need to retest it after that unless your local agriculture changes. With regard to fluorides, some well water has natural fluoride in it. Actually some steady water does too, because ultimately, that starts as well water, but some may even have too much fluoride. If your well water is low on fluoride, which should be the case for most, then ask your doctor again about the supplement for kids over the ages 6 months. If it's too high in fluoride, then you're best off just using bottled water to make up the formula. And of course, if there's lead present, then again you have bigger issues and you need to address your home's plumbing system. With all that said, even with testing with well water, I'll be inclined just to buy bottled water for infants if you have well water at home. It's not expensive. We have well water here at our house which we use for washing laundry but we use bottled water for eating and drinking. You could say that boiling well water will make it safe but what if you have nitrates in it? Then boiling is actually going to make it worse. So is boiling necessary? Not really. Really for any age, as long as you're using city water and paying attention to local news regarding water warnings or if you're using bottled water from a reputable source, you should be okay with that too. Also remember to look at the fluoride situation. If you live in an older house, make sure lead doesn't getting into the water from corroded plumbing. And as always, if you're concerned about water safety, the safety of the water supply in your community, talk to your child's doctor, there may be some circumstances in your community or your child may have health concern that I don't know about. All right, thanks for your question Chris and we'll be back with thoughts from another listener, right after this.




Dr. Mike Patrick: Moving along in the listeners' segment, here's a question from Tina in California. "Hi Dr. Mike, I can't thank you enough for taking the time to do this podcast. I've been listening since the manic mommies recommended you and I'm totally hooked. I have two boys, one just turned three and the other is 16 months. They're both generally really healthy and only suffer from the usual colds and ear infections. My question is about the one exception to that and it concerns breathing treatments. My 16th month old has had repeated problems with wheezing whenever he gets a cold. When he was younger, our doctors prescribed albuterol in the liquid form. A few months ago, they switched us to the inhaler with the mask. Our most recent visit for the same problem led them to recommend a nebulizer with albuterol breathing treatments. My doctor has confirmed that he does not have asthma but rather reactive airway disease because the problem only occurs when he gets sick. My first question is about the reactive airway disease, do kids outgrow this?& How often does this change to a diagnosis of asthma later in life? And the second question is about the albuterol. Ironically, my older son, just have a case of walking pneumonia and had to do breathing treatments as well. I know the common side effect as hyperactivity and bloated eye, I experienced that. They were both bouncing off the walls and sometimes unable to sleep. It seems like the treatments had a build up effect because it took a day or two after they stopped having them for them to return to their normal level of energy. I've heard that there are alternatives to albuterol and I'm wondering if they do exist and why they're not prescribed more often. Thanks again for all that you do. I love our pediatrician but she obviously can't spend the time that you do offering so much viable information."


Dr. Mike Patrick: Well, I'm a busy pediatrician too. (Laughs) So she probably could, if she really wanted to. But anyway, (laughs) she says, "Keep up the good work, Tina. Oh, P.S. I'm just curious; do you actually have a studio on your home? Or is Birdhouse studio is just a fun name for your living room?" Ok. Thanks for your question Tina, I'm going to put the studio question on hold but only temporarily, we'll get to it during the show wrap up a bit later, but right now let's talk a little bit about asthma. You know I could easily do several shows on nothing but asthma but I'm going to keep this answer short and to the point. I'm going to try anyway. First, young kids with asthma or reactive airway disease, it's all about the words. You know, parents don't want to hear that their child has asthma but really, the term asthma just means recurrent wheezing and they can be anything from a little bit of a cold, a little allergic reaction to something, that's the only time that you wheeze when you're exposed to something specific, or when you really have a bad cold, or it can be something that is hard to keep under control on a daily basis, and all of it, if it's recurrent is asthma. Reactive airway disease is just a nice way to say asthma. But really, it's all the same thing. What is happening is there is inflammation& in the bronchial tubes in the lung and because of that inflammation in the lining of the tubes, the diameter of the tube is smaller and the resistance increases and that leads to the breathing problems that are associated with this disease. Incidentally, allergies like allergic rhinitis when you have just the runny nose, watery eyes kind of allergy, and eczema which is the dry skin issues. These are all related and it's just a matter of where the inflammation is happening. If it's happening in the upper airway we call it allergic rhinitis, or hay fever. If it's happening in the lower airway, it's reactive airway disease or asthma, and if it's on the skin, then we call it eczema. But it's all basically the same kind of problem.


