Ear Tubes, Eating Disorders, Baby Shoes – PediaCast 100

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  • Ear Tubes
  • Eating Disorders
  • Vanilla Extract On Nipples
  • Baby Shoes
  • Tuberculosis
  • Child Panics Before Doctor Appointment



Announcer: Bandwidth for PediaCast is provided by Nationwide Children's Hospital, for every child, for every reason.


Announcer: Welcome to PediaCast, a pediatric podcast for parents, and now direct from Birdhouse studio here's your host, Dr. Mike.

Dr. Mike Patrick: Hello every one and welcome to PediaCast, a pediatric podcast for moms and dads, this is Dr. Mike, coming to you from Birdhouse studio for the 100 time that's right, it is episode number 100 for Friday January 11, 2008.


Vanilla extract, baby shoes, and tuberculosis, now you'll notice my voice is a little bit better it's not perfect but it's a little bit better and I still may have to take some frequent sips of water here and there during the episode, but it's definitely an improvement, so just goes to show you virus just get better it just takes a while.  I think I‘ve mentioned to you before about a moment to the two week mark now with this thing.  

Saturday or Sunday right around there we'll mark the two week point in which I had this cold and I have not resorted to antibiotic, I do not have a bacterial infection, no fevers associated with it, just a runny nose, congestion, and a cough, and things are slowly starting to improve.   But I'm living proof here, viruses don't go away overnight, it takes some time.  

It doesn't really matter whether this is a virus or not, I feel the need to share this with you, I think I need a vacation.  This is the first year that we did not take a family vacation in early December in a very, very long time.  


It's been sort of a Patrick family tradition to go Florida for a couple of weeks between Thanksgiving and Christmas, usually closer to Thanksgiving, so like the end of November, early December.  My mom lives in Florida as does my brother and of course we also enjoy Disney World, and we have Disney Vacation Club and go down there.  

And we usually do it, this year went out to California in the Fall and we do have a Spring vacation in late April planned, but I tell you, it is tough heading into the virus season now, the rush of the Holidays, it was crazy.  Even though I was absent from PediaCast there for a while, just life was really busy and virus season is blooming at the office, which in the midst of virus season when we're all seeing 40 kids a day, to crazy schedule, lots of sick kids, trying to get three PediaCast out.


Vacations for me are like a little burst of sanity and I have a hard time going too many weeks, in this case, too many months without one, so, anyway, just thought I'd share that.  I know there's probably plenty of you out there who have had a vacation in a very long time, I don't know, I count on those, just seems like it's a long time till I have another one.  

Don't play the violin too loudly there for me, all right; I know I'll make it.  What are going to talk about today?  We have lots on the agenda.  I thought it would be fitting with it be on episode number 100.  A lot of shows, a lot of podcasts, episode 100 is a big mark for them, you know, like, "Hey, we've reached 100…, and lots of people call in and say, "congratulations, you just had 100, great….  


And that's fine, I'm going to let that number 100 just slide by here, I did pack it though.  So this show is packed with information.  We're going to talk about ear tubes, eating disorders, vanilla extract on baby bottle nipples, baby shoes, tuberculosis, and we're going to discuss a child who panics before doctor appointments.  

That's all coming up; we have lots of links actually in the show notes from this episode.  So make sure you check out the show notes to pediacast.org.  While you're there, if there's a topic that you would like us to discuss, if you have a question, a comment, a rant, you can go to pediacast.org, click on the contact link there and shoot me an email, or you can use your email client.  Just email pediacast@gmail.com, if you go that route, make sure that you include your name, and your location so we can include that when we go through the question or the comment if we use it.  


I should point that out, I get lots and lots and lots of questions and comments, and we can't get to all of them unfortunately.  I get many, many each day, but there's a good chance, so tell me what you're thinking and send it my way, and we'll see if we can get it on the show.  All right, 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 specific individuals.  

If you have a concern about your child's health, call your doctor and arrange a face to face interview and hands on physical examination.  Also your use of this audio program is subject to the PediaCast terms of use and agreement, which you can find at pediacast.org.  And with all that in mind, we will be back with the news parents can use, right after this short break.



