Pacifiers and Spinal Manipulation – PediaCast 032
- Criticism of the U.S. Child Health System
- Pacifier Use and SIDS
- Bladder Diverticulum
- Breath-Holding Spells
- Pediatric Spinal Manipulation by Chiropractors
- Listener Comments
- Current U.S. Child Health System is a Patchwork of Outdated Programs
- Pacifier Use May Lower Risk of SIDS
- Breath-Holding Spells: Scary But Not Serious
- Adverse Events Associated with Pediatric Spinal Manipulation
- U.S. Consumer Product Safety Commission
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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, a pediatric podcast for parents. This is Dr. Mike coming to you as always from Birdhouse studio and I'd like to welcome everyone to the program. It's episode 32 and this week on the big show we have criticism of the U.S. child health system — not for me.
Pacifier use may lower the risk of SIDS, which is Sudden Infant Death Syndrome, bladder diverticulum — there's something you may not have heard of before but we're going to discuss it, breath-holding spells, pediatric spinal manipulation by chiropractors because you know, I just love the controversial topics, [laughs] right?
And then we're also going to catch up on some listener comments this week about Pediacast. Don't forget if you have a question or comment of your own, it's really simple to get a hold of us. All you have to do is to to pediacast.org and click on the contact link. You can also email me at email@example.com. If you'd like to send an audio message you can record it and send it as an audio file attached to your email or you can call the Skype line at 347-404-KIDS.
Okay before we get started I just wanted to tie up a couple of loose ends here. A few episodes back, well it's actually probably been maybe four or five episodes ago. We talked about the fact that we were looking to get a new kitten. I don't know if you remember this or not and then suddenly there was nothing else said about it at all and you're probably assuming that we didn't get the kitten because if we had, you know, there would have been some cute stories, and you know, that sort of thing.
Well actually what ended up happening is that my kids, we told them, if we're going to get a new kitten, you really need to get your rooms cleaned up because you know we want the new cat to be safe if it wants to go in your rooms and we don't want to have to keep the doors closed all the time which they have to do now because their rooms are a little messy and they have things in there that — you know, they're playing with it, set-up just right, and our older cat would go in there and just bat everything around and probably eat some things as well.
So we said, if we're going to have a new kitten in the house, the incentive is that look you're going to clean up your room, so they're clean enough so that the cats can come in your room, go in and out, that kind of thing. We'd use that as a good reason to clean your rooms, not that you need a good reason but you know, we're not perfect parents [laughs]. So, anyway the kids decided that they would rather have messy rooms and not have a kitten. Can you believe it? So okay, fine. No kitten. So you know that's what happened. We didn't get the kitten. Because they didn't want to clean their rooms up for the arrival, so we figured if it didn't mean that much to them we could just skip it. So, that's what we did.
Alright [laughs] you know, I would like to also while we're talking about family things. I know this has nothing to do with pediatric medicine at all.
But I do think that the parenting issue goes hand in hand with the medical topics, and so I do want to remind you about Karen's Pediascribe blog. Some recent topics on there, top heavy toddlers and shopping carts. Do moms need an annual review from their family? How to measure parental success and an explanation of how the new math leads to strep throat. So that's all on Karen's Pediascribe blog this past week, and for that you just go to pediacast.org and click on the Pediascribe blog link or you can go to pediascribe.com. And if you have an RSS reader, the blog does have an RSS feed, so if you'd like to subscribe to that, again simply go to pediascribe.com or go pediacast.org and click on the Pediascribe blog link. Have I got you totally confused?
Okay, welcome back to the program. This week's News Parents Can Use is brought to you through a partnership with Medical News Today. Medical News Today is the largest independent health and medical news website with at least 60 new articles everyday including weekends. That's more than any other health news site and you can visit Medical News Today at medicalnewstoday.com.
Alright first up, current U.S. child health system is a patchwork of outdated programs.
When it comes to health care for our kids, we live in a hardscrabble world that is only going to get tougher. That is the underlying message from three UCLA professors who are calling for a complete overhaul of the U.S child health care system, which they describe as a "patchwork of disconnected programs, policies and funding" that lacks "clear accountability or performance goals."
In their report, which appears in the current issue of the journal Health Affairs, Dr. Neal Halfon, director of the Center for Healthier Children, Families and Communities at UCLA's School of Public Health, and his co-authors argue that even as Congress, the nation's governors and the Bush administration debate federal spending on the State Children's Health Insurance Program, which covers low-income uninsured children whose families earn too much to qualify for Medicaid, our leaders are not tackling more fundamental challenges facing the nation's child health system.