Dr. Mike Patrick: In terms of will children outgrow it, I've said this before with other illnesses and it's just so true in so many aspects of medicine and that's you've got to look at your family history. If there's a family history of childhood asthma, and not a big history of adult asthma then you've got a really good chance that your child is probably going to outgrow it. On the other hand, if there are a lot of asthmatics, adult asthmatics in the family and they started their asthma in childhood, and now your child has asthma, well, it's going to be a lot more likely. This is going to be a lifelong treatment for them. In terms of caught asthma or reactive airway disease, the funny thing is when you code a code number for reactive airway disease and asthma is the same. I mean, it's just, as a doctor, you know, you'll tell "Hey, you just have reactive airway disease" because you feel better about it. It's not the word asthma, but it's all the same thing and again just look at your family history to see if they're likely to outgrow it or not.


Dr. Mike Patrick: What about treatment of asthma? Just sort of a quick overview, there's two prongs to asthma or reactive airway treatment. The first is going to be preventive. So kids who really have a lot of recurrent wheezing, of course if there's something you know that causes them to wheeze then you want to try to keep them away from that. If it's cold viruses that do it, that's going to be tough but they probably shouldn't be in big day care centers where they're being exposed to cold viruses right and left. If you know that they're allergic to something and that something makes them wheeze, obviously you want to try to identify what that is and keep them away from it. Beyond that, the main treatments in terms of prevention are going to be steroids and then the non steroid types. The steroids, these are the things that inhaled steroid, so what we're mostly talking about with preventative treatment of asthma. Pulmicort, flovent, advair, these all have steroid component. Mostly if you have asthma and you are listening or your children have asthma, you know exactly what I'm talking about. Other medications for the prevention of asthma would be singulair, it's an oral medication that reduces the inflammation in the lungs, it's nonsteroidal, works by different mechanism. Another one is intal, bet some of you from your childhood may remember that one. It's not quite effective and not used much anymore. Then a really old one is theophylline and that's another one that is not steroid medicine but it did help the airways open back awhile ago. What about acute treatment? This is where it's important to know the difference because if you have a child who's having an asthma attack or they're having a lot of wheezing, using these preventative measurements are not going to help. Giving him a dose of a steroid medicine or giving him a singulair, or giving him a breathing treatment with Pulmicort or a puff of their flovent is not going to help. You have to use a bronchodilator. If you just look at the difference between the two ways of addressing the inflammation to airways, the steroids helps the inflammation form in the first place, but once that inflammation is there, your steroids and singulair, intal, those kinds of things aren't going to help you out too much. What you want to do is, use something that's going to make to smooth the muscle in that airway, relax and dilate, so you can make the airway diameter larger. So use what's called a bronchodilator because you want to smooth muscle, lining the air tubes to relax so that the diameter becomes a little bit bigger and you can get air through better. And the primary bronchodilator that we use is albuterol and albuterol has been around for a long time. It does come in an oral form so you can give it to little babies with a spoon, that's not the most effective way to do it but often times it works for little babies if it's just mild wheezing. And then you can also use it with an inhaler, in older kids you can do an inhaler with a spacer and then teenagers, a lot of times they don't need the spacer anymore although you'd not hurt to use it. And then in little infants you can use an inhaler with a mask and then there's the nebulizer again with the tubing and you put the medicine in the little cup and then you give it that way.


Dr. Mike Patrick: Albuterol is the main one. There's also one called the atrovent, which is also helps the albuterol work a little bit better, it's also bronchodilator. Albuterol does have a lot of side effects and mostly it's a, just think about caffeine, it can cause a rapid heart rate, it can cause a little anxiety, can make them breath a little more rapidly, and that's because of the fact that albuterol is not having its effect in the lung, it's also a chemical and it's having an effect on the heart and it's having an effect in the brain as well. What they found with albuterol is that albuterol is actually a mixture of two types of albuterol molecules that are mere images or isomers of one another. Now you got to think back ahead of you, think back to high school biology, now you've got to think back to high school chemistry. Basically you have a right handed model and a left handed model and what they found is that one of those is responsible for these effects in the lung and the other one is more responsible for the effects on the heart and the brain so the rapid heart rate and the increased activity from the brain effect. And so a company made a purified, so to speak, form of albuterol when they separated those two molecules the right handed molecule and the left handed molecule, they took the good one that really just has its effect in the lungs, and doesn't have nearly as many side effects and have marketed it as xopenex is the name of it X-O-P-E-N-E-X. So why don't we using that? Most kids aren't bouncing off the wall, I mean, a lot of kids do, but most kids tolerate albuterol just fine. It's sort of a subset of kids that are really hyper on it and for those kids usually I do use xopenex for those kids. Now why don't I use xopenex for everybody? Well, it really comes down to cost. Albuterol is available in a generic form and is a lot cheaper than brand name xopenex, and so, I mean we're all trying to be cost conscious in medicine. I think I read somewhere that in the next 5 to 10 years, 1 out of every 5 dollars is going to be spent in on health care in our country. We really have to be aware of that. So if you have a medicine that's going to work just as well, and is well tolerated and is a lot cheaper, then I think that's the best one to use. But if you have a kid that's definitely off the wall bouncing, then I think that you can make the argument that you probably ought to use the xopenex. The other thing is that, a lot of the insurance companies, if you're going to use xopenex because it's so much more expensive, because not only as your go pay going to be more, but the amount that the insurance company is paying a lot more. A lot of them require a preauthorization. If I have a busy office full of patients to see, and the waiting room is full, and my nurse is trying to get shots together, and we have well checkups and vision screens and hearing screens, we don't have as much time to be on the phone with the insurance company getting it preauthorized.


