Potty Training and PANDAS – PediaCast 035
- Potty Training
- Plastic Leaching into Food
- Once Upon a Potty – Official Website
- Official AAP Potty Training Information
- PediaCast Episode 4 (potty training)
- PediaCast Episode 15 (bed wetting)
- PANDAS information from NIH
- Bisphenol A (Wikipedia)
- Bisphenol A (American Chemistry Council)
- Baby Bottles (National Geographic Green Guide)
- Mixing Plastic and Food: An Urban Legend? (WebMD)
- Doctor, Heal Thyself
- The Three Caballeros
Announcer: This is Pediacast.
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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 I'd like to welcome everyone to the program. It's episode 35 and you know, I'm thinking it's time for just a little adjustment to the format.
Now okay before you get too concerned, it's not a big adjustment. But beginning this week, I'm going to try and experiment in integration. Now I'm starting to cover news, listener questions and research but instead of breaking the show into those segments, I think what I'm going to do, give it as a try for a couple of weeks is to just pick three topics for each episode and I'll try to pick a nice variety that includes different age groups and then we'll read and answer some recent listener questions with regards to those topics and we'll follow that up with news and research relevant to the topic at hand. That way, we can go into a little more details about each topic without sacrificing the inclusion of news and research into the program. And we'll also likely throw in some expert interviews along the way. I do have a few of those lined up. So those should be coming to you here pretty soon. So we'll see how it goes and as always your comments and suggestions are welcome.
So if we're going to start with three topics per episode, what three are we going to do this week? Well, we have a number of questions on potty training. Now we covered this way back in episode 4 but we have some new questions that weren't covered in that episode. So we're going to tackle those this week and then we're going to have a discussion on PANDAS. Now, no, I'm not talking about panda bears. PANDAS is a medical disease that is not really all that common but is an interesting one, and even if you never come across it with your own children, I think you'll find the facts about it definitely on the interesting side. Okay and then we're also going to discuss plastic leaching into chemicals in our food. Now, no I'm not talking about leaches. I'm talking about plastic sort of coming apart on the molecular level and some of the molecules of the plastic getting in to food and is that harmful to our children.
So we're going to be discussing that a little bit later on in the show. Don't forget if you have a topic that you would like us to put on the agenda, all you have to do is go to Pediacast.org and click on the contact link. You can also email me at firstname.lastname@example.org, and if you'd like, just attach an audio file to your email if you'd like to leave a voice message or you can call the voice line at 347-404-KIDS, that's 3-4-7-4-0-4-K-I-D-S.
Now, I do want to say one thing here about last week's show. The audio quality was definitely sub-par and I'm really hoping that this week is a little bit better. But you have to understand, I've been kind of playing with some new hardware and software, and honestly I'm kind of a techno geek at heart which — [laughs], by the way when I came up with my script and was sort of typing out some notes, I found out that techno geek, it was not recognized by my spell checker, but you know it should be because I definitely am one.
And I know I am because of the other podcasts that I listen to regularly. They're pretty heavy on the tech side — things like TWit, which is this week in tech in MacBreak Weekly, and Mac OS Skin etc., etc., etc. So you know, with being a sort of a techno geek there's this big desire inside of me to check out new programs, especially shareware apps and if you stayed through to the end of last week's episode, you'll notice that I was trialing Ubercaster, which is a German software package that lets you make podcasts. And I really like it actually, but I had to make some adjustments to the settings so bear with me a little bit as we tweak things and I'm hoping that the audio quality this week is a little bit better.
Okay before we move on, I just want to remind you that the information presented in Pediacast is for general educational purposes only. We do not diagnose 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.
Okay this week, our first topic is potty training and we have a series of three questions. I'm going to go ahead and go through the questions and then we'll get to the answers and comments after that. First up, is Tracy from Springfield of Virginia. Tracy says, "Dear Dr. Mike, I wanted to thank you very much for this podcast. It literally just saved my sanity. [Laughs] I know you want more older kid questions but it's us first timers who are struggling. Your recent show about urinary tract infections just hit home. My 3-year-old started complaining about a burning sensation when she pees and began crying and screaming when she passes urine and stool. Having just listened to your show the day before, I
didn't panic, but took her to see her pediatrician right away to eliminate physical causes. We're still awaiting the result of the urine culture and to find out if it is a UTI. But the initial screening was clear. My doctor also suggested they could be a potty training issue."
"I've been trying to potty train my daughter for a year now and I've met with resistance to the potty so my doctor suggested we stop for two weeks and pick up after that. I've tried the potty chart with sticker and met with some success but nothing consistent. The potty training in a day with adult technique and putting her in padded underwear and I just got a bunch of pee spots on my carpet and an upset toddler. Nothing seems to be working. She definitely gets it and understands the concept but just doesn't want to do it. Now I fear that my toddler is withholding and emotional about the potty which in turn is causing the discomfort during elimination because she's holding it too long.
Help! Are there other suggestions for potty training that have worked for very smart 3-year-olds, or do I literally just need to wait for her to suggest giving up diapers on her own? Do I take away the diapers and just let her wet herself, and that seems so cool?"
"Does my 3-year-old need a therapist? Do I wait for summer until she can run outside without a diaper? I have another baby on the way due in June so I know this might get worst before it's better. I am also working full time so I don't have long stretches to tackle this one on one. Her day care provider has success with her using the potty but, again, not consistently. She's a wonderful, happy, outgoing kid. Any additional potty advice you can offer would be wonderful. Thanks and keep up the great podcast."
Alright, and then next up is Nicole from Toronto and Nicole says, "Hi Dr. Mike. I live in Toronto, Canada and I love your show. Here's my question. My 3-and-a-half-year-old daughter is completely toilet trained except she won't poo on the toilet. If she has to go, she asks for her diaper, does her business and then asks to be cleaned up. Her pediatrician suggested a stool softener which would limit her ability to hold it until she can get a diaper."
