Schools, Juice Plus, and Pill Swallowing – PediaCast 034

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  • Elementary Schools
  • Amish Youth Activity
  • Allergic Rhinitis
  • Juice Plus
  • Slow Resting Heart Rate (Bradycardia)
  • Waiting longer to start infants on solids
  • Pill Swallowing
  • Ear Tubes May Not Make a Difference



Announcer: This is Pediacast.


Announcer: You're listening to the Tripod Network. What's on?


Announcer: Hello, Moms, Dads, Grand Moms, Grand Pas, Aunts, Uncles and anyone else who looks after kids. Welcome to this week's episode of Pediacast, the 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 as always, I'd like to welcome everyone to the program. Ah I have to start out with a little bit of an apology. I realized there was no show last week.


I just needed a "give me week…. My kids were visiting grand ma and grand pa for the week and my wife and I got some things done around the house although not as much as we would have liked to because we did get a Wii [laughs]. We'll talk more about that, coming up in a little bit.

I do have a full show lined up for you this week, though. In our News Parents Can Use segment, we're going to talk about elementary school classrooms and how they are getting a low rating on high quality instruction. Also, Amish youth activity and obesity rates compared to youth in modern society.

And then in our listeners' segment, we're going to answer some questions about allergic rhinitis, Juice Plus, slow resting heart rate, otherwise known as bradycardia, and waiting longer to start infants on solids, is that okay? And then we'll wrap things up with our research roundup and talk about a new pill swallowing cup and ear tubes. And they may not make a difference for some kids, a new research study shows. That's all coming up a little bit later on in the program.


Don't forget if you have a topic you would like us to discuss here on Pediacast, it's really easy to make your voice heard. Just go to and click on the contact link. You can also email me at If you like, you can attach an audio file to your email and get your voice on the show or you can call the voice line at 347-404-KIDS, that's 347-40-5437.

Okay, a little bit more about our Wii. I have to give a shout out to Rob, our friendly neighborhood Walmart pharmacist because he really took care of us in getting us a Wii. I guess at Walmart, they sort of make an announcement to all the employees when they are going to be getting these things in. And a lot of times they go really fast.


So he heard that they were going to be coming in, and gave us a phone call to let us know that they were only going to get 18 of them in and they couldn't sell them until Sunday at midnight. So, Saturday evening, Karen called over to Walmart to just sort of double check to see if they were going to admit that these things were in stock. She called around 8:30 in the evening and the lady said, yeah, and they are going to go on sale at midnight, and there's already five people in line.

So the kids were out of town, so we dragged ourselves over to Walmart. I took my laptop. She took her iPod. And we sat on the dusty floor at Walmart for 3 and half hours — lovely time, really, but totally worth it because the Wii is just incredible. I mean, really, if you're going to play a video game you might as well get some exercise out of it to boot.

Okay and then one more shout out I have to give. The geniuses at the Genius Bar at our local Apple store. Wonder job. I have an older iPod. It works just fine. I don't watch a lot of video podcast, so I only need it for the audio and you know some music, some books on tape, some podcasts and the battery was dead.


I really didn't want to shell out the money for a new iPod, especially just buying a Wii, and so I took it in to get a new battery. They had told me that I would have to leave it there, and then it may take up to a couple of weeks, before I could pick it up again, because they were pretty backlogged. So, I took it in and as it turns out, I needed an appointment at the Genius Bar which they didn't tell me, but they got us in on standby and sure enough they were able to help us out. And as it turns out, they had a brand new iPod in the back room that was the same model. It was an older one that's discontinued but it had never been sold. It was not a refurbished model, with a new battery in it and they just traded it in. So you know, for 70 bucks, I got a brand new 20 gigabyte iPod with new battery, brand new iPod, I think it's third generation it has the click wheel. But, anyway, I was very surprise that I didn't have to drop it off and instead of just replacing the battery, they give me a whole new unit.


So kudos the Apple Store and the nice folks at the Genius Bar at Easton Town Center. That's where it was.

Okay and then one more shout out here. This is to all of you. My listeners rock. You know, last week, actually two weeks ago, okay rub it in, two week weeks ago, I asked for some more reviews in iTunes, and quite a few of you really came up to the plate and hit for me. We got several new reviews, all of them great, 5 star reviews, more than 10 of them, and your work, just the 10 of you, propelled us to the front page of the podcast directory, not the kids and family section but the whole front page of the entire directory and so we got about 200 new subscribers because of that week on the front page.