According to the authors, the current system is failing to produce the kind of health outcomes that it could and should because it is powered by outdated logic, outmoded organization, and inadequate and misaligned finance strategies that were designed to be responsive to epidemiology and health goals more relevant to the early part of the 20th century.
"An increasing body of science now tells us that the scaffolding for our adult physical, cognitive and socioeconomic health is built in the early years of life," said Halfon, who prepared the report with Dr. Helen DuPlessis, UCLA adjunct assistant professor, and Moira Inkelas, UCLA assistant professor, both with the School of Public Health. "We know now that many health problems have their origins during childhood and simply compound over time."
Obesity rates among the nation's children have doubled in the last 20 years, Halfon said, and the prevalence of diagnosable mental health and behavioral problems in youth has climbed to more than 20 percent, creating the prospect that the current generation could be less healthy than their parents.
"The most common diseases of the past were acute illnesses or infections, but today's children and youth face more chronic conditions that will impact them for the rest of their lives — diseases like asthma, diabetes and mental health problems like ADHD and depression," Halfon said. "These emerging health needs are simply not being addressed."
The authors call for ground-up reforms to the U.S. child care system that include:
– making transformation of the child health system a national priority.
– improving overall system performance by consolidating the fragmented array of programs scattered
across various federal departments and agencies into a new national child health development agency that can take the lead in advancing the child health agenda.
– ensuring that all children have health care coverage that is responsive to their unique developmental health needs; that coverage is comprehensive and includes health promotion, as well as disease prevention services; and that coverage addresses the whole child, including physical, mental, behavioral and developmental needs.
The authors warn that transforming the child health care system is not only an ethical and social imperative but an economic one.
"The outmoded operating system and obsolete logic employed by the U.S. child health system is analogous to a modern business ignoring the Internet, Windows and new Pentium processors and running their operations using MS-DOS on separate and unconnected 286 machines," Halfon said. "It worked in the past, but it is not very effective and efficient for a competitive business, nor is it appropriate for a health system that needs to produce health outcomes that will help our children compete in the future."
Alright well I am not entirely with agreement with UCLA's assessment. You know this is really sky-is-falling kind of report. In line, I think you know, with the whole global warming movement, I mean certainly there is room for improvement as is the case with any other nationwide system in any discipline, there's always room for improvement.
The folks at UCLA point out that the most common diseases of the past were acute illnesses and infections. So why has that changed? Well, I say mostly because of immunizations and antibiotics. And how do children get immunizations and antibiotics? Well of course by visiting doctors. How long do you think it would take for deadly diseases to routinely kill children again if we stopped giving immunizations and antibiotics? I say, not long at all. There was a time also when a childhood cancer met certain death, and now the majority of children are cancer victim survivors. They have a chance to survive without access to healthcare and without the latest cancer treatment protocols. No.
The UCLA report states that chronic conditions such as asthma and diabetes and mental health issues such as ADHD, and I'll add autism to that list, affect more kids today than ever before and they imply that we aren't addressing those issues appropriately.
But could it be that we see more of these diseases because access is improved? Could it be that there was just as much asthma and diabetes and ADHD and autism before but kids either succumb to the problems or lived with undiagnosed issues. And many more kids today are diagnosed with asthma and
type 2 diabetes but you know the asthma increase, at least in my practice, are mostly the mild cases and perhaps they weren't diagnosed in years past as having asthma.
Is the type 2 diabetes really on the rise, or are we looking for it more often? Is there really more ADHD and autism or are we better at identifying the kids who have those problems and addressing them. In my opinion, UCLA's arguments support success in the child health system. Acute disease and infections are down and we are identifying more kids with chronic diseases and improving their lives with appropriate intervention.
I mean certainly there is room for improvement. Don't get me wrong there. But the sky is not falling. And parent education programs such as Pediacast and the many other online sources of pediatric and
parenting information is hardly a 286 machine running MS-DOS.
Okay one more story — pacifier use may lower the risk of SIDS and it's most beneficial between the ages of 1 month and 1 year.
The risk of Sudden Infant Death Syndrome (SIDS), the third leading cause of infant death, may be lowered through the use of a pacifier. According to an article in Nursing for Women's Health, neonatal health care practitioners should counsel their new parents on the potential benefits of using a pacifier.