"We now don't think this will work since when she had a diarrhea earlier this month, she refused to go to the bathroom entirely since when she sat down to pee, she started to poo also and she didn't like that. She refused to pee all day until we finally gave her a diaper. I am confident that she would have otherwise had an accident which seems like a worse problem. I also feel like if we don't give her diapers, then she'll hold it until she is constipated which I understand is very difficult to undo. Any suggestions you have would be greatly appreciated. Nicole."
And then Sherry in Rochester Hills, Michigan says, "Dr. Mike, the podcast about infant UTIs couldn't have come at a better time. My 16-month-old son is scheduled to see a pediatric urologist soon because a recent urine test came back positive for a UTI. Everything you talked about was told to me by our pediatrician; however it was nice to have your explanation for reference."
"I have a question that is along the same lines as your UTI discussion. I have a 7-year-old daughter who has been diagnosed as an infrequent voider. She also had a urine test come back positive about a year and a half ago and after having the kidney ultrasound and VCUG test which both results showing no abnormalities, the pediatric urologist explained that she is holding herself too long and as a result her bladder has stretched out and she does not feels the signals to go to the bathroom. He basically says she needs to be re-trained to use the toilet. She showed an improvement for a while. We gave her lots of water to drink throughout the day even at school and had her go to the bathroom at least 6 times a day. My question is this. She's still having accidents about three nights a week and also a few during the day. How long should parents wait before seeking outside help, if any even exists for this type of thing. It worries me that she could have bacteria building up which would damage her kidneys if this continues. Do you have any advice for helping infrequent voiders. Thank you for creating Pediacast. I look forward to listening to each episode."
Well thank you very much to Tracy, Nicole, and Sherry for your questions and you certainly are not alone in your potty training frustrations and I'm sure that there are plenty of moms and dads out there right not just kind of smiling and shaking their head, you know, sort of nodding in agreement because they know exactly the kind of things that the three of you are talking about. Now again, as I mentioned at the beginning of the program, way back in episode number 4, I did a lengthy talk on potty training and you know that episode is still posted at Pediacast.org and it's also still in the feed, so it should be pretty easy for you to find. Having said that, again, there is three great questions here,
actually a series of three questions with multiple questions within them regarding potty training and they deal with some issues I left out in the prior talks so let's go ahead and tackle them now.
First up is the pain issue. Now, again, I want to remind you that we're talking about a generic situation. Now, I'm not talking about Tracy's child in particular but just in general. When you have a child who says it hurts when they pee, I think you have to kind of get in your mind that it is a urinary tract infection until you prove otherwise and you are even more concerned that it could be an infection if they also have fever, vomiting, abdominal pain, past history of urinary tract infection, those sorts of things. But even without any of that, if the only symptom is, "Hey, it hurts when I pee," then it's a urinary tract infection until proven otherwise. Now, most of the time, especially when there's not fever, vomiting, abdominal pain, that sort of thing, accompanying the painful urination, most of the time it's not going to be a urinary tract infection, but because you don't want to miss a urinary tract infection, that's why you have to sort of think that's what it is until you prove that it's not.
So, let's say that you go to the doctor and they check the urine and there is no infection there, but there is pain when they pee. So what is the most common cause of that. Well, there's actually several — most likely it's going to end up being a chemical or contact dermatitis of the area right outside the urethra right next to where they pee. And then also, what we call urethritis, which is inflammation of the urethra itself, and bubble baths, soap and shampoo are probably the most common causes of that. So if you have a child who, they take a long bubble bath and then they're complaining that it hurts for a couple of days, you take them to the pediatrician or the family practice doctor and the urine comes back negative, you know, so what's going on.
Well in that case, the bubble bath probably caused some inflammation in the urethra and that's what's causing the pain. So for those kids, I would suggest that you just have them first play in some clear water and then basically wash rinse and get out. And even if you don't do the bubble bath but you let them wash first, or they wash their hair and then they play for a little while, keep in mind that they do have soap in the water from washing their body or washing their hair and that can cause some irritation.
And then you also have some kids who, really, any soap exposure down between the legs is going to cause some problems, particularly of course with all of this right now. We're talking more about girls than boys, but sometimes we see it in boys as well. And then, for some of these kids, they are really sensitive. You just have to sort of squish that area with a little bit of water and not use soap at all, or very rarely and sparingly.
Also, something else that can cause some pain with urination — this is usually more of a common thing with boys, but they can have some stenosis or closing of the urethra, so that two sides are stuck together a little bit and so that hole that they pee out of, it's still intact, it's just most of it sort of stuck together and that can cause some issues and they definitely need a referral to a pediatric urologist to deal with that. And then girls can also get some adhesions which can sort of do a similar thing although that oftentimes is not really associated with pain when they pee as much as just more — if these adhesions start to pull apart, that can cause pain which is not just when they're peeing, it can really be at anytime. So these are all things to think about when they're complaining of pain down in the private regions.
Other things in terms of the contact that's not necessarily soap and shampoos. Some kids are really sensitive to synthetic fabrics or any dye material that's on the underwear.
You know, if they sweat a little bit and the molecules in the dye start to come apart, and again, this is on a molecular level so you're not really seeing any of the dyes or the synthetic material but it can cause some irritation to the skin. So for those kids, you want to stick with white cotton panties. And then also, laundry soap, that can cause some issue and some kids where they have a contact dermatitis, then they're really sensitive to laundry soap so for those children, if you use a hypoallergenic laundry soap like Dreft or the dye-free Tide and those kind of things — they are sort of marketed as being hypoallergenic. Even if you have an older kid, you can use Dreft and you want to use a smaller amount of the detergent, double rinse, so you are really sure to get all the chemical out of the underwear and then double rinse — I've just said that, didn't I? [laughs] — and then, don't use fabric softener in the washing machine and don't use dryer sheets because you really are just trying to minimize the amount of chemical coating that is on the underwear.
