Study Strategies, Texting, and ADHD – PediaCast 049

Listen Now (right-click to download)


  • Best Study Strategy for School
  • Teenage Texters Alter Language
  • Under-Diagnosis of ADHD
  • Over-Diagnosis of Asthma
  • Kids ARE Eating Healthier Foods!
  • Children CAN Learn From Television!
  • Safety Tips for Student Athletes

Listener Questions

  • Nuking Food: Are Nutrients Affected?
  • Does the Circumcision Need Re-Done?
  • Do Babies Need Water?

Research Round-up

  • School-Based Program Decreases Diabetes Risk
  • Using Tap Water for Wound Irrigation


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Announcer: This is PediaCast.


Dr. Mike Patrick: Hello, everyone, and welcome to this week's edition of PediaCast, a pediatric podcast for moms and dads.

This is Dr. Mike coming to you from BirdHouse Studio. I'd like to welcome everyone to the program.

It is Episode 49 text messaging, microwaves and tap water. Of course, we have lots more in store for you than just those things, including the announcement of our Bundlo contest winners that's coming up.

This week in our News Parents Can Use Segment "The Best Study Strategy for School Teenagers and Text Messaging did you know that they alter language? We'll talk about that.

Also Under-Diagnosis of ADHD and Over-Diagnosis of Asthma.


Kids are eating healthier. They really are. We're going to give you some evidence to that fact.

Also children can learn from television and we'll tell you how.

Then we have some safety tips for student athletes.

We're also going to get to some of your questions using a microwave to nuke your food. Are nutrients affected?

And what about when moms and dads don't like the way a circumcision looks, you'll know a little bit later on during childhood. Does it need to be redone? We'll talk about that.

Also, do babies need water? According to lots of grandmas, they do. That's what I've learned [Laughter] during my time in a pediatric private office. But do they really? We're going to discuss that.

Also in a research roundup this week's "School-based Programs to Decrease Diabetes Risk," at least, for Type 2 diabetes.


We'll talk about that. And then also "Using Tap Water for Wound Irrigation Rather Than Sterile Saline" what's that all about? We'll talk about it.

Don't forget if there's a topic that you would like us to discuss, all you have to do is go to and click on Contact link. You can also email or call the voice line at 347-404-KIDS. That's 347-404-K-I-D-S.

Now before we get started with program, I do want to announce the winners of our Bundlo contest. Now for those of you who don't know what I'm talking about, the Bundlo contest, for four weeks and I guess it wrapped the week before last but for the four weeks prior to last week's episode, we had interviewed, during each of those episodes, and the person that we were interviewing let everyone know what the code word was for that week, and then you had to unscramble the words and send then the phrase that I was looking for.


And the winner gets a lifetime subscription to Bundlo and also a PediaCast t-shirt. So how are we going to do this?

Well, I guess, first I should say, for those of you who don't know what Bundlo is and there is a link to in the Show Notes. But, basically, Bundlo is an online baby book that's password protected and you can share your baby book with friends and family members around the world.

You can include a blog for baby. You can upload photographs, pictures. You can also keep a journal, in terms of when they completed certain things like their first steps or their first words, or really anything that you like.

Anything you can do with the traditional paper baby book, you can do with Bundlo. And again they're at

So we do have our three winners. Let's go ahead and announce those here real quick.

The third place winner, and this person wins a lifetime Basic Bundlo subscription, is Crystal.


Second place, and this person gets a lifetime Standard Bundlo subscription, is Suzanna.

And our first place grand prize winner gets a lifetime Premium Bundo subscription and that goes to Lee.

Now, if your name is Crystal, Suzanna or Lee and you're not sure if you're the winner or not, because it could other people who entered with those same names, I am going to email you shortly.

In fact, you'll probably get the email before you actually listened to this episode. So those are our three winners. And you all get the Bundlo subscriptions and a free PediaCast t-shirt.

Now, I guess, everyone will want to know what the winning phrase was. The winning phrase was "Go Ohio Beat the Wolverines," which I know now it seems rather unsportsmanlike since the Wolverines-012 on the season.


Of course the Ohio State Buckeye offense hasn't looked much better. So our November meeting in the Big House up in Ann Arbor should be an interesting one this year.

Also special thanks go out to all of you from the state that is North of Ohio. I can't say the word during football season so we just call it the State of North here at home.

But special thanks to all of you from that State who entered the contest despite with the winning phrase actually was.

I even had one entry which said, "Typing the phrase didn't constitute being a bad fan" because she didn't look at the screen as she typed.

Look, folks, don't take the rivalry too seriously. It's all in good fun. Of course I'm one to talk right. We have to put a quarter in a jar every time we say the state's name during football season and then at the end of the season we used the proceeds to buy a pizza.

But like I said, it's all in good fun.

All right. We should move along. The information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions, or formulate treatment plans for specific individuals.


So if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination. Also your use of this audio program is subject to PediaCast Terms of Use Agreement, which you can find at

And with that in mind, we'll be back with News Parents Can Use right after this short break.

[Short Break Music]


Jamie Davies Hi! This is Jamie Davies, the Podmedic from the MedicCast podcast. And you know, I've been a paramedic and paramedic educator for a long time. But I'll tell what?

When I want up-to-date health information about what's going on with pediatrics and the world around us, I checked in with Dr. Mike and the PediaCast.

Over to you, Dr. Mike.

Dr. Mike Patrick: Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at

When you look back on your school days, doesn't it seem like you studied all the time? However, most of us seemed to have retained almost nothing from our early immersion in math, history and foreign language.


Were we studying the wrong way during all those wee hours as well? As it turns out, we may have been.

Psychologists have been assessing how well various study strategies produced long-term learning. And it appears that some strategies really do work much better than others. Consider "overlearning," that's the term learning specialists use for studying material immediately after you've mastered it.

Say, you're studying new vocabulary words flash cards style and you finally run to the whole list error-free. Any study beyond that point is "overlearning". Is this just a waste of valuable time? Or does this extra effort embed the new memory for the long haul?

