Vaccines, Milk Consumption, Dog Bites – PediaCast 058

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Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents, the research edition. And now, direct from BirdHouse Studios, here is your host, Dr. Mike!

Dr. Mike Patrick: Hi, everyone. Welcome to PediaCast. It's episode 58. Now I know Katy just said this is the research edition and we do talk a little bit about some research things. But primarily, it's going to be a news edition and this is for Wednesday, October 10th, 2007. We're going to talk about dog bites, pitching arms and soccer toes and there are some other things in there as well.

So why the switch from primarily a research round-up to a news edition? Well I have to be honest with you, my favorite sport has to be college football and you guys all know I'm an Ohio State Buckeye fan, which we, by the way, have survived all the upsets of the last couple of weeks, so I'm very happy about that. Number three in the nation. One of my partners at my pediatric practice is a USC fan so we had to rub that in a little bit. But I'm going to knock on wood and not carry it too far because there's a lot of playing time left in the season.

But anyway, my point, yes there was a point, we're watching the Cleveland Indians and the New York Yankees last night when I was supposed to be going through some research articles and putting things together. And honestly, I was kind of glued to the game and we're Cleveland Indians fans, too, although baseball's not quite up there with college football for me and for my family.

But we were watching the game and honestly it was just easier to do some news stories than to let my brain get into the research stuff, so I apologize. But I did find some interesting ones and we'll get to those in just a minute.


Don't forget if there's a topic that you would like us to discuss on PediaCast, it's really easy to get a hold of us, just go to and click on the Contact link. You can also email me at or call the Skype line at 347-404-K-I-D-S, that's kids.

Don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. If you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which of course you can find at And with that in mind, we'll be back with the News Parents Can Use and a little bit of research, right after this short break.



Our News Parents Can Use edition is brought to you in conjunction with our news partner, Medical News Today, the largest independent health and medical news website. And of course, you can visit them online at

A University of Rochester study brings relief to new parents who, while navigating a jam-packed childhood vaccine schedule, can expect to soothe their newborn through as many as 15 "pokes or jabs" by his or her six-month checkup.

The study, recently published in The Journal of Pediatrics, shows that no efficacy or safety is compromised when clinicians administer a new combination vaccine that streamlines the process — in effect, tripling up three of the recommended shots to reduce the "poke" total from five to three, at each of the three bimonthly, well-child checkups. So we're talking about the two-month, the four-month and the six-month visits and instead of getting five shots at each of those visits with the use of a combination vaccine we can do just three.

The study overturns findings (and fears) from a previous study that suggested problems when two specific vaccines were given at the same time — Pediarix, a combination of vaccines that guard against diphtheria, tetanus, whooping cough, hepatitis B and poliovirus and Prevnar, which protects against 76 strains of Streptococcus pneumonia, which is a bacteria. The earlier studies found that when the vaccines were co-administered, a suboptimal immune response was produced against whooping cough or pertussis and more uncomfortable reactions, such as swelling at the injection site, could be expected.

Both Pediarix and Prevnar are recommended for administration at two, four and six-month checkups; Prevnar was approved in 2000, shortly before the licensure of Pediarix.

This newest study unseated both early reservations, showing that the combination vaccine was in fact just as safe and as immunogenic as separate shots, even in the midst of other vaccines in the schedule. Here are some of the study details, see, I told you we're going to have a little research today.


A total of 575 healthy two-month-olds were enrolled at 22 sites nationwide. Each infant was randomly assigned to one of three trial groups:

1. Combination Vaccine Group, which received three vaccines — the combination vaccine, Pediarix; a second vaccine to protect against HiB, which is a Haemophilus influenzae type B that's another bacterial infection; and then a third, to protect against streptococcal pneumonia and again that's called Prevnar.
2. Separate Vaccine Group, which received five independent vaccines, so kind of the old way we used to do it and that would be the DTaP, for diphtheria, tetanus and pertussis or whooping cough, Hepatitis B, polio, the HiB and the Prevnar.

3. Staggered Vaccine Group that was identical to the Combination Group, except the Prevnar vaccine was delayed by two weeks at every appointment, thereby demanding a total of six pediatric office visits, instead of three at two, four and six months of age.

And then blood samples were collected before the study began, and again when infants were seven months, to test for immunity to each disease-trigger. Parents were provided a diary and asked to record temperatures, general symptoms such as fussiness, irritability or loss of appetite, and local injection site symptoms such as pain or swelling.


So what were the results? Well minor symptoms were more common in the Combination Vaccination Group. However, higher fevers and more severe shot site reactions were not significantly more likely to occur in infants in any of the three groups.