So those are all things to keep in mind. Now, pain with the stooling, with going poo — that oftentimes is caused by constipation. But, you know, you also have to rule out rectal or anal pathology such as fissures, hemorrhoids, perirectal abscess, which is a type of infection. You know, and then these kids, really whatever the cause of their having pain when they have to go poop, you know, and particularly if it's caused by constipation, keep in mind that because it hurts, they're going to hold it more and because they don't want to go, because it's going to hurt when they go, and that makes the constipation even worse. So once you see your doctor, if your doctor determines that the cause of painful bowel movements is because of constipation, usually they'll treat with a stool softener and you have to use that over a long period of time.
One of the biggest mistakes that I see parents making is stopping those stool softeners too soon. But you have to keep in mind that a lot of the kids are better because of the medicine not despite the medicine. And so when you stop it, a lot of times, the symptoms will come back. Although, their bowels sort of has to fill back up with stool and that can take a little bit of time. So, once you stop the medicine it may take, you know, a month before they start to have the symptoms again but you can bet your britches that a lot of times, the symptoms will come back if you stop the stool softener.
Okay let's move on. So beyond the painful peeing and stool issues that go along with potty training, again, you want to address those, make sure there is no infection — that's definitely something that you want to bring to the attention of your doctor right away.
Okay beyond that, just in general, trouble with potty training in a 3-year-old. This is very common. You know, first you have to ask yourself, are they ready at age 3 from a physical standpoint? You know, some kids are just going to have the physical development needed to control the muscles that hold back the pee and the poop and the neurological signals to let them know when they have to go, when they need to hold it, when they need to tell someone. So there's plenty of kids in that 3- to 4-year-old range who aren't ready from a physical standpoint and despite your best efforts, it's not going to work out. Now if there's plenty of kids who are 2-and-a-half, and they are ready from a physical standpoint. So this is one of the great things about human beings. You know, we're all different to some degrees. So not everyone is going to mature at the same rate. Now if you have a 4-year-old who is not ready from a physical standpoint, then you got to start wondering, is there some underlying pathology that's going on.
But for 3-year-olds, it's still pretty common for them to not be ready from a physical standpoint. Are they ready from an emotional standpoint? You know change at home may really impact the success and especially, the arrival of the new baby, as Tracy was talking about. That may not be the best time to really go full at it with [laughs] the potty training because you are just sort of setting yourself and your child up for failure.
Because, a lot of times, there regression when a new baby comes in because you know, your 3-year-old still wants to be the center of attention, which you can't really blame them. So, you know, these are things to keep in mind. Also, is the failure a power struggle issue? I mean, if you really want them to use the potty, and they really want to still go in their diaper, you know, it may not be that it's a physical problem, it may not be their own emotional problem, it just may be a good old fashioned power struggle.
And sometimes with those, you're better off just sort of walking away from it, like your pediatrician, Tracy, had mentioned. Just walk away from it and come back in a couple of weeks and just sort of start all over again.
Also, a lot of 3-year-olds fail at potty training because they're just too busy. They're playing, they ignore the signals that they have to go to the bathroom. And you know, if you hold it long enough, the feeling goes away the first time and maybe even the second time.
But the third time you hold it, you know, then all of a sudden you can't hold it any longer, you're running to get in the bathroom but it's just way too late. So, for these kids, sort of the reminder interruption technique may be helpful and what that is, is you just say, look, in the beginning, every 1 to 2 hours you got to stop what you are doing, you can even set a timer, and when the timer goes off, then it's not your fault. "Hey, the timer went off." It's time to go sit on the toilet for 5 minutes.
You know, that's all. You don't have to go. You just have to sit there. You have to interrupt what you are doing. And what that basically does is it just gets them used to interrupting their play time to go to the bathroom and I do find that works out pretty well for lots of kids. So you start out with doing it once every hour or once every two hours, but then over the course of a couple of days, you know, you wind it down to every three or four hours and pretty soon, what you'll find is they start interrupting what they are doing on their own to go to the bathroom. So that's something else to keep in mind.
You also have some kids who, you put them in underwear and they seem to do fine and at night time you put them in a pull up and it never fails, in the morning, they're wet and I think we discussed this once before in the past but for some of these kids, you just got to take the plunge and move the underwear and at night time and during the day, and a lot of times they'll surprise you. Even though they did go in the diaper or the pull-up, once you get to the underwear stage, a lot of times, they sort of step up to the plate and are able to meet the challenge and they surprise you a little bit because you think for sure, they're going to have an accident.
And sometimes they will have a few accidents in the beginning and that's okay. You just have to sort of roll with the punches with this. And Tracy, I think you are doing the right things — I mean, the positive einforcement, the sticker chart system. You know, sometimes an immediate reward is also helpful — you know, a little jar of M&Ms or something, or something non chokable, but you know, some kind of candy, or something that they like. That would also be helpful. And then, the delayed rewards such as the sticker chart system. I also find that the books, "Once Upon a Potty" by Alona Frankel, there's a DVD and a book that's associated with that. I've got good success in my own house with that product and I will put a link in the show notes to "Once Upon a Potty." It's a pretty good little system.
And then the American Academy of Pediatrics does have an official toilet training resource. You know, [laughs] in looking this up, the AAP’s official toilet training resource begins with this sentence: “Bowel and bladder control is a necessary social skill.” [Laughs] You got to love that wording. Okay I'll put a link in the show notes to that resource as well.