So to all the new folks out there, welcome! Thanks for joining us. And my loyal listeners out there, just thank you so much for those of you who took the time out of your busy day to write a nice review in iTunes. It really makes a huge difference. I mean just 10 reviews really pushed us up to the top. So if you haven't done that yet, I would encourage you to please do so. I don't take co-pays. You don't have submit anything to your insurance company. [Laughs] This is all free. So please just give me a little review on iTunes. It makes a big difference.

Okay I would like to remind you that the information presented in Pediacast is for educational purposes only. We do not diagnose medical conditions or formulate treatment plans 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 the Pediacast Terms of Use Agreement which you can find at


Alright, we're going to take a quick break and we'll be back with News Parents Can Use right after this.


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. So visit Medical News Today at


Alright, first up in the news segment: "Elementary school classrooms get low ratings on high-quality instruction."

For all the current emphasis on standardized testing and teaching requirements, the quality of elementary school instruction is mediocre at best, according to a National Institute of Child Health and Human Development study of Early Child Care and Youth Development published in the March 30th issue of Science magazine.

"Any given child has less than a 20 percent chance of having a rich classroom experience consistently through elementary school," says Robert C. Pianta, lead researcher and Professor of Education in the University of Virginia's Curry School of Education. And for low-income children, the percentage is even less.

Based on live observation of the same 1,000 children throughout the country in their first-, third- and fifth- grade classrooms, Pianta and colleagues reported in the article, "Opportunities to Learn in America's Elementary Classrooms," that pupils are not getting the kind of rich, challenging academic experiences that would enhance their learning and improve their test performance.


"Clearly, what we find is contrary to what is considered essential for a high-quality classroom," said Pianta.

If you asked educators what's the most effective way to teach in a classroom, they would probably include small-group instruction, for example, but we found it occurred less than 10 percent of the time in those three grades and for fifth grade, the occurrence was only 7 percent.

High-quality teaching challenges children to use reasoning, critical thinking and problem-solving skills, with lots of teacher-student interaction, and it involves emotionally supportive interactions and engaging activities, but according to the study, that kind of experience is not typical.

The learning environment in classrooms is more likely to be passive than active, with teachers lecturing to the whole group or giving students individual seatwork about 90 percent of the time.


The classroom analysis found fifth-grade teachers spending 37 percent of the time on basic literacy skills, 25 percent on math, only 11 percent on science and 13 percent on social studies. The classroom analysis found those statistics to hold true pretty much across the board. These exposures are not consistent with stated national aims to improve math and science education.

In addition, students received only perfunctory feedback on their performance.

Related studies have shown that high-quality factors observed in the instructional climate do predict higher achievement gains and even close the achievement gap for first graders.

Pianta says, "Fifth-grade classrooms are pretty well managed and positive in terms of emotional support, but they are not rich and intense in ways that would elicit thinking and learning. When it comes to instructional quality, there is room for considerable improvement, and it is apparent that teachers require different supports, perhaps more relevant to their actual work in classrooms."


Whether teachers have advanced degrees, many years of experience or meet state and federal standards consistent with term "highly qualified" (as defined by the "No Child Left Behind" Act) had little to do with the instructional climate they create in their classrooms.

The article reports, "It is troubling that opportunities to learn in classrooms are unrelated to features intended to regulate such opportunities and that students most in need of high-quality instruction are unlikely to experience it consistently."

Pianta warns that relying on regulations and test scores as the metrics for the quality of schools may not actually drive improvement in opportunities to learn.

The researchers call for more observation-based studies actually looking at what goes on in classrooms, because they may reveal ways for improving classroom teaching and the preparation of teachers.


So here we have a study from the National Institute of Child Health and Human Development telling us that small-group instruction utilizing engaging activities to promote the use of reasoning, critical thinking, and problem solving skills is the way to go, yet our students spend 90% of their time listening to lectures and completing individual desk work. How are your kids learning in school? Are they being engaged? If not, then isn't it up to us as parents to engage them? Aren't we also responsible for the education of our children? It's definitely something to think about.

Okay next up in the news segment, "Amish youth activity and obesity rates to compared to youth in modern society."

A new investigation of a rural, Old Order Amish community shows Amish children have higher physical activity levels and lower rates of obesity when compared to children living in a modern, industrialized society. The study offers a compelling look at the prevalence of childhood obesity among children who, by lifestyle, are more active and do not utilize modern technology, including television, video games, or computers.


The study is published in the March issue of Medicine & Science in Sports and Exercise, which is the official scientific journal of the American College of Sports Medicine (ACSM).