University of South Florida psychologist Doug Rohrer decided to explore these questions scientifically. Working with Harold Pashler of the University of California, San Diego, he had two groups of students study new vocabulary in different ways.


One group ran to the list five times. These students got a perfect score no more than once. The others kept drilling for a total of 10 trials and with this extra effort the students had at least three perfect run-throughs. Then the psychologist tested all the students some one week later and others four weeks later.

The results were interesting. For students who took the test a week later, those who had done the extra drilling performed better. But this benefit of overlearning completely disappeared by four weeks.

In other words, if students were interested in learning that lasts, the extra effort is really a waste. They should instead spend this time looking at material from last week or last month or even last year.

In other words, as reported in the Journal Current Directions in Psychological Science, "Cramming all the study on a single topic into a single session reduces long-term retention. It's better to leave it alone for a while and then return to it."

Rohrer and Pashler also wanted to see if the duration of study breaks might make a difference in learning. And it did.


When two study sessions were separated by breaks ranging from five minutes to six months, with a final test given six months later, students did much better, if their break lasted at least a month.

So rather than distribute their study of some material across just a few days, as millions of school children do when given a different list of vocabulary or spelling words each week, students would be better off seeing the same words throughout the school year.

All these experiments involved rote learning, but Rohrer and Pashler have also found similar effects with more abstract learning like math. This is particularly troubling, the psychologists say, because most mathematic textbooks today are organized to encourage overlearning so students end up working 20 problems on the same concept, which they learned earlier that day, when they should be working on 20 problems drawn from different lessons learned since the beginning of the school year.

In brief, students are wasting a lot of precious time with learning in ways that aren't effective.


And speaking of wasting a lot of precious time, teenagers who text message often find themselves recalling "textisms" better than real words. This is the finding of Dr. Beverly Plester from the Coventry University as presented at the British Psychological Society's Developmental Sections Annual Conference at the University of Plymouth.

Boy, there's a mouthful.

Mobile phones are a must-have item for most people with adolescence and increasingly children the fastest growing market. However, the popularity of mobile phones and the subsequent use of "textisms" in children's written school work has raised public concern about the damage this maybe doing to childhood literacy.

This study focuses on the ability of 47 adolescents, some of whom were high text users and others were low text users, to memorize and recall standard words, non-words and "textisms".


Increasingly, both the high and low text users were able to recall "textisms" more than standard words or non-words.

Dr. Plester commented, "There has been great concern about the level of children's and young people's literacy, both from further education establishments and employers." The continuing popularity of texting means that most children and young people are accustomed to seeing and writing words displayed in their "textism" form as much as in their Standard English form.

These abbreviated forms maybe easily accessible in the writer's mind because of their frequent use. We need to be sure that children and young people know when it is appropriate to use both forms and that they are aware and that they need to check to be sure they are using the form expected in various situations.

Schools might use texting experience as a key to raising awareness of different types of language and ensuring that children understand how and when and why to use appropriate language in different circumstances.


We'll file this one away and the more things change, the more they stay the same. No book. After all, how many of today's proper English words are nothing more than bastardized forms of their Archaic English equivalents?

For instance, coddleshell became coddle, rantipole became rant and gramercy became thanks. And when Shakespeare couldn't find the right word, he simply made one up. Thus non-words like gloomy and gossip and critic were born.

People don't evolve to suit language rather language evolves to suit the times. And like it or not, Dr. Plester's text messages and email will continue to influence the English language, changing today's so-called "the proper words" into tomorrows.

OK. So I ended with a little bit of my opinion but I can have that prerogative, I guess, [Laughter] since it's my podcast.


All right, although less than 4% of U.S. 8- to 15-year-olds received treatment for Attention Deficit Hyperactivity Disorder or ADHD, experts estimate that 8.7% of children in that age group meet the diagnostic criteria for the disorder.

These figures come from a recent report published in the Archives of Pediatric and Adolescent Medicine. The authors write that despite widespread concern that the rate for ADHD is on the rise, the national population-based prevalence of ADHD in American children has not been firmly established.

A person with ADHD typically is impulsive, has an inability to pay attention to tasks, and this affects achievement at school and work as well as social behaviors.

Researchers at Cincinnati Children's Hospital Medical Center looked at a representative group of over 3,000 children, ages 8 to 15, from which they could extrapolate national figures. During 2001 to 2004, the children's parents, guardians and other caregivers were interviewed by telephone.


The interviewees provided information on each child's ADHD symptoms. These included the information, when relevant, of when symptoms first appeared and reports on any impairment they caused during the previous 12 months.

The researchers also managed to find out whether each child had ever been diagnosed with ADHD and treated for with medication. They estimated that 2.4 million children were 8.7% across the U.S.A. meet the criteria for ADHD during the 12-month period before the survey began.

They discovered ADHD seems to be less common among Hispanics when compared to the white population. And boys have a higher risk of developing the disease. However, they also found that girls with ADHD were less likely than boys to have their condition recognized.

Only have of the children who met the ADHD criteria had ever been diagnosed with or treated for the condition prior to the survey.


Also researchers found the poor is 20% of children were more likely to have ADHD than the rich is 20%.

The writers added, "Reasons for increased likelihood of ADHD in poor children may include the elevated prevalence of ADHD risk factors, such as premature birth and exposure to toxic substances.

In addition, given the high genetic component of ADHD and its negative impact on social, academic and career outcomes, it is plausible that families with ADHD may cluster within the lower socioeconomic strata.

Of those who meet the ADHD criteria, the researchers discovered that 39% had tried some kind of ADHD-targeted medication, while 32% had been treated consistently with medications during the previous 12 months.

The writers conclude their study warrants further investigation and possible intervention to ensure that all children with ADHD have equitable access to treatment when appropriate.


Now moving from under-diagnosis to over-diagnosis, it's the most common chronic condition facing kids in this country. More than 6 million children have been diagnosed with asthma. But how many have been diagnosed?