Okay now, Nicole asked about her 3-and-a-half-year-old who won't poo on the toilet but asks for a diaper, does her business, and then asks to be cleaned up. When I read this email, I had to laugh because my son Nicholas basically did the exact same thing. Now, Nicole, the good news is he is 10 now and he doesn't do it anymore so [laughs], it will get better. It really will. If they can tell you when they have to go, and hold it until you have the diaper in place and tell you when they're done, and then want you to change them right away, they're definitely ready to be potty trained.
It's not an "are you ready" issue at that point. So then you have to try to figure out what the issue is. You know, are they afraid to sit on the toilet? Are they just being stubborn? Do they have just this pattern down, this is just the way that they want to do it. For a lot of these kids, an incentive program probably will help but the incentive has to be something big enough and immediate enough to overcome the fear or the stubbornness factor that's going on. Now, one suggestions, and we discussed this with bed time in 2-year-olds, but I think you could modify it to work with these kids who are afraid to sit on the toilet — and I'm talking afraid not because of pain but just they're afraid, which
probably, a lot of that really, is just stubbornness.
But anyway, one of the things that you can do is buy a toy that has lots of parts associated with it. An example would be, with my daughter we did this, the Polly Pocket had a big set with little houses. I think the whole set had like 10 houses in it. But with boys, you know — I shouldn't be sexist about this because you know boys can play with Polly Pockets and girls can play with matchbox cars there's nothing wrong with that — but you know you can get a pack of cars like one of those 5 packs or something and basically you take it home and you don't let them open it and you say, you want to make it visible, "hey, look what you have." Now, it's okay to go poo in the diaper, but, if you poo in the
potty then you're going to get one of these toys in the pack. Not the whole thing, you can only pick out one — you know, one of the little Polly Pocket dolls or one of the cars, you know that sort of thing. And then, you move it to, instead of just going once, getting one of those toys, now they have to go on the potty all day to get one, or may be you need to start with just all morning and then all afternoon and then eventually work your way to when they are only getting one thing, you know, because they didn't use the diaper all the day long, then the next morning they get one of those toys. Something like that.
Now, once the toys are gone in that package the goal is that the diapers will be gone too. And sometimes you have to just get them out of the house and you know, just not buy anymore so that you can't break down and a lot of times, again, they'll be up to meet the challenge for you.
Alright, and then Sherry asked about her 7-year-old holding her pee too long and getting a urinary tract infection and having accidents in her pants. This is a common issue, and this is something else I think we have discussed before. But let me just say it again. Holding your urine, especially in girls, will lead to urinary tract infections.
And the way that happens is, skin bacteria, which we all have, you can't get rid of it, can go up the urethra into the bladder in girls because the urethra's pretty short and the bacteria are able to get up there but the act of peeing frequently sort of rinses the bacteria out of the bladder so that they don't have a chance to really start growing in there and causing a urinary tract infection. So you definitely want to encourage children not to hold their urine over and over again over a long period of time because that can cause problems down the road.
Also, holding the urine too long can also stretch out the bladder and that makes it more difficult for children to process the signals of a full bladder versus an empty bladder appropriately. Now the good news is that with the training, with going more often, with not letting their bladder overfill, with time, most bladders will sort of unstretch and sort of shrink back down to normal size and regain their elasticity.
But this usually does require some re-training and again you can use the reminder technique. They have to go sit on the potty even if they don't have to go. They're not in trouble if they don't go, but they should interrupt what they're doing and try in the beginning every couple of hours then kind of space it out after that. And with time, things usually do improve. But again, the key here is it does take some time.
Now, what about asking for outside help? Do it! Definitely, if it crosses your mind that you are questioning how things are going and do you need some outside help, then you do. Now it sounds like, Sherry, that you already have outside help because you are seeing a pediatric urologist. So now I have to wonder when you ask about outside help, do you mean should I get a second opinion. And I have to tell you, before you run off for a second opinion, and this really goes with anything in medicine, and not just in pediatrics and adult medicine too.
When things don't go as planned, you know, a lot of times as a parent or as a patient with an adult doctor, you get a little confused because you think the doctor knew what he was talking about and he said if you take Drug A, the result is going to be B. But you know, you're not getting that result, so you think, well, the doctor didn't know what he was talking about. Do I need another opinion? Do I need to see a specialist? Really what you need to do is tell your doctor it's not working. You know, if the doctor this is the expectation. This is what's going to happen and that doesn't happen. You have to sort of be the squeaky wheel and tell your doctor it's not working, so that things can be reevaluated. Because what works for most people, what usually would work, might not work for you. It might not work for your child. And so it is important to communicate with your doctor instead of just saying, well, that didn't work. He didn't know what he was talking about. So, I do think that's important so I would definitely, you know, talk to your doctor if things aren't working, definitely get outside help.
But before I run in for a second opinion, just let your doctor know, hey, it's not working. So, sometimes I think parents get the feeling like if they keep saying it's not working that they are bugging their doctor, but look, bug us! I mean, it's usually a matter of us not explaining it well enough the first time, you know. What happens is we just don't have time to tell you, hey it might take two weeks for whatever it is that we are talking about. And so you have the expectation that things are going to get better sooner than what they really are. So a lot of times it's a communication breakdown. And you know, you can't entirely blame the doctor. You know, we definitely have time constraints, many parents don't really care to know all the details so after a while, you are just explaining something to someone that's going in one ear and out the other and they don't care, and then pretty soon you stop explaining to everybody. I know here, with Pediacast, everybody cares, but you know, this is a different audience.
You guys are coming here to find out, to learn. You want to know all these explanations, whereas if I went into this much detail in the exam room, even if I had time, you know, I think 80% of the parents will be like, "Can I have my checkout sheet? I want to go! I don't care about all this. Just tell me what to do." Ah okay. So again, if things aren't going the way you think they should, let your doctor know. That's the bottom line.