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 medicalnewstoday.com.  A new study suggests that children, who typically receive an operation to insert ear tubes because of ear infections or fluid in the ear, may not need it, according to clinical practice guidelines.  

The research conducted by Dr. Selma Kiehne, assistant professor in the department of health policy at Mount Sinai School of Medicine, and her multi-disciplinary team of colleagues, found that most children who had ear tube operations in the new York city area in 2002 had mild disease for which experts recommend either medical treatment or watchful waiting and not ear tube implantation.  


The studies published in the January 2008 issue of pediatrics the official journal of the American Academy of Pediatrics. These findings suggest, over use of ear tubes and update a similar finding made about this practice in the United States in 1990 and 1991. Tympanostomy tubes or ear tubes are small plastic implants that ventilate the middle ear space to the ear canal through the tympanic membrane which is a fancy word for the ear drum.

Ear tubes maybe inserted to treat recurrent episodes of acute otitis media, which is inflammation of the middle ear, or the persistence of otitis media with a fusion, which is fluid in the middle ear space but without the symptoms of an acute infection.  Both conditions may be associated with hearing loss, may risk long term damage to the ear structures and can often be improved with ear tube surgery.


Tympanostomy tube insertion is the most common procedure that requires general anaesthesia for children in the United States with half a million or more surgeries done each year.  Ear infection is the most common illness with which children present to the doctors, said Dr. Kiehne, lead researcher of the study.  We found that many children are getting surgeries for minor disease and the typical child who gets ear tube surgery does not have disease severe enough to warrant the operation.  

If the study findings could be applied to the rest of the country, it would be particularly troubling.  For the study, Dr. Kiehne and her colleagues at Mount Sinai examined the clinical data for 682 children who received tympanostomy tubes from any of five New York metropolitan area hospitals in 2002.  This data was collected from the pediatricican, ear, nose and throat specialist, and hospital chart for each child for the year prior to surgery.  


Clinical practice guidelines endorse by the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Academy of Otolaryngology Head and Neck Surgery, recommend that in general children with fluid in their ear should not receive ear tubes unless that fluid has been persistent for at least three to four months consecutively.  Dr. Kiehne said, "One of our key findings is that more the three quarters of the children in our study who got ear tubes had fluids for less than a month and a half….  This study suggest that many clinicians use variables other than those generally studied, such as duration of a fusion or fluid, number of recurrent infections, hearing loss, speech delay when deciding whether to insert tubes in the ear.  

Future research needs to explore both the optimal course of treatment and why clinical practice so frequently deviates from the accepted guidelines.  All right I have a few comments on this story.  Dr. Kiehne says ear infections is the most common illness which children present to the doctor, I'm not sure where she's getting her numbers on that, I've a little trouble believing that to be honest with you.  


I would submit that many, more kids present with upper respiratory viral infections, now I realized she didn't explain where she got her information on ear infections being the most common illness. I mean there's certainly common, but viral URI's or upper respiratory infections to me would be the most common.  At least in my practice it's that's certainly the most common.  

Ok, now another issue I have with this is, the data is from 2002, that's five year ago, that's half a decade and they're publishing it this month in the journal of pediatrics?  I think it must have been a slow research month for them.  I mean how do practices have its change over a five year period?  What do those numbers look like for 2006 and 2007?

 I mean that would be a better indicator of the job that doctors are doing following these guidelines, which by the way the most recent guidelines came out in 2004 so it's kind of not fair to be looking at what these doctors did in 2002 before the guidelines came out.


And this is all important because the media is going to portray this kind story as a nationwide problem, "Doctors sends kids to surgery against the guidelines…, I mean never mind that we're looking at five year old data from a single city and only 600 kids involved in the study.  I think you got to take this one with a grain of salt, don't get worried that we're sending all these kids to get their ear tubes put in unnecessarily because most of us are following the official guidelines just fine.  

So what are the official guidelines for ear tube surgery?  I was– Hate to give you the link to this because practicing medicine is not as easy as reading a cook book.  You have to look at each case individually and come up with a reasonable plan, that's what we call the art of medicine.  