For example, swelling and pain were significantly higher at the injection site of the combination vaccine, but Dr. Pichichero, the lead author, said that is to be expected, given that there are more ingredients in that single shot. But, he added, it was noteworthy that at no time did any local symptoms, such as swelling, redness, pain, lead to an infant obtaining a medical office visit.

"Vaccine opponents may liken the process of the body processing simultaneous vaccines to a computer running too many applications. The machine goes slow, and the programs, one by one, begin to terminate." But Dr. Pichichero says, "Those fears are unfounded. We have found no evidence that a child's body is at any point approaching a maximum threshold as far as learning to produce immune responses."

"When you administer more vaccines, you expect more symptoms, more fevers," he said. Fever, swelling, redness are all indicators that the vaccine is working, that the body is busy creating the right immunity to prevent disease. And I'm going to step in here just to remind you because flu shot season is approaching. A lot of people, especially if it's the first time that you've gotten a flu shot, a lot of times you'll hear people say, oh, I got the flu from the flu shot; it gave me a fever; made me feel like my head aches and chills; I just felt miserable for a couple of days.

You didn't get the flu because the flu shot, that form of it is not a live virus so it cannot infect you and what you're feeling is basically the by-products of the immune system doing its job and feeling icky for a couple of days is a lot better than getting the flu and being down and out for a week to two weeks; full week of fever and then sometimes you get pneumonia as a complication of the flu. OK. I interrupted the news story for a little personal plug on flu vaccines. We'll get to those in future episodes.


Dr. Pichichero goes on to say (this is a day for tangents, I guess), "So long as they are mild, they pale (these are side effects from the vaccines) in comparison to the benefits of convenience, the fewer number of pokes to the infant, and of course, the severity of the diseases we are preventing."

Perhaps most importantly, the study showed the Combination Vaccine Group enjoyed at least as good immunogenicity (just a fancy word to say that the shots worked) as the Separate and Staggered Groups, for all criteria, including the criterion for protecting against whooping cough or pertussis, for which previous, smaller-scale studies had yielded inconsistent results.

"If pediatricians were holding out on making the switch to a combined vaccine for fear that its protection might be inferior, they no longer need be concerned," said Dr. Pichichero."It seems the clinical relevance of any previously observed differences with regard to whooping cough immunity have been dispelled."


OK, moving on to milk. American children are drinking too little of it and what they are consuming is too high in fat, according to a Penn State study.

"There is a strong correlation between dairy consumption and calcium," says Dr. Kranz, assistant professor of nutritional sciences. "While there is calcium in fortified orange juice, for example, it is not as bioavailable as that found in milk." She notes that people need to take calcium with vitamin D and some protein for optimal use in the body.

Dr. Kranz looked at children's average daily dairy intake and compared it with that recommended by the U.S. Department of Agriculture's MyPyramid dairy recommendations and Adequate Intake of calcium for various ages from 2 through 18. Their findings, reported online in press in the Journal of Pediatrics, are that only the two to three-year olds meet the MyPyramid dairy recommendations. They also noticed that most children choose to consume more of the highest fat varieties of cheese, yogurt, ice cream and dairy-based toppings.

The various recommendations for dairy intake in children established by a variety of organizations suggest two cups of dairy for one to three-year olds, two to three cups for four to eight-year olds and three to four cups for nine to eighteen-year olds depending on the recommending agency.

Only the youngest age group met these requirements. Among four to eight-year olds, consumption dropped below two cups a day and remained steady below two cups for 9 to 13-year olds and then it declined again among 14 to 18-year olds. All these dairy and calcium intake patterns were observed declining while the actual recommendation increased to three and then four cups daily.

"Although the recommendations are all for low fat dairy," says Dr. Kranz. "People are still consuming great amounts of whole fat dairy products."

The researchers found that 43% to 51% of the dairy consumed by younger children was from whole-fat sources with only 5% to 11% was from non-fat dairy. Older children consumed about 35% to 36% from whole-fat dairy and 11% to 13% from non-fat dairy sources.


"A glass of fat-free milk has 80 calories, while whole milk has 150 calories," says Dr. Kranz. "That is a difference per glass of 70 calories or 210 to 280 calories a day for individuals consuming three to four servings of dairy."

The Penn State researcher notes that these additional calories can add to the current problems of childhood obesity. The difference between whole-fat and reduced-fat mozzarella cheese is 20 calories per ounce with another 30 calories if the cheese is fat free.