A new study suggests that some of these kids actually don't have asthma. They have a very different condition requiring very different treatment. As a hockey goalie Logan Davis, he has to be ready for anything.

But during a game last season, he experienced something he never saw coming. Suddenly, Logan couldn't breathe. "My whole throat was closed. I just couldn't ski. It was scary," says Davis.

It happens to hundreds of thousands of kids every year in this country. Most end up in the emergency room diagnosed with asthma.

Physicians in an emergency setting see this and someone says, "It's an asthma attack." "And they tend to treat the child for that and often admit them to the hospital," says Karen McCoy, a Pediatric Pulmonologist at Columbus Children's Hospital.


But Dr. McCoy says, "That can be a mistake." A recent study performed at Columbus Children's found three out of four children who had good oxygen levels and appeared to have asthma actually had a condition known as vocal cord dysfunction or VCD.

The symptoms are similar but the treatments are very different. Kids with VCD are simply taught breathing exercises to help them cope. Children with asthma need medicine, such as steroids and bronchodilators, to get better.

A simple breathing test called "spirometry" can tell doctors the difference. Dr. McCoy says, "Just a few seconds on the machine may keep kids who don't have asthma out of the hospital."

"And most importantly, not to expose those kids to medications that may have tremendous negative side effects for them," says Dr. McCoy.

The study only looked at a snapshot of some 20 cases but it raises serious questions. If asthma was ruled out in 15 of those cases, how many other children across the country are being treated for asthma they don't really have?


It's important to point out that children can suffer from both asthma and vocal cord dysfunction. Dr. McCoy says, "Further study of a wider sample of cases is needed, but if more emergency rooms made used of spirometry breathing test, it could cut down on the number of kids who are misdiagnosed and even hospitalized unnecessarily.

Now here's some good news. The number of children achieving their "5 A Day" target has increased by 13% in two years, according to a report out by United Kingdom's Department of Health.

The "Further Evaluation of the School Fruit and Vegetable Scheme," launched in the week when millions of children began a new school year, shows that scheme is working and could contribute to a reduction of heart disease, stroke and cancer later in life.

Figures show that the number of children achieving "5 A Day" has increased from 27% in March of 2004 to 44% in November of 2006.


And the number of portions consumed has also increased to a point or an average. Fifty percent of children in the scheme are closed to achieving their "5 A Day" target.

Overall, there's been significant increases in the consumption of fruits and vegetables since the last evaluation was carried out two years ago and from the baseline measured in March 2004 before the scheme was introduced into the schools included in the study.

It appears the most significant factor in the increase in fruit and vegetables consumed between November of 2004 and November 2006 are improvements to school meals.

Health Minister Ben Bradshaw said, "Children eating more fruits and vegetables each day and reaching their "5 A Day" is excellent news. The program is important in underpinning the government's commitment to healthy eating in schools in the U.K. and it provides an opportunity for children to try out new foods, particularly vegetables, and for them to become accustomed to eating them as part of their daily diet.


Several surveys now point to a significant rise in fruit and vegetable consumption across all sectors of the population linked to increase awareness of eating "5 A Day" and the importance of a healthy diet.

We now need to look at the potential for exploiting the opportunities provided by the scheme to support healthy eating initiatives in schools and engage school communities in the wider strategy to tackle obesity and ensure, that when children leave the scheme, they continue to eat their "5 A Day".

The report is good news for the School Food Trust. The evidence is that improvements to school meals means children are given more opportunities to eat vegetables. Children eating school meals are more likely to achieve their "5 A Day" than those who packed their lunch.

Beverly Hughes, Minister for Children, Young People and Families, said: "If we're to tackle obesity and get children interested in fruits and vegetables, we have to start young. That is why this scheme is so important."


"I'm pleased to see that school meals are having an impact on diet, and new tougher regulations coming in this week will mean that young people can no longer buy fizzy drinks, chocolate bars and crisps in tuck shops or vending machines in schools. Junk food is now off the menu throughout the school day."

And Judy Hargadon, Chief Executive of the United Kingdom's School Food Trust said: "We're delighted that the efforts to increase the number of children eating "5 A Day" are working so well."

This demonstrates that a coordinated and consistent approach to improving children's health across the school day is resulting in more children getting a balanced and varied diet.

So kudos to you in the United Kingdom.

OK. Throw this one into the ring of those debating the effect of television on children. Kids can learn from television if pictures are accompanied by language in the same way as in real life. This is the finding of Ms Vicki Hayman and Dr. Jane Herbert at the University of Sheffield.


Forty-eight 4-year-olds watched the video involving sequence actions, including button pressing, lever turning and drawer opening, that was performed on a box. These actions appeared to change the color of a toy.

Half the children saw the video accompanied by language cues, which explained each action, while the other half just watched the silent video. Both groups were then asked to recall the actions immediately and one week after watching the program.

Children who heard the language cues were more successful at repeating the actions, both immediately and in one week, compared to children who heard no language cues during the video demonstration.

These findings suggest that a combination of visual and verbal information on television is an effective learning tool. The researchers said previous studies have shown that language cues help children to remember things from live demonstrations.

This research shows that language cues are also effective on television, which provides both visual and verbal information but on a screen instead of in person.


Thus, they conclude that four-year olds do learn from television using similar processes to human contact.

It is well known that children are watching television, but this research shows that they are also listening to what is being said. Simple words of explanation during educational programming can help children make sense of what they see and improving what they learn and remember.

And finally, with the start of fall sports now in full swing and children returning to school, the National Athletic Trainers Association has issued timely guidance to ensure sports safety.

"Only 42% of secondary schools have accessed to athletic trainers," said NATA President Chuck Kimmel. Since athletic trainers are often the first responders when an athlete goes down on the playing field, and they help to prevent and rehabilitate injuries, it is critical to establish guidelines to keep our young athletes safe and in good physical shape.


"Schools and sports team should always have an emergency plan in place and implement a comprehensive athletic health care program, including injury prevention, education and treatment," says Brian Robinson, Chair of NATA Secondary School Athletic Trainers' Committee.