But for you cook book types and for the medical practitioners in the audience who're unsure, I'll put a link to the most recent guidelines in the show notes.  There're actually two of them, one is the diagnosis and management of a q otitis media and it is a clinical practice guideline from the American Academy of Pediatrics that came out in 2004, so there's a link to that.  

And I also have one to the management of otitis media with a fusion, which is that, a chronic fluid behind the eardrum that's not really acutely infected.  Again that clinical practice guideline is also from 2004, those are the most up to date guidelines and we'll have a link to both of those in the show notes, and again those are from the American Academy of Pediatrics.  Keep in mind that doctors being criticized here were practicing two years before the release of these current guidelines.  

An adolescent girl who regularly has family meals is less likely to suffer from an eating disorder to consume laxatives or diet pills or to take extreme measures to control her weight, that's a according to an article in the archives of Pediatric in Adolescent Medicine.  


The incidence of binge eating and self-induce vomiting is generally higher as youth progresses from adolescence to adulthood, explain the authors.  Disordered eating behaviours are associated with the number of harmful behavioural, physical, and psychological consequences, poor dietary quality, weight gain, obesity, depression, and the onset of eating disorders, thus it is important to identify strategies for the prevention of disordered eating behaviours.  

Dr. Dianne Neumark-Sztainer, from the University of Minnesota, and her team looked at2,516 adolescent children from 31 Minnesota schools.  The children completed two surveys, one in the classroom in 1999, and another one was mailed to them in 2004.  They were asked how frequently they ate with their families. With their BMI or body mass index was? How connected they felt with their family and their eating behaviours.  


Teenage girls who ate with their families at least five times each week in 1999, where substantially less likely to report using extreme measures such as using diuretics, or making themselves vomit to control their weight in 2004.  This was despite such factors as socio demographics BMI and family connectedness.  The reasons for the sex difference are unclear because boys did not show this association, the authors wrote, perhaps boys who engage in regular family meals are different in some way that increases their risk for disordered eating disorder behaviours….

"There's also a possibility that adolescent boys and girls have different experiences in family meals, for example, girls may have more involvement in food preparation and other food related tasks which may play a protective role in the development of the disordered eating behaviours.  Finally, family meals may offer more benefit to adolescent girls who may be more sensitive too, and likely to be influenced by interpersonal and familiar relationships than our adolescent boys….  


"The findings that emanated from this in previous studies should encourage us to find ways in helping families eat meals together,… the author says.  Help care professionals have an important role to play in reinforcing the benefits of family meals.  Helping families set realistic goals for increasing family meal frequency, giving schedules of adolescent and their parent.  Also exploring ways to enhance the atmosphere at family meals with adolescents and discussing strategies for creating helpful and easy to prepare family meals.  

The authors conclude, the schools and community organization should be encouraged to make it easier for families to have shared meal time on a regular basis.  So are you eating together as a family?  Or as your kids get older and more involved, is it easier to lose the family dinner?  I know it is in our house, I mean often times I'll get home, the kids and my wife are off it, play rehearsal because they're very involved in theatre, so we don't always eat as a family and I'm sure that a lot of you have that same situation.  


And when you look at a study like this you do have to think, alright, well families who don't eat together how involve were parents in the household? And how much those that really affect, whether there's eating disorders that develop or not, and also maybe mom is modelling behaviour where she doesn't eat dinner very often because she has her own eating disorder.  

There's a lot to this than just whether you all eat together or not, obviously it's more complicated than that.  Something to think about and you have a few seconds to think about it because we're going to take a short break and we'll be back with answer to your questions right after this.



Sandra: Hi Dr. Mike, this is Sandra calling from Elizabeth, New Jersey.  I want to thank you for your podcast, it's been tremendously helpful, I have a 13 month old, and I just listened to a podcast number 96, actually I have a couple of comment s for the mom who's trying to wean her daughter.  