In terms of wetting at night time, which Sherry also asked about, I'm going to refer you to Pediacast episode 15, and at the site and on the feed, it's there, and I'll also put a link in the show notes to episode 15 because that one dealt with bed wetting, pouring lots and lots of details. So you definitely want to check that out. And again, I'll put a link to episode number 4 also because there was lots of additional information about potty training in that episode.
So if this is something that really has been affecting your family then you want to head up to Pediacast.org or the feed, or just the show notes from this episode because there'll be links to episodes 4 and 15. Okay, I do believe that is enough potty talk for one episode, probably way more than I have planned. So we'll take a short break and we'll return with a segment on PANDAS right after this.
You know it amazes me just how far Pediacast reaches, and this next question comes from Heather in Bangkok, Thailand. And Heather says, "Dear Dr. Mike, I am really hoping to hear your answer on something going on with my daughter that I cannot get answers to here in Bangkok. Have you ever heard of PANDAS? So P-A-N-D-A-S. My daughter has been diagnosed with it and there's not a lot of information out there on the subject. Most of the doctors here have never heard of it and cannot recommend a course of treatment."
"We had to go home to have her diagnosed. We were told to put her on penicillin for 6 months along with an antidepressant. Can you share your knowledge on this so others may be aware of it and do you agree with what we have been old? Thank you for doing what you do. I have shared your podcast with all my friends here for it is comforting to get latest on pediatric issues from home."
Alright, well, thanks for your question, Heather. I really appreciate it. And I'll be honest, I had to do a little research myself on this topic. I've certainly heard of PANDAS but it's not something that we see often and there's even a bit of controversies surrounding it and there's a number ongoing research studies looking into this issue. So I learned a lot this week, too, and this should not surprise you. You know, to be a doctor is a continuing educational experience, you know, everyday sometimes.
And so I mean you can't learn everything about everything. You have to know when you have to look things up, when you have to remind yourself when you need to get more information and this was one of those cases. So, most of my learning actually came from a publication by the National Institute of Health and I'm going to put a link to that publication in the show notes. So if you are interested, you can take a look for yourself.
Some of the stuff, I'm taking directly from the National Institute of Health information on PANDAS. But there's more information than what I'm going to present there. So again, if you are interested, just look at the show notes and you'll be able to find that link.
Now what is PANDAS? PANDAS is an abbreviation for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections. Okay [laughs] it's a mouthful. Now you know why they call it PANDAS. The term is used to describe a subset of children who have Obsessive Compulsive Disorder (or OCD) and/or tic disorders — such as Tourette syndrome, although that is the extreme side; most tic disorders aren't that extreme — and in whom symptoms (these obsessive compulsive and tic disorder type symptoms) worsen following a strep infection such as strep throat or scarlet fever.
The children usually have dramatic, "overnight" onset of symptoms, including motor or vocal tics, obsessions, and/or compulsions. In addition to these symptoms, children may also become moody, irritable or show concerns about separating from parents or loved ones, and this abrupt onset is generally preceded by a Strep throat infection.
So what is the mechanism behind this phenomenon? Well at present, it is really unknown but researchers are pursuing a theory that the mechanism is similar to that of rheumatic fever. What happens is an autoimmune disorder that is triggered by strep throat infections can lead to rheumatic fever.
In that case, you know, really with every bacterial infection, the body produces antibodies against the invading bacteria, and the antibodies help eliminate the bacteria from the body. However, in rheumatic fever, the antibodies mistakenly recognize and attack the body itself. So it attacks the heart valves, it can attack joints and/or certain parts of the brain, and this phenomenon is called "molecular mimicry." So in other words, the antibody that is sort of programmed to attack the strep mistakes parts of your own body for the strep because that part of your body is mimicking the molecules that make up the outside of the strep, and so the antibody is sort of confused.
And so basically that means the proteins on the cell wall of the strep bacteria are similar in some way to the proteins in your body, in your heart valves, your joints, or in brain. So it's really the proteins on the surface that the antibody is attacking. And because the antibodies set off an immune reaction which damages those tissues, the child with rheumatic fever can get heart disease (especially mitral valve regurgitation). They can get arthritis, and/or abnormal muscle movements known as Sydenham's Chorea — a neurological disorder characterized by jerky involuntary movements affecting the extremities, that's what Sydenham's Chorea is. This especially affects the shoulders, the hips and the face so they basically have this jerky, involuntary movements and that is associated with rheumatic fever which again is because these antibodies that were supposed to be attacking the strep are attacking parts of the brain.
And in PANDAS, it is believed that something very similar to Sydenham's Chorea is occurring. So, one part of the brain that is affected in PANDAS is the basal ganglia, which is the part of the brain that is believed to be responsible for movement and behavior. And so the antibodies are basically interacting with the brain causing inflammation that results in these tics and/or obsessive compulsive disorders, instead of the muscle movement. So with rheumatic fever, the part of the brain that's affected is the motor part that's why you have these jerky involuntary movements that can happen with rheumatic fever, but with PANDAS, the area of the brain that's affected is more what would cause tics and/or obsessive compulsive disorders.
So is there a test for this PANDAS thing? Well, not really.
The diagnosis of PANDAS is a clinical diagnosis, which means that there are no lab tests that can diagnose PANDAS. Instead clinicians or doctors have to use 5 diagnostic criteria for the diagnosis of PANDAS. And at the present time the clinical features of the illness are the only means of determining whether or not a child might have this disorder.
So what are the diagnostic criteria for PANDAS? Well they are:
1. Presence of obsessive-compulsive disorder and/or a tic disorder. Now, I guess I have been sort of assuming that you know what that means. Tic disorder, you know, those are very brief jerky involuntary movements particularly in the face but they can involve other motor groups as well. So you have a kid who may sort of blink their eyes, or they may smack their lips together or their neck might turn a little bit. But it's not quite to the extreme of like the Sydenham's Chorea, where it's more of the big muscle groups that are doing it.