Dr. Mike Patrick: That's another hurdle in terms of why is albuterol would get prescribed more often than xopenex. We'll revisit asthma in some upcoming episodes because it is a common disease that affects lots and lots of kids and grownups too so stay tuned to feature episodes for more on asthma. Ok, let's take a quick break and then we'll be back with comments from Catherine and Michelle. So stay put, there's plenty more pediacast coming your way!




Dr. Mike Patrick: Finally in our listener's segment, we have comments from Catherine and Michelle. Catherine is from Texas and she says, "Hi Dr. Mike! My husband and I owe you huge thanks, for recommending Dr. Ferber's book on a recent episode. We read the book, and our 8 month old daughter was sleeping through the night and taking two naps daily in about three days. Thank you for the recommendation because I am pregnant again and really needed my sleep…. Now keep Catherine's comments in mind as we listen to an audio message from Michelle.


Michelle: Hello Dr. Mike! This is Michelle Marhauf and I'm a new listener. I'm really enjoying your show. I appreciate your in depth explanations to listener questions and I feel that you are really going to be detailed. And I feel like it's losing up my leisure and rewind is not necessary. I sometimes learned more from your answers than from our discussions from our own pediatrician. That being said, I just want to say that I just think you are cured by the one in your recent show about crying it out. You recommended Dr. Ferber's message to get baby to sleep off our own. Now you get the rationale that the baby needs to learn boundaries and parents need to learn to say no. But I wonder if you are out expecting too much from your own baby. Surely you need to teach your children boundaries and say no is definitely a part of that, but I subscribed to the attachment style of parenting and feel to be busy on children, toddlers and under, their want for closeness at night time aren't signs of weak. I think there's a recent phenomenon that parents to expect their infants to sleep alone and away from every one they love and a need to push young children in their independence so early. For centuries, parents have always kept their precious children close, I feel like my daughter has night time needs, just like day time needs and you can probably tell that I am quoting Dr. Williams here but again Dr. Mike, I really appreciate your show and I'm not going to stop listening because of the issue around this. I just hope you'll counter my points and give me some insights of why you don't follow the attachment file of parenting. Thanks so much! Bye bye.


Dr. Mike Patrick: All right. So we have a little bit of difference of opinion between Catherine and Michelle. I think the bottom line here is you have to do what's right for your family given the situation you find yourself in. I mean, I'm not trying to be wishy-washy here, but I think there's a right and a wrong when it comes to dealing with night time issues. My point is that if your baby's night time habits are disrupting your family, you have to deal with it. And often the best way to deal with it is do the methods described in Dr. Ferber's book because it works. Other families may not be bothered so much with getting up frequently to console the baby. Maybe it's the mom who doesn't need as much sleep as other moms. There's a big difference on how we tolerate how much sleep we get. For instance, my wife really needs 7 or 8 hours of sleep every night, or she's pretty grumpy, and I'll get by it. With 4 or 5 hours of sleep, I'm good. And the sort of way our bodies put together, there may be some differences there. Or, maybe you do need to sleep and you're not getting it but you feel good about making that sacrifice for your baby or you're not back to work yet, or is another mom might need to get back to work but then she can't function during the day. So, to say Dr. Ferber's approaches right and Dr. Sears' attachment approach is wrong, or to say Dr. Sears is right and Dr. Ferber's wrong won't get you nowhere. I think you just have to look at the situation and the context of how it affects the family and how much you can or are willing to tolerate. Personally, I leaned more to Dr. Ferber's method because I've really seen it make a huge difference in the lives of lots of parents in a short order of time.