I have little trouble weaning, actually finally succeeded weaning my son and one observed the old fashion way and remedies that my mom offered which helped a little in getting him to take the bottle with just a little drop of vanilla extract and I went ahead and did it, I don't usually try things that my mom suggest that are not sort of you know recommended by my pediatrician.


But it worked, he really took to the bottle after that and I had no trouble weaning him.  I wanted know what your opinion was on that and I certainly would be interested to hear your thoughts.  Additionally just in reference to your comments about flat feet, another thing my mom suggested was that I should get this really sturdy, hard fold little white boot that kids wore when I was growing up in the 70's and she commented that the paddy pad shoes that I had him in were too flexible and slingey and that they would hurt his feet and prevent him from developing strength in his ankles.  


I disagree but I wanted to know your opinion on that also, should he have this sort of hard fold high top boots to support his ankles or is he OK in the paddy pads or just being barefoot when the weather is warm.  Again I love your podcast and I really want to thank you for all of your useful information, I've been listening since I gave birth and it's very addictive and very helpful.  Have a great holiday and I look forward to hearing your responses, bye bye.

Dr. Mike:  All right, well thank you Sandra for calling the Skype line.  You're a mother like so many other grandmothers out there has advice for you and it's not just grandmothers who do this, well intention aunts and cousins and even the neighbours across the street.  
Everyone seems to advice for new moms, sometimes it's good advice, and sometimes it's not so good, so Sandra let's run your mother's advice through my pediatrician filter as it were.


Vanilla extract on the bottle nipple, to encourage weaning from the breast let's start with this one.  The only problem I see with that is vanilla extract has a really high alcohol content, in fact pure vanilla extract, by definition from the food and drug administration in order to call it pure vanilla extract; it has to have at least 35% ethyl alcohol content, that's pretty high.  

Now will a drop of that hurt?  OK probably not, but depending on what you call a drop and how often you do it, then it could be an issue, and if your baby is a sleepy or really cranky after you do this, I'd probably stop. Safer alternative in my opinion would be a drop of sugar solution, just take some table sugar and dissolve it in water, just make a sweet solution.  You can store that in the refrigerator although I'd make up a new batch of it every day, you don't want to store it in there too long and you could use that on the bottle.


That'll be a little bit safer, it may not taste quite as sweet or quite as good but it'll probably be good enough, and again the only issue with the vanilla extract is that high alcohol content, but again a drop of it isn't going to hurt, probably not, but I'm not going to endorse it a 100%.  Your mileage may vary on that one.  I will say don't use honey especially in kids who are less than a year old because there is that slight risk of a botulism toxin exposure which can cause some breathing problems and paralysis so I'd avoid that.  

All right the second piece of grandmotherly advice to run through our pediatrician filter here.  It's kind of like the pediatric version of myth busters.  So what's the myth?  Babies need firm rigid high top boots for their feet to grow correctly, and going barefoot is harmful and flexible soft shoe interfere with the normal development of the foot.  


That's the myth, right?  That's what grandma is saying and I bet lots of others are saying that too.  So what would we need to do to bust this myth?  Well, we'd have to design a study where we selected a big group of, let's say, identical twins.  Twin A gets grandma's plan, with the firm, rigid traditional baby shoes that are like hi top stiff things, and twin B, is going to go barefoot whenever possible and wear soft flexible shoes when protection is needed, like if they're outside and rocks or uneven soil or that they're going to scratch their feet up, then you're going to put a soft flexible shoe on their foot.  

But otherwise you're going to let them go barefoot and the kind of babies shoes I'm talking about Stride Rite has them,  Preschoolian sell them, we'll put links to those places in the show notes because they both have nice flexible soft baby shoes that you can use as an alternative to bare feet if you need a little protection.  


An then what you would do is follow this two groups of kids longitudinally and preferably go through the age of 18-21, and look for foot problems, and by selecting identical twins you minimize genetic and environmental variables and you just see if there's a statistically significant difference in the number of foot problems between the two groups and if the kids who are in one type of shoe versus the other, statistically significant less foot problems, then you would say that the others are different.  