This advice follows the release of updated recommendations from the American Academy of Pediatrics (AAP) Task Force on SIDS, suggesting that pacifier use be encouraged for children less than one year of age.
"It's important to note that the AAP's pacifier recommendations are not unique,… says author Elizabeth Damato, Ph.D., RN. "A variety of studies have indicated that pacifier use lowers the risk of SIDS, and several other countries have made similar recommendations…. She stresses, however, that parents must be counseled on how to use pacifiers safely.
"Pacifiers shouldn't be used before the age of one month in breastfed infants to avoid the disruption of regular feeding habits,… says Damato. "Also, infants should not be forced to take a pacifier and parents should not reinsert it once the infant falls asleep…. Parents should also avoid using homemade pacifiers, avoid strings or cords to secure the pacifier to the child, and regularly clean and replace pacifiers. Even though evidence is mounting that pacifiers help to prevent SIDS, no one knows why.
"Because SIDS happens so rarely, it is difficult to do large-scale controlled studies to determine why pacifiers might help,… says Damato. "However, because the risk for serious side effects is greatly reduced if pacifiers are used properly, they are a safe and sensible option in the battle against SIDS….
Alright, again thanks to our new news partner, Medical News Today, the largest independent health and medical news website at medicalnewstoday.com. And we'll be back with our first listener question right after this break.
Okay, up first in our listeners' segment is Nisha from Virginia. Nisha says, "Hello, Dr. Mike. I'm an ardent listener of your podcasts. Love your recent Q&A series where you pick and answer listeners' questions in your podcast. I have a question. My 9-month-old son was detected with bladder diverticulum at the age of 2 1/2 months. The urologist later told us that the best possible remedial action is surgery but that we should wait until he is about 10 to 12 months old to do the procedure. We will soon be scheduling a followup with the urologist but we'd appreciate if you could talk about this subject and shed some light on it if there are options other than surgery and if none, then what can we expect before, during, and after the surgery. Thanks again!"
Okay, so let's talk really quickly about bladder diverticulum. What is it? Well it's an area of weakness of the bladder wall so that then pressure is exerted from the urine leads to an outpocketing or a blind sac in the bladder.
So you basically have an outpocketing in the bladder that forms a blind sac. The problem with this is that urine can get stuck in this sac and sort of be a residual or an amount of urine that the bladder does not empty in this outpocketing and that can lead to infection. We've talked before that especially in girls bacteria often make their way into the bladder because the urethra which connects the bladder to the outside world is pretty short and skin bacteria can go up the urethra and get inside the bladder and the active peeing and getting the urine out on a regular basis flushes the bacteria out and prevents a urinary tract infection. But if you have this outpocketing from a weakness in the bladder muscle, then some of the urine can get stuck in that outpocketing and the pool in there, and then that can be a breeding ground for bacteria so it is possible to get urinary tract infections as a complication of having a bladder diverticulum.
Now, the other issue is this outpocket, depending on where it is located, it could cause obstruction of the ureter, which is the tube that connects the kidney to the bladder or the urethra, again that's the tube where the urine leaves the bladder and goes outside. So if this outpocketing is large and it's putting pressure on one of these structures, then that could lead to an accumulation of urine around the kidney, which we call hydronephrosis or again to an infection of the kidney if some of the urine is backwashing up toward the kidney because this outpocketing is putting a little bit of pressure on the area where the urethra enters the bladder and then the little valve that keeps urine from going back up toward the kidneys is not functioning properly because of the pressure from this outpocketing.
So hopefully I haven't confused too much there. Now recurrent infections, even silent ones, where we have just mild urinary tract infection and it doesn't necessarily have to have a high fever or vomiting or belly ache or really anything. But if you have these recurrently, then eventually that can lead to kidney damage and eventually kidney failure. So it is important that we– You find even just one urinary tract infection, especially in boys because they're less likely — even in girls — to get urinary tract infections. So if you find one in a boy, you really have to look to see if there is nothing anatomically wrong with the bladder that could be doing this or with those valves.
We did talk about kidney reflux in a previous episode. So if you look in the archives for that you'll find it. And in girls too, especially young ones, and definitely in babies, you know you want to look for these things. Most often, a weak bladder that causes this outpocketing in an area is congenital, meaning that you are born with it. So if you have an infant who gets a urinary tract infection, you really have to do some studies to look and make sure that they have a bladder diverticulum. That's why we do what's called a VCUG, which is where you put a catheter in, put some contrast into the bladder and then fill that really full and take some x-rays while the kid is peeing to see if any of the urine goes into a diverticulum or if it goes back up towards the kidney which is kidney reflux. So the congenital weak bladder is probably the leading cause in kids that you would see. Now this is really rare, but it can be associated with bladder wall cancer that can be causing the weakness and that's going to be much much more common in adults.