It's critical to have these elements approved and continually reviewed as part of an overall sports safety protocol.

The NATA recommends the following tips for parents, coaches, medical professionals and athletes.

Number 1: Pre-participation Exam. Children participating in sports should receive a general health exam prior to activity to make sure they are fit to play. Discuss any pre-existing conditions with the physician.

Number 2: Emergency Plan. Develop a written emergency plan and consultation with the local emergency medical service, review it regularly and share it with the appropriate team, school and medical professionals.


Number 3: Appropriate Safety Gear. Make sure to read the manufacturer instructions for proper use and fit. It is especially important that masks, gloves, pads, guards and other gear fit snugly for best protection. Equipment should be inspected on a regular basis to ensure proper fit, that it's in good condition and meets national standards.

Number 4: Preconditioning and Training. Coaches, athletic trainers and parents should ensure that children are physically and mentally conditioned, properly trained in particular sports or activity and match with children of similar skill level, weight and maturity.

Number 5: Facilitate Safety Inspections. Remove debris, water, rocks and other hazards from the field, ring or court. If playing outdoors, adults must consider current and potential weather conditions, such as lightning as part of their inspection. Inspect all regular equipment, such as goals, baskets and nets on a regular basis and make sure the items meet standards for play.

First Aid is number 6. Stack a First Aid kit and keep it on site for medical emergencies.


Include supplies for wound management and bee stings, such as elastic wraps and bandage, an ice and cold compress, medical tape, and sterile solution among other items.

Number 7: Adult Supervision and Trained Sports Staff. Children should be supervised at all times on the playing field by a parent, coach, certified athletic trainer, or medical professional.

Number 8: Proper Hydration. Establish a hydration plan that allows children to drink water or sports drinks, such as Gatorade throughout exercise sessions. They need about 7 to 10 ounces for every 10 to 20 minutes.

Children should hydrate before and after activity. Without proper hydration, children are at risk of developing exertional heat-related illnesses.

Number 9: Beat the Heat. If young athletes are exercising in the heat, make sure to assess their fitness before participation. Acclimate them to the warm weather conditions and start activities slowly while building endurance.


If an athlete doesn't feel well, stop activity and assess his or her fitness status before returning to play.

Number 10: Eat to Win. Incorporate healthy foods in a day, in a daily diet, including grains, fruits and vegetables, dairy and meat, poultry, fish to give them the fuel they need to exercise. A balanced and moderate approach is always the best.

And finally Number 11: Proper Warm Up, Flexibility and Cool Down. Always warm up before activity. Take rest breaks and cool down and stretch after play.

To avoid overuse injuries, players should not participate with more than one sports team at a time.

"Parents, coaches and athletic trainers should instruct and practice proper techniques and be alert to injuries," added Robinson. Our primary goal is to prevent injuries and these recommendations will not only help to reduce risk but ensure proper plans are in place if medical care is needed.

For more information on new sports and sports safety, you can visit the National Athletic Trainers Association's website and we'll put a link to that in the Show Notes.


And for those with an interest in Sports Medicine, be sure to stay tuned to PediaCast next week, because Dr. Thomas Pommering, a professor of Pediatrics and Family Medicine at the Ohio State University and Medical Director of the Sports Medicine Program at Columbus Children's Hospital, who's going to stop by for a visit.

So we're very excited to have Thomas Pommering, Dr. Thomas Pommering on the show, next week.

All right, well, that concludes our News Parents Can Use and we'll be back with Listener Questions after this.

[Short Break Music]


OK. Our first Listener Question comes from Heidi in Ontario, Canada. Heidi says, "I've heard many people are getting rid of their microwave oven because it depletes food nutrition. I often heat up frozen corn or peas for my son, when we are having salad, or some other vegetable he isn't ready to eat.

Am I giving him nutrition-less veggies and should I ditch the microwave?


All right, great question, Heidi. I think to understand this. First, we really have to have an understanding of how a microwave works. I looked this up because I have a general idea, but I didn't know the specifics. I couldn't remember them.

So I did a little research and the bottom line is, the microwave has a device in it called a magnetron and the magnetron produces electromagnetic waves. And these waves represent non-ionic radiation.

Now it's important because it's ionic radiation, which is emitted in x-rays and in nuclear reactions. Those are the dangerous types of radiation. So this is non-ionic radiation so it's not a health risk like x-rays or nuclear reactions.

So these are electromagnetic waves that are just the right wavelength to excite water molecules. Now excited water molecules move faster, and remember when molecules move faster, that translates into an increased in temperature.


So the end result of conventional heat sources, such as a burner, a broiler, toaster oven all these things is basically the same. It just uses a different mechanism to increase the molecules moving faster in the food, which thereby increases temperature.

So it does just in a different way. Now the so-called microwaves, which what we call these electromagnetic waves that are just right wavelength to excite water molecules, these microwaves pass through plastic and glass but they reflect off metal.

And reflected microwaves may damage the magnetron causing it to stop working. That's why you can't put metal things in a microwave.

Now there are dangers associated with microwaves, since they excite water and since living organisms contain lots of water, microwaves can burn skin that can boil the blood and cause death through the heat effect, not from the radiation effect, but from the heat effect.


Of course, conventional forms of heating can do the same thing. All microwave ovens made since 1971 must contain two safety switches. Each can stop the magnetron independently, if the door opens, and also adequate seals are required to prevent significant microwave leakage outside of the unit.

OK. So what about the nutrients? According to a recent article in the New York Times, every cooking method destroys some vitamins and nutrients in the food because it is the heat not the waves, not the electromagnetic waves it's the heat that alters chemical structure.

Microwave ovens often use less heat and shorter cooking times than other methods. Thus they generally have the "least" destructive effect.

And at Cornell University scientists studied the effect of various cooking methods on the food quality. And they found that, for example, with spinach when it's cooked in the microwave, it retains nearly all of its vitamins and folate.