"This Old Order Amish community provides a glimpse at what may be possible if physical activity were not engineered out of so many daily tasks," said David R. Bassett, Jr., Ph.D., the study's lead author.

"Based on our results, it's fair to say that advances in modern technology are contributing to the current obesity epidemic. Although it would be impractical to mimic the Amish lifestyle, this study suggests that increased levels of physical activity could mitigate some of the health problems caused by sedentary habits."

Like a previous study on Amish adults, 139 children and adolescents (6-18 years of age) in a southern Ontario farming community wore a sealed step counter and logged their physical activity for seven days.


Body mass index was computed for each child, using their measured height and weight. Children were told not to modify their activities, and also were asked to record several activities they had participated in that day.

The results indicate that obesity is rare in Amish youth. Only 7.2 percent of the Amish children were overweight; with only 1.4 percent obese. Approximately 25 percent of American and Canadian children in the same age categories are overweight and nearly 11 percent are obese.

Physical activity is significantly higher in Amish youth. Amish boys averaged 19,400 steps per day and Amish girls averaged 15,300. In modern U.S. elementary schools pedometer counts were lower, at approximately 12,000 steps per day.


In their activity logs, Amish children reported daily chores requiring considerable physical activity, including milking, gardening, feeding farm animals, and carrying wood. Additionally, most Amish children walked to school, even in inclement weather. During the school day, two scheduled recesses and one lunch hour were spent outdoors.

"The high levels of physical activity and low prevalence of overweight and obesity in these Amish youth are striking," said Bassett. "From that perspective, modern conveniences in contemporary society may be contributing to health problems down the road

So once again, you know, we just add to the bank of evidence that physical activity is important as a part of a healthy lifestyle for children and adults, and we just are not getting enough of it. No news there but you know, it's time we do something about it. What can we as parents do? Well, of course, limit screen time. You know, get outside with your kids. Roller blade, bicycle, hike when the weather allows it. And for those rainy days, trade in your PlayStation for a Wii! [Laughs]


You know, of course, always be a good role model by including exercise in your daily routine. Now trust me, I am not lecturing to you on this. My wife and I — yeah, sorry Karen [laughs] — need to exercise with more regularity, no question about it. And you probably should too. I'll keep you up to date on our progress and if you make a decision to increase your family's level of physical activity and you stick with it, shoot me a note telling me about your success.

Alright, thanks again to our news partner, Medical News Today, the largest independent health and medical news website at And we'll be back with our first listener question, right after this.



First up in the listener segment is Sarah from Brooklyn, New York. Sarah says, "Hi! I really enjoy the podcast. I've learned a lot about many interesting topics. I wanted to ask about my 2-and-a-half-year-old son. He has had a pretty much constant runny nose since he was a few months old. We tested him for allergies and he does have an allergy to dust. He has also been in day care w since he was about 3 months old. I'm not convinced that it's an allergy. Do you have any advice as to how to figure out why his nose is always running and how to stop it. On another note, a friend of mine sells Juice Plus vitamins. What is your opinion on vitamins in general, and Juice Plus if you know anything about it. Thanks!"

Alright, Sarah. Well, thank you very much for your questions. I'm going to tackle them individually. The first one on allergies. You know, allergies in young kids is common. There's no question about that. But if you have a child who's in day care. you know, getting recurrent virus infections is also pretty common.


So I think, you know, if you are not convinced it's allergy, certainly a recurrent virus, and by that, I just mean in any given day care, you have viruses A, B, C, D, E, F, G and probably all the way to Z. And so if your child gets, let's say, virus A, they're going to be sick with it for, you know, anywhere from 7 to 14 days, and then on day 10, they pick up virus B, and then on day 10 of that one, they pick up virus C, and next thing you know, you know they've just had a runny nose for a couple of months because they're just getting one virus after another because they are exposed to so many of these viruses in day care. So that's definitely a possibility. Another possibility — and I only mention this because it's something that some people need to think about, I'm not saying that, Sarah, this pertains to your family. But I do see a lot of kids wear someone's smokes in the house and the cigarette smoke is causing their children to have chronically runny noses and they don't want to believe it's allergies. They don't want to believe it's virus.


They just say something's wrong with their kid, then you tell them, you need to stop smoking or smoke outside, and you know they don't want to hear that. But you know, cigarette smoke exposure, even in small amounts, can cause a chronic runny nose. So that's something to think about too.

Also, this one is one you don't see very often but every now and then you'll get a kid who puts a bead or a marble or you know something smaller than that up into their nose, so they have a foreign body in their nose and that can cause a chronic runny nose. Although, with that, usually it's going to be more of a green or yellow discharge because there's some infection associated with that foreign body being up there, or just irritation and the body has some inflammation, and that makes it green or yellow. And so, also often there's a foul odor involved with that too. But it's something to keep in the back of your minds.