Okay so what are the symptoms of a bladder diverticulum. Well, it stands to reason that recurrent urinary tract infection would be the most common symptom. But if there is a large degree of obstruction because this outpocketing is pushing on either the ureters or the urethra, then that could cause abdominal pain, decreased urine output, and symptoms of kidney failure can also eventually result. But again, these are going to be rare. Diagnosis, again, you have to suspect it and then, you either do a VCUG which we've just talked about or a cystoscopy where they put a little tube inside with a sort of microscope on it and the urologist can look at the inside of the bladder and could find out that way. But in kids, most of them are going to be diagnosed because they have a urinary tract infection as an infant and you do the VCUG to see if they have a reflux, because that would be the most common thing and then in doing that you find this bladder diverticulum.
Now, treatment, what do you do? Well, if there's significant obstruction then treatment is urgent. It really needs to be treated and corrected because, again, if that obstruction is causing backup of urine that can really damage the kidneys so if there are signs of obstruction then treatment would have to happen right away. If the only symptom is recurrent urinary tract infection, then what you could do is antibiotic prophylaxis which just means it's a daily dose of antibiotic, and I know, I know, I know we are not supposed to use antibiotics as much but this is one of those cases where it is accepted to use a daily antibiotic to prevent recurrent urinary tract infections until you get it fixed and that's the case with the reflux of urine back up toward the kidney as well because your kidneys are important, you only have two of them [laughs] and you don't want bad things to happen to them.
So this is one case where it is acceptable to use a daily antibiotic in order to prevent a urinary tract infection and you could do that to the point where you know you can get the elective surgery scheduled, if there's no obstruction associated with the diverticulum. You know I think it does make sense to wait until infants are a little bit older in this case, 12 months sounds good to me. When they are bigger, it's going to make the surgery easier and they'll have less of a chance of general anesthesia complications. However, if there is significant obstruction or breakthrough urinary tract infections, despite daily prophylactic antibiotic, then your urologist is likely to tell you that the benefit of getting it fixed outweighs the risk of performing the procedure really, regardless of age. Now in terms of expectations with this kind of surgery, it really depends on the location of the diverticulum, the experience of the surgeon and the operating room team including the anesthesiologist, and how much experience they have working with kids.
In my opinion, the best bet would be having this fixed by a pediatric urologist who sees only kids and has a lot of experience doing this type of surgery and I would also have it done at a children's hospital because, you know, if something does go wrong during the procedure, you'd rather that the intensive care unit be down the hall or one floor away instead of a helicopter ride over a couple of counties. Now again, that's just my opinion. It might get me in a little bit of trouble. But you know, if it was my kid, and whenever I give advice, you know, I always think, what would I do for my own kids? And for my own kids, this is the sort of thing that I would personally want fixed at a children's hospital by someone who does it and they have the support and resources they need if problems arise. You know, it's like the boy scouts, be prepared. We don't expect there'd be a problem more than likely the most dangerous part of the whole thing is the car ride over to the hospital but you know you want to minimize any possible issues that could arise.
You know, as with any surgery, there is a chance of complications regardless of the surgeon, the procedure or the hospital you go to so you always want to have a healthy respect for the operating room and avoid it whenever possible but sometimes you know it's not possible to avoid it because the risk definitely is worth the possible consequences if you don't fix it.
You know also I want to mention too if the diverticulum is near the ureters or the urethra, then there's going to be more risk of complications but of course those are also the ones that have to be done with some degree of urgency. So you know sometimes you just can't avoid taking the risk but you know by having someone who's experienced and doing it in a place that's used to dealing with kids you're going to minimize the risk. So, alright, let's go ahead and take a break and we will get to another listener question right after this.
Okay, oh I love this one. This comes from Melissa in California. Melissa says, "I have a 13-month-old son who literally holds his breath until he passes out, when he's cranky or just plain upset. This is a behavior that I've never seen before. Both of my sons held their breaths as infants but my eldest grew out of it. My 13-month-old's behavior startled our pediatrician and my sister who is a pediatric nurse. The pediatrician was about to start rescue breathing when I told him that it was that happens all the time and eventually my son will start breathing again.