"While children are not meeting the diary or calcium requirements, it is not a good idea to try to meet them by eating premium ice creams or other high fat products," says Dr. Kranz. She suggests frozen yogurts or sherbets or low or non-fat yogurt, cheese and toppings.

Also, researchers noted that dairy consumption patterns have not changed recently. Although physicians once recommended that children receive whole milk during the first year of life, that recommendation is no longer true. Of course we now recommend consumption of baby formula if the child is not nursing.

Starting with the second year of life, reduced-fat or fat-free milk is appropriate. However, children are still drinking whole-fat milk. A cup of milk provides 250 to 300 milligrams of calcium, a cup of low-fat yogurt contributes about 400 milligrams of calcium and an ounce of cheese includes about 200 milligrams of calcium.

In dairy products, about 32% of the calcium is bioactive and used by the body. Other sources of calcium such as soy milk and fortified orange juice at 300 milligrams are only about 25% bioavailable, that means that even though the calcium is in there it just doesn't get absorbed by the body as well.

Dairy products in general are the best sources of calcium for children, but knowing this and getting children to eat more low-fat dairy options (yogurt, cheese and milk) are not the same thing. Kranz suggests that one solution would be non-fat, non-sugared flavored milk products. These can range from milk with a little cocoa powder to milk blended with strawberries or blueberries.


All right. Then there are dog bites. Did you know that the majority of dogs that bite kids do so for the first time? But they may have a behavioral medical problem, according to an article in Injury Prevention. A team of scientists looked at 111 cases of dog bites over a four-year period, involving 103 dogs. All the dogs had bitten kids and had been referred to the same veterinary behavior clinic.

The researchers found characteristic patterns of behavior. However, these behavior patterns were not linked to specific breeds. A dog is more likely to bite a child if it feels that its food, toys, or other resources or possessions are under threat. Older children seem to be at the receiving end of most aggressive canine territorial behavior.

They found that if the dog knows the child, it is more likely that child may be bitten because the dog is guarding food, while dogs that bit older children they did not know were more likely to do so because of territorial guarding. So the littler kids are getting bit more often because of food; whereas, the older kids it's more often that the dogs didn't know the older kid and it was because of territory guarding.

According to behavioral analysis, by far the two most common causes of dog bites were the guarding of possessions and the guarding of territory.

The authors also report that about three-quarters of dogs that had bitten children showed signs of anxiety when left by their owners or were exposed to loud and sudden noises, such as thunderstorms or fireworks. The authors suggest that demonstrable fear in dogs could be a signal of having a tendency to bite when confronted with an apparent threat. Young children may be boisterous and unpredictable – two factors which could trigger violent behavior in an anxious dog.

Half of the dogs that had bitten children had medical problems, mainly problems related to their skin or bones. And some of these dogs also had kidney disease, hormonal problems, infections, growths or eye problems. It is possible that pain aggravated the dogs' behavior, suggest the authors.

So if you want to predict whether your dog is going to become a biter, I guess some things to look for would be if they have medical conditions or if they are anxious with loud noises and that sort of thing, so something to think about.


OK. Now a couple of stories for our student athletes. At this year's Little League World Series, new rules for the first time forced players to limit the number of times pitchers could throw the ball, and coaches had to strategize how pitchers were used more carefully.

Under the old system, a pitcher aged 12 and under could throw up to six innings per week and six innings per game. But in response to an increase in reported cases of young pitchers experiencing arm and shoulder problems, this year the Little League instituted pitch limits rather than inning limit, and required specific rest periods when a pitcher reached the threshold of pitches delivered in a day. Under the new rules, anyone who throws more than 20 pitches in a day needs to rest a day before he can pitch again. If pitchers throw 85 pitches in a day, they must rest at least three days before pitching again.

When Dr. Scott Mair and his colleagues at the University of Kentucky began research into what throwing really does to young arms and shoulders seven years ago, they had many questions about those physical changes since most research until then had focused only on adult players. Now that their research is complete, Mair has those answers, along with one surprising finding.

To evaluate these adaptive changes, the study followed 32 male baseball players between 13 and 21 years of age for six years to study changes in the shoulder's range of motion and strength, along with any growth plate changes shown by X-ray images.

What the researchers found was that repeated pitching does cause changes in the upper arm bone and soft tissues in the shoulders of young baseball players, but that these types of changes generally help protect players from injury, so it's not necessarily a bad thing. Mair said these changes may actually allow for better throwing velocity and less injuries to the shoulder.

"However," he cautioned, "pitching too much and playing year-round can push those adaptive changes to the point of injury. Young men in particular may be prone to injury, because some play the game year-round, and because the bones and muscles in their arms are still growing and changing."