Now, I would predict that there is no difference between the two groups, but I can't really bust the myth without doing that sort of study.  Now, to my knowledge that sort of study has not been done.  


Now interestingly enough Stride Rite and Preschoolian, on their websites, both of them say, "research shows that barefoot is best but if bare foot's not possible use our soft, flexible shoes….  Of course they don't source out their assertion that research shows this.  So I did some searching on the internet to try to find out what kind of research really is out there and came up largely empty handed.  

One thing I found was a survey that was done by the American Academy of Pediatrics called "Pediatricians Attitude Concerning Infant Shoes… and pediatricians across the country were basically sent a survey asking, if rigid baby shoes are important for normal foot development, or are flexible tennis shoe type of footwear acceptable?

And three quarters of the pediatricians surveyed thought flexible shoes were fine, but still a quarter of them were recommending stiff shoes.  Thing to keep in mind is the survey was done in 1972.  


So even in grandma's day three quarters of pediatricians thought flexible shoes were fine.  I did find also one excellent resource that just dated back to 1991; it's about the most recent one I could find.  There really has not been a lot done since then in terms of large research study in the major journals.  This one comes from the journal pediatrics, it was an article called "Shoes for Children: A Review…, and this was one in 1991.  

Unfortunately I can't put a link to the article in the show notes because it's on a secure server that only members of the American Academy of Pediatrics can access, I can download it as a pdf and upload it to my server and put a link to it but except when you download it as a pdf they put this thing on it that says, "Dr. Mike downloaded this…, and I don't want to get in trouble so I don't have a link for you.  


I do have a link to the abstract which anyone can see, and that'll be in the show notes.  But this is an excerpt from that article on the barefoot, I thought this was interesting enough for me to actually read part of the journal article to you because I think this is really interesting.  The author says that the natural state of the foot, in other word, the barefoot has been studied by several investigators.  

Hoffman examined the feet of a 186 natives of the Philippines and Central Africa who had never worn shoes.  Although he found some variability in the tribes, he noted that all feet showed excellent mobility, thickening of the plantar's skin just bottom of the foot, and wide variability in the height of the arch so with no shoes no arch support, there was a wide variability in the height of the arch.  


He reported that eversion of the feet were rare, and that these people's feet were generally pain free.  Then Engel and Morton studied the feet of unshod natives in the Belgian Congo, they found an absence of static foot deformities, meanings, deformities of structure, and noticed that because of the extreme thickening of the plantar or bottom of the foot skin, the natives would not hesitate to walk through a bed of live coals apparently experiencing no discomfort, whatsoever.  

They found that major foot problems were due to parasitic infections, so parasites attacking the bare foot and trauma.  And then James studied the foot prints of natives of the Solomon Islands and found no static foot deformities, so no structures foot deformities at least in their foot prints and then Sim-Food and Hodgson, compared a 118 shoe wearing and a 107 non-shoe wearing Chinese, and they found that the feet of the barefoot subjects showed greater mobility and fewer deformities than those wearing shoes.  


These studies consistently showed that the unshod human foot, so never having worn shoes is characterized by:  One, excellent mobility especially of the fore foot. Two, thickening of the plantar's skin as great as one centimetre which was usually determined by the surface features in their environment. Number three, creases on both the plantar and dorsum or upper part of the foot due to the flexibility of the midtarsal joints, midtarsal joints just mean that joints of the foot and the actual foot part.

So below the ankle but above the toes, the alignment of the phalanges, which is the toes, with the metatarsals which is the bones in the foot itself, causing the toes to spread and then five; there was variability in arch height and six; an absence of static deformity.  


So the authors going to conclude that optimum foot development occurs in the barefoot environment, the primary role of shoes is to protect the foot from injury and infection stiff and compressive foot wear may cause deformity weakens and loss of mobility.  The term corrective shoe is a misnomer so there is no such thing as a truly corrective shoe.  

Shoe selection for children should be based on the barefoot model so you want the shoe to be soft and flexible and mimic the foot so that really all that is doing is offering protection from the elements and physicians should avoid and discourage the commercialization and media-ezation of foot wear and finally they go on to say that merchandizing of the corrective shoe is harmful to the child, expensive for the family and a discredit to the medical profession, that's the authors words not mine.