Blowing in his face worked when he was younger but then nothing works. All I can do is move him to a safe place and let the fit pass. Is there anything else that I can try? Will he eventually stop doing this? Or am I the only mother with a child like this?"
Thanks for the question, Melissa. The answers are no, yes, and no. There really is nothing more that you can do and yes, he will eventually stop doing it, and no you are not the only mother with a child like this. So let's talk a bit about breath-holding spells.
This would be a brief presentation of the problem but if you look in the show notes, I have a link to a great article from Contemporary Pediatrics that provides lots of detailed information on breath holding. Children with a family history of breath-holding spells may be at higher risk of having their own breath-holding spell compared to other children perhaps because of an underlying genetic predisposition.
Most children who have breath-holding spells have the first spell between 6 and 18 months of age. Breath-holding spells that begin at a younger or older age than is customary call for special attention. In the neonatal periods, or right after babies are born, when spells may start during feeding and diaper changing, then in that case breath-holding spells are a diagnosis of exclusion. What does that mean? It means that you have to do an extensive workup to eliminate any other problem before you call it a breath-holding spell.
Now again we're talking about young infants much less than 6 months of age because there are major central nervous system problems or heart problems, lung problems, metabolic problems that can babies to stop breathing. Sometimes, they'll turn a little bit blue in the face and that makes you very concern. So you would want to call that a breath-holding spell.
Similarly since there are no documented cases of children having first breath-holding spells at 4 1/2 years of age or older, then a child whose spells begin this late must be carefully evaluated for brain tumors, acute hydrocephalus, which is a fluid in the brain, epilepsy or seizure problems and heart arrhythmias. So if you have a kid who's older particularly, older than 4 1/2 years of age who has their first breath-holding spell, again you wouldn't want to call that a breath-holding spell, they stop breathing and you got to find out why.
So if you have a kid though, again, 6 months of age and 18 months of age and that's when it's starting, that's the most typical time. You also note that — one difference too is that usually this happens when the kids are upset. So you know, they are holding their breath because they are upset about something that's usually when you see this happen.
You know, I've certainly seen kids you know, come in for their kindergarten shots who, you know, are breath holders and they pass out and as soon as they pass out they start breathing again but again these are kids who are upset because they are about to get a shot. And they're known usually at the point to be breath-holders; they've done it before.
An individual child may have a breath-holding spell once a year or many times in a single day. One-third of affected children have two to five spells each day while another third have only one a month. Then most children, the spells peak between 1 and 2 years of age and then gradually become less frequent. The incidence in girls and boys is similar though some studies show a slight predominance of boys. Studies from the 1960s show that children with behavioral problems such as stubbornness, disobedience, aggression, temper tantrums, head banging, hyperactivity, hypersensitivity, or enuresis which is wetting their pants, are more likely to have breath-holding spells than other children.
Breath-holding spells often start during a time when children are displaying negativity and oppositional behavior to demonstrate their independence. A newer prospective study of children using the child behavior checklist and profile found no significant behavioral differences between children with breath-holding spells and controls and no correlation between the frequency of breath-holding and scores on the overall behavior profiles.
So, the take home here is, again, you worry about breath-holding spells in young infants less than 6 months of age, and first-time breath-holding spells in kids over the age of 4 years. And if you have an older infant or toddler who does have breath-holding spells, chances are very good based on the more recent studies that they'll grow out of them before kindergarten and do not have an increased risk of developing other behavioral or developmental disorders. The article I linked to in the show goes on to describe a typical breath-holding spell, you know what does it look like, looks at possible causes and has some great tips for dealing with them at home.
It also takes a look at the other medical conditions that can mimic breath-holding spells and explains some of the studies doctors may do to rule out those conditions. So if you want to know more, again, simply head over to the show notes at pediacast.org and click on the breath-holding spells link.
Okay this week, our third listeners' segment is also going to count as our research roundup since my
answer to the question relies heavily on a recent research study. This comes from Jill in Michigan. "Hi, Dr. Mike. I love your show and I think it's a great way for parents to gain information. As one show is ending, I am always looking forward to the next Pediacast." Well, thanks, Jill. "I would like to hear your thoughts on chiropractic care for infants and children. I've read some information in support of this and I'd like to know how you feel. I have a 10-month-old daughter and my husband and I are considering having her adjusted on a regular basis as I do. Do you think it's a good idea? Thanks in advance for your response and keep up the good work."