It's usually more of in the face and neck, that sort of thing. Ah okay so that's number 1. Oh and obsessive compulsive disorder you know, this is where — it's pretty self-explanatory, but how does an obsessive compulsive behavior show up in a kid? Well if they are school aged, you know, even though you put the lunch money in their pocket they may think it's not there. They keep checking. They get to school. They're sweating. They're anxious because they don't think they have their lunch money. You know things like that.
2. Pediatric onset of symptoms. So to qualify for PANDAS, it has to be a kid who's between the age 3 years up through puberty.
3. Episodic course of symptom severity. So that's an important part and we're going to talk more about that in a minute.
4. There has to be association with strep infection, and in particular it has to be group A Beta-hemolytic strep, which is the specific type of strep that causes strep throat and/or scarlet fever.
5. They have to have an association with neurological abnormalities such as muscular hyperactivity, or just sort of abnormal neurological signs other than just the obsessive compulsive disorder.
So they have to have tics or they could even have Sydenham's Chorea; it could go that far. Or they may just be sort of hyperactive. But definitely their neurological sort of overallness is a little bit on the abnormal side whether that be manifested through tics or through just sort of general hyperactivity. Okay so what is this episodic course of symptoms. Well, children with PANDAS seem to have dramatic ups and downs in their obsessive compulsive tendencies and in their tic severity and the tics or the obsessive compulsive disorder, which are almost always present at a relatively consistent level do not represent an episodic course.
So many kids with obsessive compulsive disorder or with tics are going to have good days and bad days or even good weeks and bad weeks; however, patients with PANDAS have a very sudden onset or worsening of their symptoms followed by a slow gradual improvement and then if they get another strep infection, their symptoms suddenly worsen again.
So, the increased symptoms severity usually persists for at least several weeks but may last for several months or longer as well. And then the tics or obsessive compulsive disease seems to gradually fade away and then the children often enjoy a few weeks or even several months without any problems and then when they have another strep throat infection, the tics or the obsessive compulsive tendencies return, just as suddenly and dramatically as they did previously.
So you're going have kids who have normal tic disorders or obsessive compulsive stuff but it's more of underlying some good days and bad days but it's really always there. It's not this episodic pattern. And also of course keep in mind that kids with tics and obsessive compulsive disease are going to have strep throats now and then. So, it's not that just because they have tics or some obsessive compulsive tendencies, it's not necessarily from their strep throat because all kids are going to get strep throat from time to time.
But if you are seeing a pattern of they have strep and things get a lot worse, and then they get better, and then they have strep, and things get really worse, and then they get better, that's when you're starting to think, is it PANDAS?
Are there any other symptoms associated with these PANDAS episode? Well, yeah. Children with PANDAS often experience one or more of the following.
Okay so now, we're going to talk more about what some of these other neurological conditions that go along with their tics or with their obsessive compulsive disorders. And what these are going to be, again, are ADHD symptoms but they can also manifest in other ways like separation anxiety, or the child suddenly is very clingy, difficult separating from caregivers. They may want to not even leave the same room that their parent is in. They're just so clingy, even when there's not strangers around. They may have severe mood changes with irritability, sadness, emotional roller coaster. There can be sleep disturbances. Really, any of these things are possible with this disorder but the key really is it gets worse right after a strep infection.
Now, can adults have PANDAS? That's something that sometimes comes up. And no, by definition, PANDAS is a pediatric disorder. It is possible that adults and adolescents may have immune-mediated obsessive compulsive disorders. But this is not known for sure and there are some studies looking into that.
But all of the research so far has been restricted to younger children. Now, if they keep having these recurrent strep infections, which leads to all of this, is it a good idea to have their tonsils taken out? It seems like a logical question.
But the National Institute of Health does not recommend tonsillectomies for children with PANDAS as there is no evidence that they are helpful. If a tonsillectomy is recommended because of frequent episodes of tonsillitis it would be useful to discuss the pros and cons of the procedure with your child's doctor because of the role that the tonsils play in fighting strep infections. They are important. You know, your tonsils are important. They're kind of your first line of defense for organisms that are invading through the mouth and nose. So you know, you don't necessarily want to take the tonsils out for this.
You want to try to keep them from having the recurrent strep infections in a different way. Now, speaking of which, what about antibiotics? Can penicillin be used to treat PANDAS or to prevent future PANDAS symptoms becoming worse? Well, you know, penicillin and other antibiotics kill strep and other types of bacteria. The antibiotics treat the sore throat or the pharyngitis caused by the strep by getting rid of the bacteria. However, in PANDAS, it appears that antibodies produced by the body in response to the strep infection or the cause of the problem, not the bacteria themselves. Therefore one could not expect antibiotics such as penicillin to treat the symptoms of PANDAS. But researchers at the National Institute of Health have been investigating the use of antibiotics as a form of prophylaxis or prevention of future strep episodes. So that's something to consider which is what, Heather, your doctor had suggested. So it sounds like it's a good idea.
Now according to the latest statement from the National Institute of Health, there isn't enough evidence to recommend the long-term use of antibiotics, which again is why your doctor said let's do it for 6 months. So it does sound like that advice is in line with the current thinking as of today from my reading from the National Institute of Health.
Now, what about other treatment options for children with PANDAS?
Well, the treatment for children with this are basically the same as if they had other types of obsessive compulsive disorders or tic disorders. Children with OCD, regardless of whether or not their illness is strep triggered, usually benefit from behavioral therapy and also anti-obsessional medications. And this is where the antidepressants come in, but we're not using them as antidepressants. We're really using them as anti-obsessive compulsive type medications.