However, spinach that's cooked on the stovetop lost 77% of its nutrients. Also, bacon cooked in a microwave had significantly lower levels of nitrosamines, which is a chemical known to cause cancer, when compared to cooking bacon on the stovetop. However and, of course, isn't there always a "however" broccoli immersed in water and cooked in a microwave lost up to 97% of its antioxidants which, of course, to the good guys in the cancer battle. But when steamed or cooked without water, most of the antioxidants were retained.

So in cooking vegetables, it's best not to emerge them in water as this is the biggest source of nutrient loss whether you're doing it on a stovetop or in a microwave because those nutrients can leak into the water and basically leave the vegetables. So that's an important thing to remember.

I'm not planning to ditch my microwave any time soon.


Besides, I want to get along without microwave popcorn. OK [Laughter].

We do have a couple of links in the Show Notes for you. There's a comprehensive microwave information site from the FDA. We have that. And also the New York Times article, which debunks the microwave nutrient myth, we have a link to that in the Show Notes as well.

OK. Our next question comes from Randy in Arlington, Virginia. Randy says, "Hello, Dr. Mike. I just found PediaCast and I am enjoying it. I had a question about my five-year-old son who had a circumcision."

"He appears to have a bit of excess skin on the bottom of his penis. Is this an issue? Does something need to be done? If something needs to be done, should it be done now or later? Our doctor hasn't said anything about it. Thanks. Randy."

OK, another great question. Pediatricians here lots of concerns about the looks of circumcisions. Now natural foreskins can vary greatly in length.


I mean some allowed you to see the top of the glans penis and others. The foreskin protrudes well beyond the glans. So I mean there's different ways that penises can look right from the beginning.

So we don't expect perfection from God, yet we do expect perfection from the doctor performing a circumcision. [Laughter] The problem is this. The penis shaft and the foreskin don't start at the same place when you're looking at the base of the penis.

So the penis shaft begins deep down near the pubic bone, but the foreskin is a continuation of superficial skin. So it starts at the top of the skin around the base of the penis where the shaft itself begins deep down by the pubic bone.

Now, many bones develop a subcutaneous fat pad, which is basically a pad of fat below the surface of the skin, at the base of the penis.


Thus, the foreskin is lifted up by the fat while the shaft starting point remains deep down by the pubic bone. So this has the effect of pushing the foreskin over part of the glans or over the entire glans, with the glans being the tip of the penis.

Now if the fat pad is uneven, then part of the foreskin may overhang the glans more than another. And typically this occurs at the bottom of the penis so it looks like there's excess skin there.

And if the fat pad is particularly large, the whole penis shaft may actually sink down into the fat, which is what we call a "disappearing penis". Now why is this fat there?

Well, for the most part, it's going to be genetic. There's just some families, they develop this fat pad underneath the skin at the base of the penis.

So again the shaft doesn't change but the foreskin is pushed forward because of this fat.


Now if a child losses that fat pad, then the foreskin will drop back down to its original position. And to demonstrate this, if you encircle your fingers around the base of the penis and push the skin down towards the pubic bone, so you're squishing that fat later, the foreskin gets pulled down in the process and this allows to see what the penis and foreskin relationship would look like without that fat pad.

Now some kids, especially if they watch their diet and exercise, as they get older will lose that fat and really nothing needs to be done because it's going to crack itself.

Now in other kids, that fat pad is going to remain or it may get even bigger, and then you may have the foreskin pushing even further or the penis disappearing down into the fat.

Well, are you going to have a perfect looking penis in the end? Probably not, but look, the penis wasn't perfect to begin with. So I think we're good, all right. [Laughter]


Sometimes the foreskin grows longer or not enough was taken off with the original circ. So in that case, if you discount that fat pad, the foreskin in some kids is still going to be a little bit too long.

And circumcision revision can take off more of that foreskin. But whether you want to do that or not, or when you want to do it is really a decision you have to make with your doctor because this is usually a cosmetic issue. And opinions on this are really going to vary.

Personally, I'm not a big fan of circumcision revisions unless there's a major issue. It usually requires general anesthesia. There's a risk involved with that. It's usually painful, and then you got to ask yourself "Is it going to look perfect when all is said and done?" I mean, what if the fat pad comes back or it grows larger? Are you going to redo it again?

And what if the fat pad does go away and you've taken off more of the foreskin, and now the remaining foreskin because it drops back down, because the fat isn't there anymore, and it stretches the foreskin back down too tight.


So now you don't have enough foreskin that's left and then this can cause painful erections and a curvature of the penis. So may end up making things worse than if you had just left it alone.

So again, there's no perfect penis, even from the beginning, even when kids were born. Boys, you get what you get, OK [Laughter]. It's just sometimes you have to be happy.

Now there is one other issue here, and that is the issue of foreskin adhesions, and this is particularly a problem if boys have developed that pubic fat pad that we've talked about.

So basically what happens here is that the foreskin, because of this fat pad gets pushed forward, it overlies the glans again. And now because you have these two layers together, the top of the glans and the foreskin that is now pushed forward, sticks together. And parents who've had this know exactly what I'm talking about.


The problem with this is that often times it will those two layers will come apart on their own when you least expect it. And it's painful and there can be some bleeding associated with it. And the kids will start crying. The parents look down there. They're bleeding. They start freaking out because their penis is bleeding and they're crying in pain.

So this is something that it can be dealt with in the office so that you don't have to deal with it at home. I also should mention that when you pull the two layers apart, a lot of times some trapped debris between the two layers, and this is made up of, what we call sebaceous material, because there's some glands in that area, and also just some skin cells that have been sloughed off where your body is coming new skin.

They get trapped in this layer that's stuck together and the body starts to digest the skin cells. That, plus the sebaceous material is what we call "smegma".

And what do you do? Well, again, some people would say you just leave these adhesions because when kids go through puberty, the layers generally will separate on their own.


Hopefully by that point the fat pad is gone and everything is going to look fine and you didn't need to do anything at all. But sometimes you do get this what we call "skin bridges" occurring which is where the foreskin has become so attached that the regular skin below the foreskin starts to grow over it, and it becomes attached as well.