Again that comes from a review of children's footwear.  Going clear back to 1991, but like I said I didn't find anything more recent than that in a pretty comprehensive literature search.  These shoe companies that say that they may have done their own little research study but none have been published in any journals and for our purposes that's what we use.  So what's my point here?  I would say I'm going to say this myth is busted.  Soft flexible shoes are fine.  


Susan: Hi Dr. Mike, this is Susan from Vienna, Virginia.  I was calling this question about tuberculosis.  I've got a college student who's getting ready to head off in the fall to a university that requires a TB skin test.  He was exposed and treated for tuberculosis when he was very young, about two, so obviously the skin test is going to come back positive, although he's never exhibited any symptoms of the disease.  

I was wondering you if could talk a little bit about tuberculosis, why their college would require that and we have to get a chest x-ray for him and then apparently have to update that every couple of years.  I appreciate the show, keep up the good work, I hope that the cold and flu season isn't too bad on you.  Bye.

Dr. Mike Patrick: all right so let's talk about tuberculosis, now I'm just going to cover the basic facts about tuberculosis, if you're interested in the details of the disease, check out the show notes, I have a link to an overview of tuberculosis from the Mayo clinic, and it goes on to great detail of what I'm going to cover in about two minutes here.  


Tuberculosis is caused by the bacteria, mycobacterium tuberculosis, and this is a bacteria that enters the respiratory tract through droplets.  Person with a coughs and some of the little droplets are suspended in the air and you breath them in, it's very contagious, it does not take many of the little organism to enter your body to give you the disease, because they rapidly reproduce and they're pretty hardy and the body really has trouble fighting it.  

And what the body ends up doing is rather than killing the bacteria sort of walls it off, and these results in a lung cavities and abscesses, and without treatment this can spread and infect a brain, bone, spine, joints, skin, it can really be nasty and it's tough for the body to fight it.  


A one third of the world's population is been exposed to tuberculosis and new infections occur at the rate of one per second worldwide and without treatment the mortality rate is 50%.  So if you get tuberculosis and you're not treated, chances are 50% that you're going to die from it.  Normal antibiotics won't kill it; we have to use two different antibiotics for several months at the time in order to treat it.  

This is really nasty stuff, this is a bad disease, and so we do want to scream for it especially in populations that are at risk for developing tuberculosis and the screening test that we use is called the PPD and that stands for Purified Protein Derivatives.   So basically they take proteins from this bacteria, the mycobacteria tuberculosis and inject it just underneath the skin, and if you've been exposed to tuberculosis, your body has antibodies against it, those antibodies are going to react with what they've injected under your skin and your body mounts an immune response and you basically get inflammation at the site where it was put in.  


And in order to get a positive result we looked at the induration of the injection site, that just mean the hardness, so if have the skin around the injection site becomes hard and that hardness extends a measureable amount, then we would call that a positive skin test.  Now, if you got a positive skin test because you can have a false positives and a false negatives, so the next step if you get a positive skin test is a chest x-ray to see if there's any evidence of active tuberculosis because you're going to see those walled off cavities and abscesses and then treatment begins.  

United States if you have a positive skin test an normal chest x-ray, generally treatment is still is begun because the risk of the treatment is less than if you really do have some of that bacteria in your system and you don't treat, and then you get an active TB a few months later, that can be an issue and so it's better really to treat so that's what most of us do.


Once you have a positive skin test you can expect that it would always be positive and the reason for that is because, once you're exposed to tuberculosis and you have this antibodies in your system to fight it they're always going to be there and so any time that you inject this PPD material you're going to have a reaction even though the disease is gone because it's not the presence of the live organisms in your body that make it positive, it's your immune system attacking what you just injected.  And so that's always going to be positive and it becomes useless as a screening device at that point.  