Dr. Mike Patrick: Here's the thing, if it tends to work and usually works quickly and I say that from my own experience with it and also I'm talking to parents who've used this technique. If babies learn to console themselves within a week, was that really a need. A need is like they're really hungry or they just wet themselves and they're very uncomfortable or they're too hot or they're too cold, those are needs because they're just keeping upset about it until you fix it. Is the need for emotional attachment a true need? I guess you could argue about that. I think if it's something that goes away three nights and babies learn that you're not coming; does that hurt them from a psychological point? If it's something that goes away after three days, is that really significant as a significant need? I don't know. I don't know what the right answer is there but I do know that you have to look at it from the context of the whole family, and I don't think it's asking too much for the baby 4 to 6 months old to start learning to sleep through the night. Thanks for your comments both Catherine and Michelle; as always, we enjoy hearing from our listeners and Michelle, I'm glad that you're still listening to the show despite our difference of opinion on that. All right, coming up at the end of the show I'll remind you how you can get your own question or comment on the program. But first we need to add an item to our research round up and I'll be back to do that right after this break.




Dr. Mike Patrick: All right. Welcome back to the program! We're ready to head into the final portion of the show our research round up. Today's item comes from Tonkai Medical College in the People's Republic of China. And it's a study published in the journal Environmental Research. Fluoride: When is it too much of a good thing? Researchers for this study looked at four areas in Hainan province with different levels of fluoride in the drinking water. It looked at 210 children altogether, that were equally divided from these floor areas and each of the four groups were matched for age, sex, and nutrition status. They tried to make it so the amount of fluoride in the drinking water was only the difference between these four groups. You know you can't do that exactly, but they tried their best. The average amount of fluoride in drinking water is measured in parts per million. The average parts per million of fluoride in water, among these four groups, one was 0.76, another was 1.47, the third was 2.58 and the last was 4.51. And so, you have basically low fluoride in 0.76 and high fluoride 4.51 and then a couple groups in between. And then multiple lab tests were done on the children, they looked at blood and urine levels of fluoride, they also looked at liver enzymes, and markers of kidney function. What they found was that there was a significant increase in the number of kids with compromised livers and kidneys by the blood tests that they did in the groups that had 2.58 parts per million and 4.51 parts per million when compared to kids in the 0.76 and 1.47 groups. The authors conclude that fluoride water levels above 2 parts per million have a higher incidents of causing kidney and liver damage than water with fluoride below 2 parts per million.


Dr. Mike Patrick: The reason this is important is because the optimal range for fluoride in drinking water was determined more than 40 years ago by the US Public Health Service. And they came up with the number 0.7 to 1.2 parts per million which is well below that 2 parts per million that was considered a sort of the cutoff point in this Chinese study. However, in 1986 the EPA, Environmental Protection Agency, set the maximum acceptable cutoff concentration for fluoride in drinking water of 4 parts per million which is quite a bit higher than 2. I mean, that's up there in that damage group. About 220,000 Americans live in communities where fluoride levels are known to be higher than 4 parts per million. I am assuming that these communities with fluoride water above 4 parts per million, which is above the EPA maximum acceptable concentration, I assume this is natural fluoride because I don't think any community would fluoridate their water higher than what the EPA says you can. But then the question becomes if your natural water has natural fluoride in it and it's higher than 4 parts per million and the EPA comes to town and tells the whole city they have to buy bottled water because all of their wells are going to have too much fluoride, there's going to be a huge outcry. So this becomes a political issue and I think probably these 220,000 Americans who have drinking water that's 4 parts per million or higher they probably know that they have high fluoride in the water. I would assume 1. Since we can't count them, 2. They're probably being stubborn, or want to be told whether they can drink their water or not. That's my guess anyway.


Dr. Mike Patrick: So what does a high level of fluoride do? In addition to the liver and kidney stuff, it also causes dental fluorosis which is dark staining and enamel loss and tooth pitting and can also cause weaker bones that fracture more easily. This study suggests that we should probably lower maximum allowed level of fluoride to reduce these risks. Now, how much fluoride is in your water? That's the big question here and for trying to make a difference with pediacast, I think really as a parent, you have the responsibility to know the answer to that question. If you have city water, it's easy, just ask the water department with the fluoride concentration, and if it's less than 0.7 parts per million you should consider a supplement from your doctor for fluoride for babies 6 months and older, or buy bottled water that has fluoride added in it. If it's too high, if it's somewhere between probably 1.5 and higher, with well water, you might want to consider buying bottled water and not using your well water because that may be too much fluoride and again, that's not the kind of case for most people. Most natural water does not have fluoride in it but there are some pockets of areas, even in where I practiced areas, one corner of the county that does have a high amount of natural fluoride in the water.& You should know, of course it's easy to find out, you just have to take your water into the health department and they'll test the fluoride for you and lets you know exactly what it is if you have well water. And if you have city water, you don't really need to test it. You could just call the water department and they'll tell you. And if you're buying bottled water and getting bottled water with fluoride in it, if you have young kids you should be, then it should say on the label how many parts per million of fluoride is in that water.