So now you not only have foreskin that's attached, you have regular shaft skin that is attached to the glans as well. And those usually do require surgery.

So by pulling those adhesions apart and keeping them away usually can prevent surgery in the future. So what we do is, basically, we pull it back. And it's like a Band-Aid coming off the skin. I mean it hurts but very briefly and then the kids seem to be pretty OK with it.

And as a parent at home, you just keep it pulled back. Even though it's overlying the glans when you change the diaper, you pull it back a little bit and you can put some Vaseline to keep the layers from sticking.


But despite your best efforts, sometimes it comes back. So [Laughter] it's like the adhesions come back.

So it's like Murphy's Law. I mean, there's no best solution. The anti-circumcision folks cite all these issues as reasons to avoid circumcision in the first place. I won't go that far.

I mean circumcision is a personal choice. There are hygiene benefits. There may be sexual and cosmetic benefits because this is debatable. We're also seeing research suggesting that there's less risk of HIV or AIDS transmission and also HPV, which is the virus that's associated with cervical cancer.

The circumcisions having that done may decrease the transmission of that virus as well. So we go back to weighing benefit versus potential problems. And I think the take-home here is there's no perfect penis.


All right, there's very few perfect penises [Laughter]. How's that? There are very few perfect circumcisions. And if you're worried about the looks of your child's penis or the circumcision, by all means bring it up with your doctor.

But keep in mind, penis appearance varies greatly and what you have in your mind of what it should look like isn't always what's going to end up looking like. You want to bring it up with your doctor because they see all the variations of penises and they can let you know whether it really looks normal or not normal, because what you consider normal may not be what your doctor considers normal.

All right. Again, sometimes you just have to be happy with what you have. But please, don't quote me on that.

All right. Do babies need water? That's the next question. This one comes from Shanna in Georgia. She says, "Hi, Dr. Mike. I have a 14-month-old son. It's been pretty hot here lately and I was wondering if babies and toddlers need to drink water throughout the day to stay hydrated.


"I had heard that too much water could cause water on the brain. Thank. Shanna."

So another great question. It's one of those things that grandmas are famous for. "Give that baby some water." Most babies don't need water to stay hydrated. Remember that formula and breast milk are mostly water, so babies get plenty of water just with their formula and their breast milk.

Now there are some situations when you could consider adding some water to the diet. But you should always consult your doctor about this and how it relates to your particular circumstance.

One would be if there's increased in, what we call, insensible losses. This will be like through sweating, fever. But in this case, remember that you're sweating salts, too, and you need to replace them as well.

So this is where you would use Pedialyte and other oral rehydration, electrolyte solutions. You want to avoid Gatorade and other sports drinks because they're the wrong amount of electrolytes for babies.


They have too much too sugar in them. They're going for sports rehydration but they're not good for rehydrating babies and toddlers. So if you want to add water because of sweating or because they have a fever, then you do want to replace the electrolytes or the salts as well and that's why Pedialyte and other oral rehydration solutions are better.

If you only replace the water, then you further dilute the electrolytes in the blood and that can cause low sodium and low sodium can cause seizures and brain swelling or cerebral edema. And also low potassium can cause heart arrhythmias as well. So you don't want to replace with just water, that's why you use Pedialyte.

Now if you have vomiting and diarrhea, again, you're losing electrolytes. You don't want to just replace water. You want to replace these electrolytes or salts as well for the same reason. So again, we would use Pedialyte in that situation.


You don't want just use Pedialyte during an entire illness though, while you're replacing water fluid and electrolytes or salts, there's not really much in a way of calories in Pedialyte. And you need the calories to fight infection. So you want to get them back on a regular diet as quickly as possible.

Now, speaking of decreasing calories, this would be the most likely reason to put kids on just straight on water. And, usually, it's unusual to have to do this. But when it does happen, it's usually an overweight infant who just is not satisfied when you try to decrease the amount of formula or breast milk that they're getting.

So they're overweight. They already have an obesity issue that's starting to form and you want to decrease the amount that they're drinking with calories in it, such as with formula or breast milk. But when you do that, they get really upset at you.


And so, for some of these kids, you can substitute a formula bottle or breast milk, or a nursing feeding episode with a bottle of water so that way you're filling up their belly but you're not giving them more calories.

Now you don't want to overdo that. And again, individual circumstances are going to vary and I would recommend that you consult your doctor before you substitute formula or breast milk with water, because you don't want to overdo it.

You do have to be careful about that. But that would be the most likely reason to do it. Otherwise, they're getting plenty of water in their formula or in the breast milk.

All right. That wraps up our Listener Question segment this week.

We do have a couple of research topics to present to you in our research round-up and we'll get to that right after this.

[Short Break Music]


Welcome back to the program. It is time for our research roundup. And our first topic for discussion, the title of this is called "School-based Intervention Acutely Improves Insulin Sensitivity and Decreases Inflammatory Markers and Body Fatness in Junior High Students".


OK, let's break that down. So basically, they're saying that a school-based intervention, so basically a learning program at school, improves insulin sensitivity, which is a risk factor for Type 2 diabetes. And it decreases inflammatory markers and body fatness which are also risk factors for Type 2 diabetes in junior high school students.

This was a study that was completed by researchers at the New York Presbyterian and St. Luke's-Roosevelt Hospitals in New York City, and it was published in the Journal of Clinical Endocrinology and Metabolism in February of 2007.

Now the question before the researchers, we know there is an obesity epidemic among American, both junior high and high school students.


An increase body fat is accompanied by some inflammatory markers, which are basically chemicals in the blood, and decreased insulin sensitivity, which leads to an increased risk for developing Type 2 diabetes.

So let's explain some of the science here real quick because I really feel like I'm using some words that many moms and dads aren't going to understand.

Obesity, increased lipids, increased triglycerides, increased cholesterol all of these things are accompanied by a rise in some chemical markers in the body for inflammation. Why this is? We don't know.

But we do know that in some people, as you become obese, some markers in the blood, some chemicals begin to be present and that is a risk for them developing Type 2 diabetes. And we know that people who have obesity and these chemical markers are not present, they have a lower risk for developing Type 2 diabetes.