Thanks for your question, Jill. So you guys are dragging me into another controversial subject area. Thanks a lot. [Laughs]
But you know as my regular listeners will tell you newcomers out there, Pediacast does not avoid the controversial, even when it gets me in trouble. So first let me say that this is my personal opinion and then I'm going to support with a little research for you.
You know I think that chiropractic manipulation of infants is fine if it's in the form of infant massage. You know, but I would not use a musculoskeletal manipulation for disease treatment or as a substitution for immunization. I would also avoid spinal manipulation including the back and neck in all children.
Now in support of this advice, I would direct you to a study reported in a January 2007 edition of the Journal of Pediatrics entitled "Adverse Events Associated with Pediatric Spinal Manipulation: A Systematic Review." And this comes from the Department of Pediatrics at the University of Alberta, Edmonton Alberta, Canada, and the Department of Graduate Education and Research, Canadian Memorial Chiropractic College in Toronto, Ontario, Canada.
So, this is a collaborative study between a group of pediatricians and a group of chiropractors. So I think this is important to know because there's often a dispute between allopathic which are the MDs, osteopathic which are the DOs and chiropractors regarding the use and benefits of musculoskeletal manipulation. But here we have a study where two of these groups are coming together and having some advice for parents.
So first, a little bit of background. Spinal manipulation is a non-invasive, manual procedure applied to specific body tissues with therapeutic intent. So what specific body tissues, well obviously the spine, which is the back and neck. Although spinal manipulation is commonly used in children, there is limited understanding of the pediatric risk estimates. So the objective of this study was to systematically identify and synthesize available data on adverse events associated with pediatric spinal manipulation. So what they did is they did a comprehensive search of eight major electronic databases including Medline, AMED, and MANTIS and others. From the time that these databases began until June of 2004, irrespective of language, the reports were included if they were primary investigations of spinal manipulation, whether they be observational studies, controlled trials, surveys, any of those things, if it was any study in the electronic databases that store all of medical research, then it was included in the survey.
It also had to include a study population of children who are aged 18 years or younger and have reported data on adverse events. And then the data was summarized to determine the nature and severity of adverse events that may result rather than their incidence. So they can't really say what the incidence is because there were enough cases to look at to extrapolate it out to an entire population. So they are really just looking at you know, what adverse events occurred, how severe were they, you know, sort of what is in the realm of possible rather than trying to determine how often an injury would happen if you did spinal manipulation in kids.
So what were the results? Well, 13 studies in all, 2 were randomized trials and 11 were just observational reports. And so these 13 studies were identified for inclusion in their survey. They identified 14 cases or direct adverse events involving neurologic or musculoskeletal events and 9 cases involving serious adverse events such as subarachnoid hemorrhage, which is a little brain bleed; also paraplegia even occurred. In 9 of these cases there were serious adverse events like this. Two involved moderately adverse vents that required medical attention such as severe headache and three involved minor adverse events such as mid-back soreness and another 20 cases of indirect adverse events involving delayed diagnosis and/or inappropriate provision of spinal manipulation for serious medical conditions.
So what are they talking about here? Well, they are talking about kids who had things like — again, these are examples from the study itself — diabetes, neuroblastoma, which is a type of tumor, meningitis, and rhabdomyosarcoma which is another type of tumor. So there were 20 cases in the literature where there was a serious medical condition whose diagnosis was delayed because the parents were spending time having the child undergo spinal manipulation instead of examination that would identify what the problem actually was that was causing the child to have issues or symptoms. So the conclusion of the authors — and again, this is both from pediatricians from a group of chiropractors — is that serious adverse events may be associated with pediatric spinal manipulation. Neither causation or incidence rates can be inferred from the data.
They recommend that a prospective population based active surveillance study will be required to properly assess the possibility of rare yet serious adverse events as a result of spinal manipulation on pediatric patients. So what they're recommending is that anyone who performs spinal manipulation of course have — you know, you'd want the parents to have informed consent of what could happen but again, but it's unlikely that it will, it's just in the realm of possibility and then have a database where you look at how often and what types of adverse events occur. Now of course the problem with this is that because of liability, you may people who do spinal manipulations not want to report any adverse events and their patient population for fear of liability and the lawsuits.