One surprise finding in the study was that X-rays showed changes in the growth plate in the throwing shoulder in almost all of the kids. In the past it had been thought that these types of changes only occurred when there was a problem and resulted in pain with throwing.

Overall, Mair said parents of young baseball players shouldn't be overly concerned about their children's shoulders. "Throwing is fine as long as it's in moderation and the parents and child use common sense," he said. "A 10-year-old pitcher shouldn't be throwing through pain to win a Little League game, for example."

Young children do need a break from throwing. In the old days kids played baseball in the summer and then played basketball or football in the winter. "That was better for growing children because varying the sports used different muscles and movements," he said. But now, some children play only baseball year-round and that can be a problem. It can cause shoulder changes that go beyond normal adaptation and can lead to pain and even growth plate injuries, which will pretty much end your career. Kids that are pitching in three different leagues and pitching 12 months of the year tend to get growth plate problems that turn into a source of chronic pain.

Jim Madaleno (forgive me if I botched your name there, Jim), a senior athletic trainer for the UK Department of Athletics and father of a 14-year-old son who was part of Mair's study, knows all too well about the variety of pain that can come with playing sports. "Aches and pains are a part of it, but when an ache and a pain become significant enough that it alters how you're doing your everyday activity, then you should consult a physician," he said.

Now that this part of the research is complete, Mair said there's still a lot of work to be done in finding out how the growth plate responds to throwing, how to keep kids from being injured, determining pitch counts and days of rest needed and in educating kids, parents and coaches.

Both Mair and Madaleno agree children shouldn't be pushed to play a sport just because they may be better at it than others. "There needs to be time put aside to let the kids be kids and not just kids who are in a sport."


And finally, this is a bad time of year to be a juvenile toenail. Suffolk, Virginia foot and ankle surgeon, Dr. Matthew Dairman, DPM, FACFAS, says he sees a lot of children with ingrown toenails during fall soccer season. "It seems like every child is enrolled in a league," says Dairman, "The young kids wear hand-me-down cleats that don't fit exactly right and the older kids like tighter cleats to get a better feel for the ball and the field."

Dairman says these tight-fitting shoes crowd the toes together. Combine that with repetitive kicking, and you've got a recipe for painful ingrown toenails. Dairman can relate to his young patients because he had an ingrown toenail himself. "I can certainly sympathize," he says. "Such a small problem with such big pain. If you hit the corner of that affected toe, it shoots an intense pain that lingers."

Dairman says many of these kids don't tell their parents about the problem because they're afraid to miss a game. "By the time they come to my office, they've got a good infection brewing," he says. Young soccer players sidelined by an ingrown toenail may be able to get back into the game pain-free thanks to a simple, 10-minute surgical procedure. Dairman's ingrown toenail was cured permanently using this common treatment. He uses his experience to calm his sometimes apprehensive young patients.

"I take my shoe off and show them how my toe looks perfectly normal now," he says. During the short procedure, the foot and ankle, I'm sorry, I just have to laugh. You can just see this foot doctor taking his shoe off and showing the kids his own foot.

Dairman says parents should teach their children how to trim their toenails properly. Trim toenails in a fairly straight line, and don't cut them too short. He also urges parents to make sure their children's cleats fit, since a child's shoe size can change even within a single soccer season. If a child develops a painful ingrown toenail, soaking their foot in room-temperature water and gently massaging the side of the nail fold can reduce the inflammation, but you still need to see your doctor.

Dairman's four-year-old daughter hasn't shown an interest in soccer yet. But if she does, her father says he'll make sure her cleats fit right. "After all," he says, "She has my eyes and probably has my toes too."

For more information on treatments for ingrown toenails, including myths about home treatment, visit the American College of Foot and Ankle Surgeons consumer website at and of course we'll have that link for you in the Show Notes at

All right, that wraps up our news/research edition and we'll be back to wrap up everything, right after this.



All right. Thanks go out to Medical News Today for helping us out with getting our news stories together. Also thanks to Christian Nordqvist for writing some of the articles. And, Vlad is our artist that takes care of us in terms of the artwork at the website and then the feed, so be sure to support and visit Vlad at

Tomorrow we're going to answer more of your questions, get caught up on those. And then on Friday, we have a special guest, Cat Schwartz is going to stop by. She is the parent tech guru and we're going to talk about parenting tech devices and things. It's going to be fun, so make sure you tune in on Friday as well.

And until tomorrow, this is Dr. Mike Patrick saying stay safe, stay healthy and of course stay involved with your kids. So long everybody!


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