Now some other things or symptoms that can sort of clue you in to the fact that allergies rather than a virus is what's going on is, one, you know, no fevers are involved with viruses.


If they have frequent sniffing, rubbing or blowing their nose, watery, itchy eyes, chronic cough. When we look up inside their nose, we see swollen tissue up there and allergic shiners are sort of dark semi-circles underneath the eyes, we see that often. And kids with allergy drainage often times will have a belly ache in the morning and/or sore throat along with that as they have their drainage all night long. And chronic headaches, especially in the front, are also common with allergy problems.

Now, if you think it's allergies, one thing that I like to do, is just trial of a little bit of over-the-counter Claritin. And there's a dose for kids all the way down to 12 months and even younger. Just ask your doctor about that. You don't have to get the brand name Claritin, you can do generic and if that by itself really seems to make the symptoms go away, It'll take being on it you know a good week or two but if you are starting to see after a week or two of Claritin that the symptoms are going away, then you probably have your answer that it's allergies.


Now, on the other hand, you know, 1 to 2 weeks, did it go away because the virus went away. That's possible. You know in that case, you could try them on the Claritin. Do it for maybe a month and then when you take them off of it, if the symptoms are coming right back, get them back on the Claritin and then just leave them on it. If Claritin by itself is not working, then another prescription medicine that we consider is Singulair and that also can be used even in young children and then if that's not working, I like to use a nasal steroid like Nasonex, Rhinocort, Flonase, those kind of things.

So, there's definitely treatments that we can do. And a lot of times with allergies, if the allergies go away — the symptoms of them — when you treat it as if it were an allergy then you pretty much have your answer that that's probably what it is that is going on. So if your doctor thinks it's allergies, it probably is, although recurrent virus, since you're in that day care setting, that could be a possibility as well.


Okay let's talk about Juice Plus Vitamins. First I have to tell you a little story about my first experience with the Juice Plus product. I had a patient whose mother sold Juice Plus vitamins and she asked me if I wanted to buy. Well I have never heard of them before. This is a couple of years. And I wanted to do a little bit of research. This mother you know was very much into herbal supplements and vitamins and I really wanted to do a lot of research just to see, you know, is this something that's good, that's not so good and basically, after looking at pros and cons, I did not see any evidence to suggest that there was a proven benefit that justified the cost.

So when the mother came back, she asked me what I thought, and I said, you know, I really think fruits and vegetables and a well-balanced diet is really the best way to get vitamins and if you have a kid who is a really picky eater and they are not eating much in the way of fruits and vegetables, you know then some over the counter vitamins are fine.


However, I don't think that the added expense of Juice Plus vitamins justified any particular advantage that you got out of them. So I didn't really see that much of an advantage. Now, again, I don't think that Juice Plus vitamins are necessarily harmful, but I just didn't see any advantage, and you know, I wasn't interested in buying them, or specifically recommending that brand to my patients.

And honestly, I was kind, I was cordial, I explained my point, I didn't put her down for using them and within a week, I received a records release that this mom wanted to transfer care to another doctor. So my point is this. People are passionate about products that they like and believe in. And there are many who are very passionate about Juice Plus. That's fine. I'm just not one of them.


So again, my position on this is get your nutrients from a well balanced diet. If you have a child who's a really picky eater and they are not eating much in the way of fruits and vegetables, then over-the-counter vitamin supplement is fine, but does Juice Plus have a proven benefit that justifies the cost? My personal opinion on that is, no.

Now don't send me emails about this. You aren't going to change my mind. And that's okay, I'm not trying to convince the believers in Juice Plus not to buy them. All I'm saying is that I haven't seen anything to make me want to jump on the Juice Plus bandwagon.

Alright, thanks for your question, Sarah. As always, they are greatly appreciated and we'll be back with some words from another listener right after this break.



Listener question number 2 comes from Debbie in Sanatoga, Pennsylvania. "Hi, Dr. Mike. At his annual physical, we were told, my 12-year-old son had a slow heart beat. He was asked to run a few flights of stairs a few times and his heartbeat did not increase. We were sent to the hospital for additional tests which confirmed that he had sinus bradycardia and blood tests were ordered. The blood tests came back and everything was fine — great I suppose. But his heartbeat is still slow and we are just going to get it checked out again in three months. Also they said there are no restrictions on his activities so he doesn't have to stop doing sports. Great again, I suppose. But what could be up?"