OK, so now let's get to Susan's question, now they have a little understanding of tuberculosis and how we screen for it.  You have a college, you have young adults living in closed quarters and it's an international population, remember 1/3 of the world's population has been exposed to tuberculosis and tuberculosis spreads like crazy and it's an awful disease and you've got kids living in close contact with one another.  


If there is an outbreak it's going to happen pretty rapidly and quickly, and easily in a college especially a dorm setting.  It's going to be terrible for the individuals who get tuberculosis, it's going to be costly because of all the medicine that's going to be needed, and it's going to be total nightmare for the colleges PR department.  I mean if they have a whole dorm with 20 kids with tuberculosis, are you going to send your kid off to that college when you're looking at schools? Probably not.

College is definitely have an interest in keeping tuberculosis off of their campus, to do that they need a policy, and their policy is 100% screening of all entering students, regardless of where you're from, that way it seems fair and there are pockets of tuberculosis risk if you're someone who's worked with in a health care setting, if you have a relative who just got out of prison, if someone who's homeless so you volunteered in homeless facilities, this are all high risk things for coming in contact with tuberculosis even in the United States.


You're going to 100% screens all entering students.  Now how do you screen them?  Well you screen them with a skin test.  Well what if the skin test is useless because it was previously positive?  Then you screen with a chest x-ray, and from the colleges' point of view, there's no exemptions, period, this is what you do and that's that, and I would agree with that.  What about this yearly, every couple of year screening?  

Most colleges and universities, their policies is going to be, that once you've had that initial screening, if you have had a history of a positive skin test then you need a yearly exam and you have the option of doing it yearly chest-x-ray, but you don't have to, although if chronic cough ever develops then certainly you would repeat chest x-ray and make sure that you don't have reactivation or a new infection with tuberculosis.  


Because you're always worry that someone who's been treated for tuberculosis, if you leave one bacteria behind and it stays dormant it can reactivate so you always have to be thinking about that.  But do you need the yearly chest x-ray?  Again personally I think that would be overkill to do a chest x-ray every year, there is going to be, this is the art of medicine, and this is a grey zone.  

There's going to be those, who say, "You should get a yearly chest x-ray and make sure that you don't have reactivation of this tuberculosis or new infection with it, since you can't do a skin test….  But year after year of chest x-ray exposure, you know, that's a radiation, you have a risk of radiation exposure and what can that do over time in terms of cancer causing, those sorts of things.  You got to be smart about this, I think it definitely makes sense to have a chest x-ray before enrolling if you can't use a skin test as a screening tool.  


But every couple of years, I don't know about that that's kind of a grey zone.  Talk to your doctor about it I'll find out with the school official policy is and then talk to your doctor and kind of go from there.  Now we have that one last question that I have to read because it's not a Skype question.  This one comes from Anne, and Anne is in North Carolina, she says, "Imagine you have an almost five year old son who gets really upset when he has to visit a medical professional….

"Said child had an unpleasant experience when he was two and a half when he sees the doctor, and he has cried and fuss over every doctor and dental appointments since.  He's due for five year well child appointment, and those last few shots needed for kindergarten.  Should I spring in on him as we're pulling out of the drive way towards our very nice pediatricians' office?  Or give him fair warning a day or two in advance, knowing that hell worry about it?…  


"He's usually well behaved in the office until he sees the syringes but he'll cry and yell before we get there and when it's shot time….  All right Anne, well thank you for your question. There really is not a right or wrong answer to this question, it's kind of come down to the type of relationship you have with your child and your child's temperament.  

In our family we've always given our kids fair warning, but then again they haven't really freaked out about it until the shot actually come in, and at that point, especially with my daughter, there is a little bit of drama including an incident a few years ago when my daughter came in specifically for a flu shot, this was the days before a flu mist the nose very kind and we didn't want to take up an exam room because it's a busy day in the office, my nurse was just going to give her flu shot and while my nurse is drawing it up Katy takes off, barricades herself behind the refrigerator.

Now granted she was seven or eight years old at the time and she did come out when she was told to but there was lots of drama and that's Katy for you.  