So you know, it's just going to be tough to do a prospective study on something like that. Again a
prospective study is where you sort of design the study and then go forward rather than looking back at data like this study did. So I think the bottom line here, you know, in the literature approximately 50 children had adverse effects following spinal manipulation over a period of several years and they ranged from very serious such as delayed diagnosis of meningitis and brain bleeds, to very mild just, you know, their back was sore after they had it done. Does the benefit of spinal manipulation in children outweigh the risk? And that's what a parent has to decide. For my own kids, I would say the benefit would not outweigh the risk of potential adverse effects of spinal manipulation.
Massage therapy, fine. But I wouldn't use chiropractic care as a substitution for immunizations or the appropriate use of antibiotics or any other accepted pediatric treatment modality. If you are interested in the full text of this article, I do have a link in the show notes at pediacast.org. Alright we will return with our final segment after this short break.
Okay welcome back to the program. I wanted to spend a little time this week catching up on some of our comments about the show. So we're going to go through some listener comments rather than questions here. The first one is from Melissa in Fort Worth, Texas and Melissa says, "I loved your information about car seats. I have a 9-month-old and she is getting ready to move into the next size. One thing you didn't mention is that most fire or police stations have a certified person to check your car seat and make sure it is installed correctly. It's good to go when you're still pregnant, so you are certain you have it right to bring your baby home. Love your show! -Melissa."
The next one is from Mark in Washington, D.C. and Mark works with the U.S. Consumer Product Safety
Commission. He says, "Hi, Dr. Mike. I just wanted to give you a heads up about the U.S. Consumer
Product Safety Commission's weekly podcast. It highlights product safety recalls and many of it affect
young children. CPSC recalls toys and children's clothes and other products for choking, aspiration,
strangulation and other hazards. Check us out at www.cpsc.gov or subscribe by searching for CPSC on
And I think that's a great podcast to check out and again, we'll have a link of course in the show notes to that. Next comes up is Arwin, from Reno, Nevada. Arwin says, first of all thank you, Dr. Mike. I love your podcast and it has been of great help. Thanks for your tip on getting my toddler to go to bed. I wanted to say bravo to the listener that mentioned Early Intervention. I think that it is important to mention that there are services that are for the most part free for parents. Dr. Mike, you had mentioned that speech therapy is not always necessary partially based on the cost involved.
Early Intervention will ask for permission to bill a patient's insurance but parents will not be responsible for any co-insurance or co-payments for the services. Also in most states, once a child turns 3, the local school district will take over with education of the children who are found to be developmentally or physically delayed. Again, thank for all the great info in your podcast. And then Cara, from Austin, Texas says, "Dear Dr. Mike. First off I have a 6-month-old at home and I really enjoy your show. I listen to it every week. I most appreciated the segment on autism and the MMR vaccine. It was so helpful to have the related literature reviewed. I just wanted to make a comment about Pediacast 27 and the mom who wrote in about her child not taking solids. I am a pediatric occupational therapist who routinely sees children for oral aversion and related feeding difficulties. You may have avoided this topic on purpose, if so, please forgive me." No, I didn't.
"But I just wanted to mention that sometimes, if there is a problem with food and texture aversion, often the children have aversion to textures everywhere. So they might panic in the grass or in sand or in the water etc., or they don't mouth any toys. The advantage to knowing this early is that the parent can prevent setting up negative experiences and often a therapist can help with this for the child and then he can work toward tolerating environmental textures and mouthing non-nutritive texture sources first. Once the child is anxious around food or the parent makes strange adaptations, I had one parent puree food until the child was 3 and fed it to them in a bottle with a nipple cut off, then often it takes a very, very long time in therapy to work out a normal feeding situation. Anyway, you probably are aware of all this but I thought I would mention it that early intervention in these cases is key. Thank you so much for all your help and a great podcast."
And then Bristol in Lake Wales, Florida says, "Dear Dr. Mike. I just wanted to tell you that I love your podcast. I am lucky to have a great pediatrician that takes what time she has to answer my questions. You are an awesome supplement to her. I like that you tell us your life and goings-on. Thanks for all the extra work you do for all your listeners. It means a lot to us. Also, thanks for the info on changes to the
immunization schedule in a recent podcast. I found the new schedule online and hung it up with the catch-up schedule at my daughter's day care center. They didn't even know about the changes. Thanks for everything you do for parents and children."
And then Cristy in Grand Rapids, Michigan says, "Dr. Mike, I really have been enjoying your podcast, and would like to leave a review for you on iTunes per your request, to keep your numbers up. However, I can't figure out how to do this. Help!" [Laughs] Alright, Cristy and anyone else who wants to know because the reviews in iTunes are very important.