Well, Debbie, thanks for your question. I see this very often. And you know when I see this, it usually is at a well checkup. So you have a kid who's not having any symptoms, no problems at all, we're taking a listen to the heart, and you know, the heart rate is 60, and you think wow, gosh, that's kind of slow.


And so this does come up pretty often. Now, what I'm going to do is basically go through what I would do for a child who came in in that kind of situation. So the first thing, and again, this is not, Debbie, to say, that this specifically pertains to your 12-year-old son, but just in general, this is what I would do. Basically, first is, you want to get a history of their activity level. So kids who are conditioned athletes are going to have a little resting heart rate and the reason for that is because their heart has become conditioned to put out more blood with each heartbeat. So their cardiac output, the amount of blood that they get each time that the heart pumps out is increased. So their body is more efficient at delivering oxygen to the tissues by getting more blood circulated.


Now because they are more efficient, their heart rate can slow down, because even though with that slower heart rate, they are still going to be able to deliver the same amount of blood and oxygen to the tissues, compared to someone who doesn't have as much of a conditioned heart where their heart has to pump more times to get the same amount of blood and oxygen distributed. Just in terms of being a conditioned athlete, most of these kids, that's really the only issue. Now sometimes, it's a genetic thing where dad also has a slow heart rate, grand pa has a slow heart rate. And then when you get the combination of genetics and physical conditioning, that combination is probably what we see most of the time.

Now of course you don't want to say, oh, everything's fine. That needs to be — that's not the default.


The default is you're going to assume everything is not fine and let's really look at this and make sure that there is not an underlying reason for this and if we don't find one, then we can say, oh, it's genetics, oh it's physical conditioning.

So the first thing that would clue you in that something is not right is, do they have any symptoms related to the slow heartbeat. So if they have any history of frequent episodes of dizziness, history of passing out, extreme fatigue, those kind of things, shortness of breath — those would all be indications that cardiac output is not where it should be. So if the reason the heart rate is slow is because you have better cardiac output. Your heart is better at getting blood out. Then if your heart rate is slow, but it's not from physical conditioning, you know then, you're not going to get as much oxygen out as the body needs and that's going to result in dizziness. It could result in passing out, fatigue, shortness of breath, those kind of things.


Also, chest pain would make you concerned or palpitations where you feel your heart beating, you feel it skipping beats, you feel it beating too fast — this would all be things that would make you concerned that there may be something more or else going on.

The next thing is the physical exam, do they have normal heart sounds, are there any murmurs, is there a regular rhythm, are their pulses are all nice and strong, and all for extremities, these kind of things.

And so, you know, you want to make sure that physical exam basically is normal. Next, I usually check an EKG, this looks at the electrical conduction of the heart. There are some conduction abnormalities that can result in a slow rate, it's called heart block. And those, you just basically need to look at the EKG and make sure that that looks normal. I also like to get a chest x-ray, just to look at heart size. There are some conditions where you have an enlarged heart but there may not be any murmurs or abnormal physical exam signs.


Usually, their EKG is going to be abnormal but not always, so I think a chest x-ray at least on as a baseline is probably a good idea. In terms of blood test, probably the biggest one you think about is with thyroid because hypothyroidism can result in a slow heart rate.

Now if we do all of those things and everything is normal, you know, so they don't have any symptoms, the physical exam is completely normal, the EKG is normal, the chest x-ray is normal, and they don't have a hypothyroid issue. You know I am very reassured and probably it is a low resting heart rate that is just normal for them.

Now, I will say this. Even if all those things are normal and the heart rate is extremely low, like in the 50 to 60 range, or even if the heart rate is you know more in the upper 60s to 70 but there is a really high degree of parental concern, then I would seriously consider a pediatric cardiology referral even if the only reason in my mind is that it's for peace of mind.


But there's a lot to be said for peace of mind. And if your pediatrician is saying everything's okay and you see the cardiologist and the cardiologist says everything's okay, physical exam's normal, EKG is normal, chest x-ray, blood test, all of that, then I think it's time to say yeah, everything really is normal and it's time to stop worrying about it. Now does that mean that there's a hundred percent no chance that anything is wrong, there's never — never ever is there a hundred percent chance. But I think what we can do is do the tests and feel the best about saying that everything is okay based on the tests and the exam and the referrals that we make, but still there's no guarantee.

I can recall a child who basically was in this situation and everything was normal.