If you stick around for the closing we'll have a link to some more of her drama for you.  But getting back to my point, here's what I would do, I think I would give him a warning the day before, I would just say, "hey, you got doctor's appointment tomorrow to get ready for kindergarten….  That way you're not prolonging the anguish by telling them, week in advance, but you also aren't springing in any unpleasant surprises.  

If you tell him when you're in the car going, then the next time you're going shopping, or going out to eat, there's going to have this fear that she's going to take me some place different that might not be so pleasant, so I don't know that I was springing it on him as you're heading out.  Maybe the day before, just say, "Hey, tomorrow we're going to doctor so you can get ready for kindergarten….  And then with regard to the shots, I really have no problem putting off the answer to that.  I'd say it's up to the doctor if you're getting shot and how many, I just don't know for sure.  


I wouldn't promise that he will get shot, I wouldn't promise that he wouldn't get shot, I'd just say we have to wait and see, it's the doctor's decision.  Now in your case Anne, this story's technically a fib, I understand that.  He's going to need some shot, and when you tell him, "I don't know, it's up to the doctor…, you're fibbing.  And there are those out there who're going to say we should never tell our kids any fibs.  

Of course this same parent still sneaks gifts under trees, and hides baskets in certain times of the year and blame others for those actions but that's somehow better fib than mine.  In the end I think I just go with your gut.   Which will be somewhat dictated again by your relationship with your son and his particular temperament, but that's what I would do, I'll just say a day ahead of time, "we're going to the doctor's tomorrow, I don't know what shot you you're going to get or if you're going to get any, so we‘re going to ask the doctor….   So hope that helps and do write back and let us know how it goes and which end up deciding with that.  

All right, we're going to take a one final break here, we definitely gone over, but I feel it's OK, its show 100, what can you do?  We got to pack it with information, make it little special.  We'll take a quick break and we'll come back and wrap up the show, right after this.



Dr. Mike Patrick: We're going to wrap up the show.  First I want to say, thank you for putting up with my sniffling and my occasional coughing, it's getting better, there's still little bit of an issue with it but all together I think things have improved with my cold and hopefully future episodes, things will be even better, but I know there's been some sniffling and coughing.  It's kind of gross but I apologize, I guess I should be better soon.  


With busy practice and busy family life, I'm trying to get all this information together; post production is the thing that sort of falls aside I apologize, you just got to put up with that.  Thank you go out to Nationwide Children's Hospital as always for providing the bandwidth for PediaCast, also thank you to Medical News Today which you can find at medicalnewstoday.com for helping us out with our news stories, Vlad, over at vladstudio.com.  He's responsible for the artwork at the site, we appreciate his efforts.  

And of course, thank you to all of you for listening and providing commentary and questions and all that good stuff.  On the lighter side, the Pediascribe blog, I mentioned Katy's drama which is just kind of part of her life as it turns out.  I just want to say that she host this little inner mitten YouTube deal called "What can you do with your dorky things?…  


The first episode was her pointy episode, well the sequel has finally arrived, and it's the round episode.  I know this has nothing to do with pediatrics, this is just something fun and on the lighter side, and in the second episode, Katy is joined by my sister and her aunt Ashley, so you want to check out the show notes at pediacast.org and there'll be links to the Pediascribe blog which is done by my lovely wife Karen.  

We'll have links to both of those episodes of Katy's videocast on YouTube.  So the first one was the pointy episode, the second one's the round episode and this is her little diddy called, "what can you do with your dorky things….   There and check that out, do so and you'll see what I have to live with.  

Don't forget, PediaCast shop is available at the website, pediacast.org, it's in the side bar, and you can get PediaCast merchandise including t-shirts to help spread the word about the program.


Again I've mentioned this before, we don't have any upcharge on that, I don't make any money off the t-shirt, they're a little more expensive but they're nice ones.  I've ordered a few myself, and they're good quality.  I'm not letting them to iTunes reviews.  A poster page, we do have that at the website and of course word of mouth is so important spreading the word about PediaCast.  

So that wraps up the show number 100, I'm excited about it and we'll start with our next 100 episodes after the weekends.  I hope everybody has a great Saturday and Sunday and 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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