First you have to have iTunes, so if you don't have the software, you just want to go to Apple.com and click on the iTunes link and you can download iTunes. It is free. It's a free software. You do not have to have and iPod to use it. And they have a wonderful podcast directory within iTunes where you can find tons of really really great podcasts and you can listen to them at your computer right there through iTunes. Also, if you don't have an iPod, you can use the iTunes directory to find a podcast that you like and then there is always a link to go to that podcast's home page where then you could find the file and download it to any MP3 player. So you do not have to have an iPod in order to use iTunes. Of course, I would highly recommend the iPod. It's a great little device, and it really has become something that I use you know, every single day.
So you know, I would definitely highly recommend one if you can get it. But again, you have to have the iTunes software in order to do an iTunes review. So once you have the software downloaded and installed, and there is a Windows version and a Mac version, if you have Windows Vista, from what I understand, there's some compatibility problems at the present time, that should be worked out pretty soon. But once you open up iTunes, then you go to the iTunes store and then within the iTunes store, click on the kids and family section and you'll find Pediacast right there. Click on the Pediacast link and then it'll take you to our page with all the shows listed and then kind of look around that page you'll find a link that says to leave a review and that's how to do that. So if you are not using iTunes, it is easy to get at Apple.com, easy to install, compatible with everything except for Windows Vista at the present time, but that should be fixed pretty soon and it is a great resource to find other great podcasts. So that's how you do that, Cristy.
Alright, thanks to all of you who wrote in with comments, they are always appreciated. And if you have a comment you would like to add to the show or a question that you want us to address, then it's an easy thing to do, and I'll be back to remind you how and wrap up the program right after this break.
Okay well thank you to everyone who is tuning on to Pediacast this week.
Before we go, I did want to mention that my daughter's play has opened. She is in the "Sleeping Beauty Kabuki" which is a Japanese theater type presentation of Sleeping Beauty. [Sighs] I missed the opening night. But I am going to see it later on today. I missed the opening night because I was on-call, so I had to see sick kids in office instead of my daughter’s opening night performance but my son and mom was there, not my mom, my daughter’s mom, that would be my wife, Karen, sorry [Laughs]. She was there and I am looking forward later today to seeing Kabuki presentation of Sleeping Beauty.
Also I wanted to follow up a little bit. Last week, I had mentioned that I'm trying to talk my family, um, Karen into [Laughs] getting a Wii and you know I hear over on MacBreak Weekly, you know they are always talking about Wiis and the Munich Mommies have a video posted now with their family and neighbors playing the Wii.
And you know we did a research study last week where we talked about it, and of course, I think it would be a great health benefit for the family and believe it or not I even got the kids to agree to chip in $50 each from their allowance fund. So, you know, this is great news, right? And Karen said, "You know, this does look like fun. I agree it is healthy and you know, if the kids are going to chip in $100 to pay for the thing, then yeah, let's get one." So great news, right? Well, now we can't find one. [Laughs] We called around. You know, we called around the Best Buys, to Toys R' Us's, to Circuit Cities to Walmarts to Sam's Clubs, looked at Amazon, nobody has them. So you know we'll keep looking and I'll let you know how that goes. If anyone out there has a Wii and, you know, has any helpful hints or insights or, you know, "definitely get one," "definitely don't get one," let me know.
Alright, so thanks also to our news partner this week, Medical News Today, which you can find at medicalnewstoday.com. As always thanks to Vlad over at vladstudio.com for so graciously allowing us to use his wonderful artwork at the website and with the podcast. Also thanks to all of you for listening to Pediacast and making it what it is. We really appreciate the support and the feedback that I get on the show. And of course, thanks to my family for being patient with me and giving me the time that I need to get this thing out and about.
Reminders, don't forget that if have a question or comment that you would like us to address, then you can go to Pediacast.org and click on the contact link. You can also email firstname.lastname@example.org. If you want to attach an audio file to your email, that would be great.
Or you can call the Skype line at 347-404-KIDS. Also don't forget promotional material is available at the website on the poster page so you can download material advertising Pediacast and put up in break rooms and nurseries and day care centers and church bulletin boards and that kind of thing.
Also, look for a Cafe Press store to be opening sometime soon with Pediacast logoed merchandise so that should be coming soon. So look for that. Also, again iTunes reviews are most helpful as are digs over at Digg.com. Alright be sure to tell your friends, family, co-workers and neighbors about the show so we can empower more parents to 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 stay involved with your kids. So long everybody.
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