And the ones that really have been shown useful in kids are going to be the SSRI medicines such as Zoloft and Prozac, those kind of things. And those have been shown — those medications either alone or with behavioral therapy were better at getting at getting rid of the OCD symptoms as compared to no-treatment or the use of placebo such as sugar pill. And it often does take time, though, for this kind of treatments to work so the sooner at therapy is started, and this whole thing is diagnosed, really the better it's going to be for your child.
Alright, one other thing, there's a sort of new fad out there on plasma exchange. What that would be is the idea is if you have these antibodies floating around in the blood stream, if you could take out some blood and put in new blood, you would get rid of these antibodies that are floating around causing the problem, and that's called plasma exchange.
There's also have been some studies that look into giving a substance called IVIG and immunoglobulins to help with this. And these are all investigational things and if you go to the link in the show notes, again, that article at the NIH has lots more information and there are about those types of newer things. But those are all sort of research-oriented, experimental things and not necessarily what the standard of care would be. So the standard of care would be more short term antibiotic use to prevent more strep infections in immediate future and the antidepressant type medicines not using them for depression but using them for their anti-obsessive compulsive things — [Laughs] so, what am I trying to say here? — for their obsessive compulsive disease breaking ability; let's put it that way. I'm sorry. My brain is getting a little bit shot here.
You see, normally in the office I can take a little break between patients, right? You know and sort of rest my brain briefly, but here it's just going on and on.
Alright, boy, I'm running really late here. We still have a whole another topic and I'm 50 minutes into the program. So, if you have to take a break, I understand. We're going to get back with the whole plastic leaching into food. That's the next topic and we will get it started right after this.
Okay, okay okay, under our third topic. I don't know. This whole new format, you know, I'm going a little bit long here. I get a bit long-winded. You have to [laughs] forgive me for that. Okay, we have a couple of questions regarding this and then we'll get to my comments and I'll try to go through it quickly here for you.
Kim in New York City says, "Dear Dr. Mike, thanks so much for your wonderful podcast and all of the really comprehensive information you provide. It's a great help to new moms, like me, who are learning as we go. I have a 7-month-old daughter and I am concerned about the report that came out recently on the study done on plastic bottles showing that they contain levels of Bisphenol A. They can leach out enough to cause harm to animals. I realize that this study was limited in scope but the fact that San Francisco has banned the products with this chemical makes me worried about the fact that I have been using Avent plastic bottles all along."
"It looks like just about every major brand of plastic bottle contains this chemical. Are these bottles safe to use?
Would switching to glass be a better option? I've been freezing and storing breast milk in these bottles and I'm wondering if the plastic freezer bags are a better option for this or if they too contain Bisphenol A. I appreciate any guidance you can offer."
And then Annie in San Francisco said, "Hi, Dr. Mike. I started listening to your podcast a few months ago and I love it. I like getting all of the background information that you just can't get when you are in the doctor's office. I have a research question for you. I live in San Francisco and recently there has been a lot in the news in local mother's groups about Bisphenol A and it leaching out of plastic bottles and city cups. Before I rush out BPA-free sippy cups, what do you think about this? Is this just another think to scare parents? Keep up the good work and I look forward to hearing your thoughts. Annie."
Alright, well first of all, what is Bisphenol A? Well, it's a chemical, it's a molecule that is part of the physical make up of many plastics. It's been used in plastics for decades and we do know that heating plastics breaks chemical bonds and this leaves the possibility of some of these plastic component molecules from entering food that contacts the plastic. And so this then is why there's such a wide implication for plastic containers of many types, including bottles and sippy cups. So, we definitely know that some plastic particles get into the food that is contacting these plastics.
Now, the question becomes, is this a problem? And the current thinking is that the amount we are exposed to on a normal basis has remained steady over the years and this includes maternal use of plastics during pregnancy and then also plastic exposure by infants.
So, 40 years of sort of ubiquitous plastic use in all age groups would suggest that this is a safe exposure according to the FDA. Now what's going on in California is that there was an independent laboratory study that was done in conjunction with a group called the Environmental California Research and Policy Center and basically they tested five popular brands of baby bottles and they were, Avent, Dr. Brown's, Evenflo, Gerber, and Playtex. And all five were shown by this independent lab to leach Bisphenol A at levels that "were found to cause harm in numerous laboratory animal studies."
Now it is also true that high levels of Bisphenol A have been linked to other studies to cancers impaired immune function, early onset of puberty, obesity, diabetes and hyperactivity. So, because of these findings, the Environmental California Group recommends that consumers choose glass or safer plastics that do not contain the Bisphenol A.
And they also advise against heating food or drink in plastic containers and harsh dish washing soap and hot water for cleaning plastics. And it was basically this recommendation that then has led some legislative bodies to consider banning the use of plastics containing Bisphenol A.
Okay so what's the flip side of this? What's the other side? Well the American Plastics Council at their website basically says that Bisphenol A is one of the most extensively tested materials in use today. And the weight of scientific evidence clearly supports the safety of Bisphenol A and provides strong reassurances that there is no basis for human health concerns from exposure to BPA.
Okay so that's the take from the American Plastics Council. Okay [laughs] they're going to be a little bit biased here, you know. They're selling a product. But you know, they do make a good point that there are also studies that show there is not an association with these things. In fact many of the studies that showed that there was a relationship. In fact the studies that the Environmental California folks talk about actually admit that they do not have statistically significant results. So they show that there may be a linkage between this Bisphenol A and these other problems that we talked about but the correlation was not statistically significant. Also, the next question you have to ask, are the levels that harm mice, are those the same level as that could potentially harm a human infant?
And the Environmental California claims it does, and that's probably a bit of a stretch as well. So you know, it's probably a bit of a stretch for them to say this definitely causes a problem, and it's probably a bit of a stretch for the American Plastics Council to say, no, it's absolutely safe. I think we're definitely in a gray area here.