We also know that when those markers are present, insulin resistance begins to be seen so you have a decrease in the insulin sensitivity. Now what is that mean? Well, remember insulin, the purpose of it is, it's a hormone that helps sugar the glucose get into cells.

And when you have insulin resistance, the cells don't respond very well to insulin, and so blood sugar is going to increase and then we see that as diabetes. And in this case, it would be Type 2 diabetes.

Now, what your body doesn't respond to that is, insulin production increases to compensate. So if cells aren't going to react very well to insulin, the body says, "Hey, we're going to make more insulin and try to make these cells work right" so that the insulin will affect them the right way.


And the if this happens over a long period of time and chronically your body is making more and more insulin but the cells aren't responding to it, and so the blood sugar starts to go up and stay high and then we call that Type 2 diabetes.

Now compare this to type I diabetes or juvenile diabetes, and this is where the problem. It's not the cells not responding to insulin. It's basically decreased insulin production, so your pancreas is not making insulin.

You don't have insulin around. The glucose can't go into the cell because there's no insulin and you get increased blood sugar in type I diabetes.

In this case, your pancreas is making insulin just fine. It's just that for some reason the cells don't respond to the insulin, and we think that has something to do with these chemical markers of inflammation, which are accompanied by obesity and increased lipids, triglycerides, cholesterol that sort of things.


So the question before the researchers is basically this. If we institute a program in school, can we have an impact on obesity, lipids and Type 2 diabetes risk? Can we lower those inflammatory markers? Can we increase the cells ability to react to insulin that's there?

And what they did is, they looked at eight grade students from a predominantly Hispanic New York City Public School who participated in the study. They first had to obtain approval from the Local School Board and also the New York City Board of Health, and then they also had written informed consent from the parents as well.

So they went through a lot of trouble to make sure that they were doing this in an ethical fashion. And because they had to obtain written informed consent from the parents, they had a little bit of trouble getting as many students at the school to participate as they wanted to.

In the end, they did have some people who started the study and didn't want to do it and dropped out.


But in the end, they looked at 73 students who participated in the study. Again, they're all eight grade students at a predominantly Hispanic New York City Public School.

Fifty-eight percent of the students were boys and all these kids were basically randomly assigned to two groups. So you have your test group and you have your control group.

Now regardless of what group they were in, they all had some baseline measurements done that included their height, their weight, their percent body fat, their BMI, their fasting insulin level, their glucose or blood sugar, those inflammatory markers, which go along with obesity and then having an increased risk for Type 2 diabetes and those include CRP, interleukin-6, TNG Alpha, and Acrp30.

So these are just chemical markers that they looked at that are typically increased when there's an increased risk of Type 2 diabetes.


They also looked at total cholesterol, HDL, LDLs and triglycerides. They looked at insulin response which was three- and five-minute insulin level in their blood, following a three-minute glucose infusion.

So they gave him high dose of glucose into their blood over three minutes and then they measured their insulin at three minutes and five minutes to see if their pancreas was capable of making more insulin if they needed to.

And they also looked at insulin sensitivity and that goes along with how well are the cells using the insulin. And they used a standardized insulin sensitivity test known as there are two of them known as QUICKI and AIR. And the specifics of those go a little bit beyond our research round-up because it's a little complicated.

And so the test group, when they did that, they measured all those baseline statistics for all of the kids, whether they were in the intervention group or the control group.


So the test group, what we're calling the intervention group, these kids all went through 14 weekly classes. They were each 45 minutes in duration, and these classes were integrated into their Science curriculum. And they covered a lot of things.

They covered experimental design. They learned about this research study. They didn't just participate in it. They also learned how to design a research study, how you get subjects to recruit them, what ethical issue are involved there.

They talked about diabetes education, nutrition education, dietary modification for decreasing fat intake, how to review the baseline data, and they looked at the data among the two groups. They talked about responsibility of scientists and what kind of ethical things you have to consider, how you analyze the data.

They talked about principles of thermodynamics, the importance of regular exercise.


They talked about calories in, calories out. Review of all the intervention and material and then a final analysis of the data. The students not only participated in this study, they basically also did the study and looked at the data themselves.

So it's really a great educational program not just on diet and exercise but also on how you go about doing scientific studies.

Now the test or intervention group also was introduced to a weekly exercise program. It was gender and somatotype neutral. I love that. That's the way to describe this exercise program. It's a nice way of saying that the exercises were equally easy for boys and girls and for jocks or geeks.

All right. So it's the gender and somatotype neutral. It consisted of dance and non-contact kick boxing three times a week. But the students also had the option of participating in the regular gym class if they preferred to go that route.


Now the control group had no intervention and no special exercise program. So, basically, they just went to school like they do all the time. They did have the regular gym class. That was fine.

And now we're going to compare this group of kids who had no intervention with the group of kids who did have the intervention.

At the end of the 14 weeks, all the measurements that we talked about before were repeated and compared to the baseline data. And what they found was that, at baseline, there was no significant difference between the two groups.

However after the 14-week program, subjects in the intervention or test group had statistically significant reduction in the percent body fat, their BMI, the inflammatory markers, CRP and interleukin-6.

And they also had statistically significant improvement in their QUICKI score, which again that looks at insulin sensitivity, compared to the control or non-intervention group.


So the authors conclude that a feasible school-based program exists, which can reduce several risk factors associated with Type 2 diabetes.

And incidentally, following the study, all the students in the control or non-intervention group did complete the 14-week course. So they did end up getting the benefits of the control or the test group. I should say the test group.

This is a small study. It's not very ethnically diverse and it only looked at eight graders and I think in order to convince legislators, which is really what you're going to need in order to institute state-wide school programs like these.

And in order to convince the lawmakers, I think we're going to need larger studies across more ethnic groups and grade levels and more long-term follow up. But this is a great start.


And giving the rising public health issue of obesity and Type 2 diabetes and the strains that these problems present to our health care system and our economy, I think this type of school program could really make a difference in the lives of our children.