He did have some dizziness and history of passing out a couple of times but he was a conditioned athlete, played basketball. I did send him to a cardiologist. The cardiologist said everything's fine. And he did an echocardiogram where they look at the heart with sound waves, still didn't see anything and this child did pass away playing basketball.

Now, I've had over a hundred kids, I'm sure, in the exact same situation who have not died. So, my only point with that is that even when everything is normal, you can't say everything is a hundred percent okay. But you know what? There's chance and risk involved in everything that we do. Even if your child has this history and your doctors say everything's safe and they have done everything, your child could die in a car accident. Your child could dive into a pool and make a dumb decision and break his neck.


So my point is just that life is not risk-free, but we can do, you know, everything in our power to minimize risks but you can't wrap them in cellophane and stick them in a closet. Okay [laughs]. Alright, thanks for your question, Debbie. I hope I answered it well enough for you.

Okay we're going to go ahead and take another break and then we'll get back with another listeners'
question, right after this.



Alright our third listener question this week comes from Nicole in Massachusetts. Nicole says, "My daughter Zoe started solid foods a few weeks ago, just a few days before she turns 6-month-old. So far she has only had rice cereal and a couple of different fruits and vegetables all at stage 1 consistencies. He is going very well. She loves eating food and is being fed with a spoon. All of the information I can find online an in books seems to assume that the child will start solids at 4 months and gives guidelines for new foods based on that assumption. Had she started then, apparently, she would now be eating thicker consistencies stage 2 foods. Because she started later, I cannot determine when I can start giving her foods with a stage 2 consistency. Can I give them now because she is over 6 months old or should I wait 2 months from when she started solids?"


That's a great question. And really the right time to start solid foods is between 4 and 6 months of age and most are anxious to start sooner rather than later and a lot of times it's because you have relatives who are bugging you about it. You know, grandma saying, "Why don't you start that kid on cereal?" or you know, Aunt Jane telling you the same thing. So most sources sort of assume that you are going to start cereal at about 4 months, just because that's when most people start them but it's perfectly acceptable to wait until 6 months of age to start solid foods.

Now, I'm sort of at fault at this as well. For instance, last week, we talked about infant feeding and I did also assume that you are starting solid foods with cereal at around 4 months of age, but again, it really is perfectly fine to wait until 6 months of age.


If you do wait, most kids would tolerate sort of an accelerated schedule and the reason is because stage 2 foods really have about consistency as stage 1 foods. The big difference between stage 1 and stage 2 is that jar size is generally bigger for stage 2 foods and also with stage 2 foods, you start to get combinations of products and when you are going through those, you just want to make sure that you are not introducing two new things at one time. So there's really not a huge difference between stage 1 and stage 2 baby food.

So would be a good accelerated schedule for you. If you started cereal at around 6 months of age, and then 6 and a half to 7 months of age going to the stage 1 foods, 8 to 9 months of age with the stage 2 foods and then 10 to 12 months of age with stage 3 and finger foods.


But again, the rate of advance here is going to depend somewhat on your child's acceptance of new textures and their chewing and swallowing skills. Some kids won't tolerate an accelerated schedule and need more time to adjust and get used to new thickness and textures.

For example for these kids, you may start the cereals at 6 months. You're not really moving on to stage 1 foods until they are 7 to 8 months old; stage 2 foods around 10 months; and then 12 to 15 months of age with the stage 3 and the finger foods.

So there are going to be some kids who lag a little bit behind. They sort of progress more slowly through these stages and as long as your child is growing well and is healthy and they are advancing, you know, even though it's slower, that slower schedule is going to be just fine. But it really does sort of underline the importance of the well-checks that we do, and timing them out at 4 months, 6 months, 9 months, 12 months and then 15 months because it gives us as pediatricians an opportunity to discuss feedings and look at their effect on growth.


Now, again, a slow progressor who's also having poor weight gain — that may be a concern, but usually slow progressors grow just fine. There's simply on their own schedule. Alright, we're going to wrap up our listeners' segment, and — oh, that actually does wrap up our listeners' segment, I'm sorry! [laughs] — I wasn't reading my notes correctly, you have to forgive me. See, I'm out of practice. It's been two weeks.

Alright, the research roundup is coming up next and we'll get to that right after this.



And we're back with our research roundup. First up is "Pill-swallowing ability and training in children ages 6 to 11 years." This comes from the October 2006 edition of Clinical Pediatrics.

There's limited information on when healthy children can be expected to learn to swallow a pill.


Since some medications are available only in tablet form, they can be neither cut nor crushed, the ability to swallow a pill can be valuable. It is also a way of avoiding unpalatable liquid formulations. Behavior modification methods such as practicing with increasingly larger pieces of candy have been used to train children in pill swallowing but they have not been thoroughly evaluated.