Dr. Mike Patrick: Again, 0.7 to 1.2 parts per million is sort of the target range, and everything over 2 parts per million is too much and anything less than 0.7 parts per million is probably not enough. Ok, that concludes today's research round up and we'll be back with the final word after this break.




Dr. Mike Patrick: All right. We're back with our wrap up. I promised some information about Birdhouse Studios, so here goes. I do have an actual studio in my house. It's not too fancy, in fact it's in the basement but you know, it's a finished basement so it's not too dark and dingy. The same room doubles as an exercise room. We have a treadmill, a gazelle and one of this total gym contraptions and that equipment doesn't get used nearly as much as it should but that's a topic for another day. Uhm, I have a oversized desk, a microphone boom arm, a studio style condenser mic, mixer board, and a tube composer. The tube composer access a gate so that it cuts out background noise and it also adds warmth to the recording as well. And then I record each episode with an external sound blaster audio card that connects to my new MacBook Pro which I love very, very much, through a USB cable. Using an external sound card eliminates electronic noise from inside the computer casing and gives a little bit of a cleaner audio. And then I use a DSP Quattro, which is a Mac software package, to record and edit each show segment, it's just got a nice recorder, I can actually monitor the voice with headphones as I'm doing it with the grudge ban I find there's a little bit of delay of with what I'm speaking and what I'm hearing so I can't monitor it very well, but with DSP Quattro, that works really well. I record the individual segments with that and then use this grudge ban to mix the segment tracks together, make the interlude beds, the intro, the outro, make it all into one package. Then finally, I export from grudge ban, convert the pod in mp3, doing to ensure maximum compatibility to our listeners and that has become an issue too. I've had several people in email, wanting me to do an enhanced podcast that includes chapter markers instead of the interlude music for helping you find one section to the next. I've been sort of hesitant to do that because I don't want to cut out people who would not be able to listen to an enhanced podcast. But I guess I could do a second feed with one regular and one enhanced so that's something to consider. So if you have strong feelings either way on that let me know. Of course, once I've got the file together you're going to upload it, add it to my feed, the show notes and publish everything to Why Birdhouse studio? Well, you know how home decoration changes over time. The old stuff goes into a box into the basement and we have a few of those boxes and one of them was filled with some decorative birdhouses from a few years ago. A couple of them we have purchased but most of them we had received over the years as gifts from well meaning friends and family. Once word goes out that you collect something because you've got two of them, in our family things gets a little crazy and the next thing you know, people are giving us birdhouses right and left. Birdhouses don't go with our decorating style as particular home. I wanted to make the studio a little warmer and inviting, my wife stumbles over this box, well, literally stumbled over it, and suggests that I decorate the birdhouse on a shelf. Birdhouse studio, I wasn't too hip on the idea, but as it turns out, it looked good and these birdhouses have a home now. So I can look at the shelf and I can see 1,2,3,4,5,6,7. I see 8 birdhouses and then there's a cross stitch thing that's got a birdhouse too. I'm surrounded by birdhouses so I called it Birdhouse Studio on a whim and then the name stuck and its kind a grown on me really though. There you have it. That's how Birdhouse studio got its name and I'll work on getting some pictures together so you can see where the magic happens.


Dr. Mike Patrick: Are you still listening to me because I'm calling it too long. Walt Disney World, where the magic happens right? (laughs) Oh brother. All right, I want to thank all our new and returning listeners out there for making a little time in your day for pediacast. Thanks also go out to my family for supporting this crazy project. And of course thanks to Vlad over for contributing our artwork. You can find free custom wallpaper and easily affordable high definition prints at his website. Again, you can find his work at, that's vlad, V-L-A-D Don't forget if you have a question or comment for the listener's segment, you may simply browse onto and click on the contact link. You can also email me by writing to And if you want to send a voice message, you can attach the audio file to your email or call the Skype line at 347-404-kids, that's 347-404-K-I-D-S. Views on iTunes are really important for the continued success of the show. As are digs of each and every episode in the podcast section of, that's dig, with two g's and you can get there by clicking at the digg us link at You can also leave reviews on podcast at podcast alley and promotional materials are available for download on the post your page at And be sure to tell your friends, families, coworkers and friends about the show so we can empower more parents to understand and make great decisions regarding the health and well being of their children. So until next time, this is Dr. Mike saying, stay safe, stay healthy and stand tall with your kids. So long everybody.




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