Now the question is, will it die here? And that's up to further researchers, school officials, lawmakers and parents. And I guess time will tell.

OK, our second research study for research round-up this week, this was using tap water for wound irrigation. The actual title was a multicenter comparison of tap water versus sterile saline for wound irrigation.

And this was a study that was done by the Department of Emergency Medicine at the State University of New York and Buffalo and was published in Academic Emergency Medicine in May of 2007.

The question before the researchers it is known that wound irrigation is more effective than cleansing wounds with antibacterial solutions.

Bottled sterile saline is generally used for this purpose with an estimated cost of $66 million each year in the United States.


What if tap water were used instead of bottled sterile saline? Would there be an increased rate of wound infections if you did that?

So what the researchers did is they did a multicenter prospective trial. So they're going to use more than one hospital. And it's a prospective trial meaning that they're going to have a group of test subjects and then follow that same group along.

And they looked at 715 adult patients with simple lacerations. Following wound anesthesia, so we numbed out the wound. The patients were randomized to two groups. One was the control group and this was clinician-administered, so either doctor or nurse, administered sterile saline irrigation of two minutes duration on the wound.

The test group had patients self-administered tap water irrigation at the sink for two minutes and then all the wounds were closed using sutures or staples.


No antibiotics were prescribed for any of the patients and then 88% of the patients followed up either by returning to the ER or participating in a telephone survey.

And what the results showed was that the rates of wound infection were not significantly different between the two groups. So the group that just had tap water irrigation did not have a higher incidence of wound infection than those who used sterile bottled saline.

The conclusion that the researchers made was that using tap water instead of sterile saline for wound irrigation is equally effective in preventing wound infection and has the added the benefit of a substantial cost savings.


OK, now on to my discussion which I was so eager to get to. This was a study of adults. And of course, this is a pediatric podcast and I think a study involving children would be helpful. But it is easier to ask parents to participate in this kind of study when you have adult data to report.

So you tell the parents, "Look in adults, it made no difference. We think the same is going to be true for kids. Could you or would you be willing to participate in this study?" So I think parents will be more likely to do it, knowing that this kind of study was done.

Now the hospitals in question with this study were connected to municipal water system. So what if a hospital had its own well? Would that make a difference? So that's something else to consider in future studies.

I think this also has an implication for care of superficial wounds at home so cuts and scrapes that don't necessarily need stitches. You don't necessarily go to an emergency room for it.


And parents do not usually have access to sterile saline, anyway. So we usually advise using soap and water. But we know irrigation is better than soap and water. So the next question becomes, "Would two minutes of irrigation with tap water be more effective than a quick wash with soap and water for wounds that you're going to treat at home? So this is a question.

And again, would it make a difference if parents use municipal water versus a private well with well water for that kind of irrigation? So these are the basis for more studies. And see, this is how scientific knowledge is advanced.

I mean common sense will tell us that sterile saline would be the best, right? It would also tell us that municipal water would be better than well water, that there's less chance for infection that way.

But this study shows as another example of the problem with common sense. It isn't always right.

All right, well, that wraps up our research round-up this week and we will back to wrap up the program right after this.


[Short Break Music]


All right. I want to thank each and every one of you for tuning in PediaCast this week.

Also thanks to my family for putting up with me on all the hours it takes to make this podcast.

Thanks to Vlad over at Vladstudio for contributing the art work that we used in the feed and at the website. And also thanks to the folks at Bundlo at for supporting our recent Bundlo contest.

And congratulations again to the winners. You will be hearing from me through email, in terms of how to redeem your prizes.

Reminders. Don't forget that if you have a topic you would like us to discuss, all you have to do is go to and click on the Contact link.

You can also email or call the voice line and leave us a message at 347-404-K-I-D-S.

The poster page is available at the website. You can download posters. Give them to your pediatrician or family doctor and say, "Hey, why don't you hang in this in the exam room? So we can tell more people about PediaCast."


Also, the PediaCast shop is open for your pleasure, which has basically t-shirts and some other types of shirts there. There's no up-charge. They're all at our cost because we'd rather have you advertising PediaCast for us than making money off of the shirts.

And as usual, iTunes reviews are very, very, very, very, very helpful. So if you haven't taken the 30 seconds or so it takes to write a quick review in iTunes please do that. That would be so helpful to us.

All right. A little highlight on Karen's Pediascribe blog which is at where you can click on the Pediascribe link at

And that my favorite from this past week was "15 Ways I Save Money". So Karen was participating in a blog meme. And you can read the 15 ways that our family saves money.


And if you have other ideas for saving money, in the context of family, you just add those to the Comment section of Karen's post and that way as a community we can learn some cool new ways to save money from one another.

There'll be a link to that also to get you to that particular post in the Show Notes.

All right, this week's featured music is brought to you by Iota Promonet and Quango.

Bitter:Sweet is an electronic/trip hop duo with jazz-like qualities from Los Angeles. The band is comprised of Shana Halligan and Kiran Shahani. They're frequently listed in the iTunes Top 10 for electronic pop.

They've been featured on the soundtrack of the Devil Wears Prada, in Season 3 of Grey's Anatomy and the movie Because I Said So and in several advertising ventures. The duo was formed when Shana answered in the ad listing on Craigslist for a singer posted by Kiran.

Their 11-track debut album "The Mating Game" was released April 4th, 2006 under Quango Music Group and has been reviewed and recognized by several national magazine publications.


In summer of 2007, Bitter:Sweet released The Remix Game featuring re-worked versions of tracks from their debut album by renowned producers, such as Thievery Corporation, Fort Knox Five and Skeewiff.

These tracks were previously available only on vinyl, or unreleased.

So this is Bitter:Sweet from their album The Remix Game and the track is Salty Air.

And don't forget you can download the DRM-free MP3 version of this song in the Show Notes. And you can purchase the remainder of the album by following the links at

So I will leave you with Bitter:Sweet's song, Salty Air.

[End Music]

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