In this prospective observational cohorts study, done by the Allergy and Asthma and Research Center in San Diego, California, 124 children ages 6 to 11 years were enrolled. Children with a history of swallowing difficulties, choking or an anatomical malformation in the head and neck were excluded from the study. Children were asked if they thought they could swallow a tablet. Yes or no?


Those who said yes were asked to demonstrate this capability by swallowing a placebo tablet, using an ordinary 4 ounce plastic cup of water. They were given up to two attempts. The placebo tablet was 7 millimeters across with flat, upper and lower surfaces and a wax coating.

Those who said they could not swallow a pill but were willing to try were given swallow technique instructions in ordinary cup and up to two attempts at swallowing. Those who were unsuccessful after the two attempts were given a special patented pill cup by Promotions Unlimited in Baltimore, Maryland. For those able to swallow the tablet using the special cup, ease of swallowing was assessed and the children were asked to reattempt pill-swallowing using an ordinary 4-ounce plastic cup with the usual two-attempt limit. 91% of these kids who were ages 6 to 11 swallowed the tablet using the regular cup or the patented pill cup, and 100% of the kids who initially said they could swallow pills proved capable of doing so.


Of those who initially answered they could not swallow a pill, 84% successfully learned to swallow pills using this training technique.

So there is hope for kids out there who can't swallow pills. I did an extensive internet search for this particular patented pill cup from Promotions Unlimited and I could not find it, but I did find one from Oralflo that looks pretty slick and the way that this research article described the pill cup, it seems very similar. I can vouch or choose because I have never tried one and have never personally recommended one in the office where I could get some feedback although I may start doing that. But I did come across this in doing my research and, really, even before this I've never even heard of such a device. You can find that pill-swallowing cup at and of course I'll put a link to that in the show notes.


You know, I would use it if you're going to try it as a training device which is how it's described in this study rather than a long term solution. And I certainly would not try it in any child who's less than 6 years of age, because you do worry about the risk of choking.

Alright and then second up in the research roundup, PE tubes, which are ear tube may not make a difference. This is from the New England Journal of Medicine, March 2007.

Before I start going through this, I do want to define something for you. An ear effusion is just fluid behind the ear drum. Now for a lot of kids, when you have an acute ear infection, you have pus that's back there behind the ear drum and effusion is more of a clear liquid that just is not going away over time and in the past, in the distant past, we did use antibiotics or daily antibiotics to try to prevent infection of that fluid that's back there.


The more current thinking is you just sort of watch that fluid over a long period of time, but if it's there too long, you think about putting the ear tubes in to get that drained out and to clear the middle ear space behind the ear drum. So with that in mind, let's go through this article from the New England Journal of Medicine.

Decades of reports in the pediatric literature on the possible association of middle ear effusion and delays in cognitive and psychosocial behavioral development produced official recommendations advocating prompt drainage of middle ear effusion. This study, carried out by investigators at the University of Pittsburgh, Stanford, and the University of Texas, Dallas, is an update of prior studies and was designed to evaluate whether prompt placement of tympanostomy tubes in the ears of young children with middle ear effusion resulted in differences in literacy, attention, social skills and academic achievement as compared with children undergoing delayed tympanostomy tube placement.


In 1991 through 1995, 6,350 healthy infants aged 2-61 days were enrolled and had their middle ear status monitored by means of clinical examination, audiometric tests, and pneumatic otoscopy.

That just means — I'm going to pause here — that just means that someone looked in their ears, did hearing tests to make sure they could hear okay and also did puffs of air to see if the ear drum moved because if the ear drum doesn't move when you blow a little air in there, you can assume there's probably fluid on the other side of the ear drum which is keeping the ear drum from moving properly.

So children were eligible to participate in the trial if, between the ages of 2 months and 3 years, they had middle ear effusion that persisted for 90 days in the case of bilateral (both ears) effusion or 135 days if they had a unilateral (or one ear) effusion.


Before age 3 years, 429 of the children with persistent middle ear effusion were randomly assigned to undergo the insertion of tympanostomy tubes either promptly or up to 9 months later if the effusion persisted that long. Of the 429 children randomized, 391 were available for follow-up at 9-11 years of age, 195 in the early treatment and prompt tube insertion group and 196 in the 9-month delayed treatment group.
Developmental testing was carried out between their 9th and 12th birthdays. A broad spectrum of tests (48 in total) were used to ascertain literacy, attention, social skills, and academic achievement and tests done included Woodcock Reading test, Child Behavior Checklist, Social Skills scale, Wechsler Abbreviated Scale of Intelligence.