Now in terms of moving to a safer plastic, the only problem with that is we have been using Bisphenol A in plastics for, you know, 40 years and just now, we're saying there's a harmful effect. You know, what is in the safer plastic that we're going to find out causes a problem 40 years from now. You know, so that's something to think about. And then switching to glass, you know, there is the potential for glass products to shatter, to chip, pieces of glass can become ingested, babies can cut themselves; it's unlikely; it's probably not going to happen, but it can, you know.
And possibly, these things that they are talking about — harmful effects from the plastic — it's probably not going to happen. I mean most kids do not end up getting cancer, extreme obesity, diabetes all these things. So, you know, they're using plastics too, so what about these kids where this doesn't develop?
Okay as a parent, you know, I know I'm just confusing you more. So let's look and see what the FDA has to say about all of this. Well, this is George Pauli who is the Associate Director of Science and Policy at the FDA Center for Food and Safety and Applied Nutrition, and he says, "Generally speaking, any food that you buy in a plastic container with directions to put it in the microwave has been tested and approved for safe use. What the industry does and runs by us for approval is simulated testing to determine what could come out of the container."
"We assume there will always be something that will leach out of the container into the food, so we look at how much someone could consume over a lifetime and compare that with what we know about the toxicity of the substance."
So whether it's Bisphenol A or, really, another chemical, the FDA's job is to monitor the amount that we are exposed to including the amount known to leach out of plastic and make sure that the exposure is at a safe level.
And so far the FDA says that it is. Now could they be wrong? Sure, they could. And research is ongoing to test the validity of their position and if that research shows that there's a danger, the FDA will pull the products including infant bottles and sippy cups from consumer shelves. But, again, the alternative may comes with its own risks of exposures we don't yet know about or with glass being used and their potential for breakage.
Now, until that time, if I had to make a decision for my own children. This is just me. This is personal. My personal opinion, I would stick with using the baby bottles and the cups that we've been using for the last 40 years. You know, look I've said it before, living is risky. I mean there's dangers lurking around every corner. We can minimize risks but you can't eliminate it from our lives. Again, you can switch to a different plastic; you can use glass. But, you know, what other problems are going to be shown to hold true down the road.
You know, I think, as a parent, personally, it's more important to encourage a well-balanced diet, encourage lots of exercise, keep your kids away from cigarette smoke, avoid overcrowded day care centers if you can encourage lots of stimulation of all the sense and really all aspects of your life. Am I going to worry about the safety of bottles and sippy cups that have been used for the last 30, 40 years. At this point, me, personally, no.
Now, that could change as we find out more through ongoing research. Now should you as a parent be concerned about this. It's up to you. I mean it's a gray area. You have to look at both sides, and you have to come up with a decision you can live with. Now, in that spirit of you, you know, sort of looking into it more, I'm going to present some interesting links in the show notes for you. And I gave each of these links a good looking over and I really think it's a fair and balanced approach. [Laughs] I've been watching Fox News too long — a fair and balanced approach.
So basically the links are going to be the Wikipedia definition of Bisphenol A. It's got a little bit of history of the chemical. Also, from the American Chemistry Council, they go into a little bit more detailed information with a slant toward proving that Bisphenol A is safe. And then I also have a link to the National Geographic Green Guide.
And this is slanted more toward caution without going so far as to claim that the sky is falling with Bisphenol A. So those are some links that sort of look at it from some different perspective so that you can read through it and make up the mind for yourself.
And then also I have a link from WebMD which is sort of a nice overview. It's called "Mixing Plastic and Food: Is It an Urban Legend?" So, look for those in the show notes at Pediacast.org.
Okay we're running way over, 4 minutes past the hour. So, if I was on radio, I'd be in big trouble. We'll wrap up this episode of the program after this break.
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Alright this week on the Pediascribe blog, I thought what I would start doing is giving you a blog highlight of the week. So my pick for the best post this past week from my lovely wife, Karen, is one called "Doctor, Heal Thyself." So I'm going to put a link in the Pediacast show notes to that blog entry. Now I will admit it's a bit disparaging toward me but I also have to admit, it's pretty funny, and it's well written and it's garnered more than a little interest in the blogosphere, let me tell you.
So if you want to hear a funny story that is a bit embarrassing for me — but that's fine, you know, whatever — [laughs] if you want to read it, you got to check that out.
Also, I'm going to put in a plug. I don't do this very often, but I want to put in a plug for my other big project that I do on a regular basis. It's called Mouse Matters. It's a weekly column on anything Disney. It's over at wdwinfo.com which is the Dis and we'll put a link to that in the show notes. Mouse Matters, it's pretty widely read. I get about 20,000 readers every month to that column and this most recent column deals with the 1940s Disney animated films "Saludos Amigos" and the "Three Caballeros." It looks at the interesting historical significance of these films and how they impacted the events of the second World War.
And we also explored their connection to the Mexico Pavilion at Epcot. So, I know a lot — you know, this audience is made up mostly of parents. There's also some folks in training who listen as well, but I know parents you know usually you have a lot of Disney stuff in your house and so I thought you might be interested in what's going on over at Mouse Matters.
Okay thank you to my media partners: Vlad Studio, the creator of the artwork on the website and in the feed and also home to wonderful desktop wall papers and poster prints and you can Vlad online at vladstudio.com.
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And of course thanks to my loyal listeners by subscribing, listening and contributing to Pediacast, you are the ones who ultimately keep this project going. And last but not the least, thanks to my family — my lovely little wife, my son Nicholas, and my daughter Katie.
And reminders, if you have a topic you would like us to discuss, you can click on the contact link at Pediacast.org. You can email me at firstname.lastname@example.org. You can attach an audio file if you like, or call the voice line at 347-404-KIDS, that's 3-4-7-4-0-4-K-I-D-S.
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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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