Plus there were 48 tests in total. No significant differences were found in the mean scores of children who received early insertion of tympanostomy tubes compared with those undergoing delayed tube insertion on any of the 48 developmental measures administered at 9-11 years of age.

So I think it's pretty clear from this study that the presence of fluid in the middle ear space has no effect on language development or any other development or milestone. But when this study says PE tubes may not make a difference, keep in mind that we're only talking about kids with persistent ear fluid over 9 months long. We're not talking about kids with recurrent episodes of acute ear infection who had pain and fever and the need for frequent antibiotics. We're not talking about kids who have their effusions longer than 9 months.


Those kids perhaps still could benefit from ear tube placement. As always, of course, talk to your doctor about that. This, again, Pediacast is just for education and information. Everybody has their own set of specific circumstances and it's really important that you take a look at each kid and each kid's situation when you decide what you're going to do.

So, again, you can't take a research study and say this applies to everyone in the group. You really do still have to practice medicine clinically and make some individual decisions from time to time. So always keep that in mind as you are taking a listen to Pediacast.

Alright, we're going to wrap the program and we'll be back to do that right after this break.



Hi everyone! This is Dr. Mike's better half, Karen, and I would like to fill you in on the latest Pediascribe blog topics. Last week, I described our recent camping session at the local Walmart. What motivated us to sit on a dusty discount store floor for 3 and a half hours? Check out the Pediascribe blog to find out. That, plus nosy neighbors, an official proclamation, a tongue-in-cheek look at chocolate Easter bunnies and a real coup on reader interest. You can find these topics plus many more on the Pediascribe blog. Simply click on the blog link at


Also, Mike tells me he wants to start contributing to the blog on weekends starting now. Stop by and see if he keeps his word. For Pediascribe, this is Karen, I'll see you on the blog.

[Laughs] Alright. Thanks, Karen.

I did keep my word. I did a put a blog post up this weekend. So, you might want to check that out. And also I have to apologize to Karen. I kind of gave away the scoop on sitting on a dusty floor at Walmart but it still good reading, so you may want to check out the blog. Just go to and click on the Pediascribe blog link.

Alright, well that wraps up this episode of Pediacast. Next week, we're going to do a special on potty training, so if you have a child at home and you're having trouble with potty training, we're going to answer several listener questions about potty trainings. And then we're also going to talk about pandas, not the animal, not the whole controversy with the panda that died in the German zoo because of the polar bear, apparently — but anyway, haven't of you [laughs] heard about that recently?


No the polar bear didn't attack the panda. I guess there were so many people at the zoo seeing the polar bear that somehow that stressed out the panda and zoo staff couldn't concentrate on the panda because of this polar bear, so it's kind of controversial a couple of weeks ago.

Anyway, that's not the pandas I'm going to talk about. There is a disease process where kids who have a history of strep throat begin to have tics and obsessive compulsive tendencies and we're going to talk about that as well as potty training next week.

Okay thanks go out of course again, to you, all my loyal listeners. I really appreciate you stopping by and taking a listen to the program and for contributing with all of your questions and comments. It's really appreciated and thanks in particular to the 10 of you who out of, you know, over almost 900 subscribers.


Ten of you gave me a review in iTunes and they were nice reviews and it did propel us to the front page of the Podcast directory at iTunes and again, I just want to say thank you. Those of you who have not done that, if you could please just take — it will take you 5 minutes to leave a nice review over at iTunes, and when we get 10 of them in one week, boy, it makes a huge difference. So please do that.

Also, thanks go out, of course to my family, my lovely wife, Karen, my son Nicholas, my daughter Katie, thank you so much for giving me the time and space I need to put this podcast out every week. Well okay. Two weeks this time. Sure. Rub it in.

Alright, thanks also to Vlad from He provides all the artwork for the website. He's a fantastic artist and you can check out his stuff at There's also a link to his place over on the website.


Remember if you would like to contribute to the program, just stop by and click on the contact link. You can also email me at If you'd like to send a voice file, you can attach an audio file to your email. Also, the voice line is available for you at 347-404–KIDS, that's 3-4-7-4-0-4-K-I-D-S which is 5437 there at the end.

If you have your iPod, you'll notice that in the show title, the voice line number is displayed there. So if you listened to the program and you want to call in, you don't have to memorize the number just look at the screen and it should be there in the title of the program.

Promotional materials are available on the poster page at the website. And also don't forget to dig us at

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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