Sex Education, Dry Drowning, Foreskin – PediaCast 133
- Candidates Views On Sex Education
- Stronger Bones
- Medicine For Near-Sightedness
- Dry Drowning
- Foreskin Issues
- Differences Between McCain, Palin Over Discussion Of Condom Use In Schools
- Jumping For Joy … And Stronger Bones
- Medication Slows Progression Of Myopia In Children
- Dry Drowning (WebMD)
- Mean Mommies Club
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Dr. Mike Patrick: A warm thanks goes out to the good folks at audiblekids.com for being one of our sponsors today on PediaCast. Be sure to visit Audiblekids.com/pediacast. To download a free audio book today.
Announcer 1: Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every child, for every reason."
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now direct from Birdhouse Studios, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone and welcome to this week's edition of PediaCast or should I say this month's edition of PediaCast.
It is Episode 133 for Monday, September 15th, 2008, "Sex Education, Dry Drowning and Foreskin".
You have to say foreskin because if you put the big P word in there, the appropriate name for the anatomical part, iTunes stars it out because they think that you're being "bad". [Laughter] You know what I'm saying.
It's a little censorship that goes on in the iTunes world and because they don't understand that moms and dads want to know about their kid's penises.
And so you get thrown into that category of porn or something. I don't know. So, anyway, we're going to talk about sex education and foreskin today, but in light of pediatric medicine, so we're OK.
I do want to say sorry for the delay. The end is in sight. OK, I'm recording my last two episodes of PediaCast from BirdHouse Studio and then we have to say goodbye to BirdHouse Studio, goodbye to Ohio and hello, Florida!
That's right. PediaCast is moving 1,000 miles away across multiple state lines. I haven't decided if it's still going to be the new BirdHouse Studio or we may just have to come up with a new name for it, New Decor. We'll see.
So that's all exciting but it does mean that we have been slow in getting the shows out because of all the craziness involved. We are renting a house for six months while our house is being built.
So it's an exciting time but just lots going on in trying to keep up with this and finish up my office practice and all these things. It's very difficult to do.
One big change you'll notice that our shows are in a different format. Last episode, I switched from MP3 to AAC or M4A files. Now I didn't mention it because I thought if I mention it I'm going to get a huge onslaught.
And I thought if I just do it then we'll see how many people write to me that "Hey, I can't listen to the show anymore. What's going on?" And then at that point, we'll just deal with it. And actually, I only had one person write in. Only one!
And that person is good. We figured out exactly what they can do so we're still just having one feed but instead of an MP3, the shows are AAC.
Now why do I do that? AAC you know, we can do chapters. We can put graphics in as we talk about things, with links and pictures.
I don't have anything fancy like that for you this show because, you see, I have to move a thousand miles in a week [Laughter] so but that's coming. OK. We're going to do a lot more neat of things with it and that format allows us to do that a little easier than MP3.
I also want to mention that we have a Facebook page. I have not seen it [Laughter]. It's like John McCain. He doesn't know how many houses he has. I have no idea what my Facebook page looks like and that's not a punch on John McCain there. OK. Just don't take it like that.
Because his houses were investment property and his wife was taking care of that so OK. In fact, I think, they were in her name. But look, this is not a politic show and I didn't have my medicine this morning, so I get a little side track easily.
OK. So we have a Facebook page. Karen put that together and as soon as we get moved and life settles down, I do want to become involved in that.
I don't even know what you get to it. Just go to Facebook.com and search for PediaCast and then you can become one of our friends or something like that. So I'll figure it out. I promise I will, coming up in a couple of weeks once we are settled.
I also like to welcome a new sponsor. Of course, Nationwide Children's Hospital and AudibleKids have been great sponsors of our show in the past and so is minutepiemold.com and Mariner Software, actually.
But our current ones right now, Nationwide Children's and Audible and I'd also like to welcome Saturn. No, not the planet – the car company as a sponsor so be sure to check out the Show Notes for more information about that.
And there also will soon be, if there's not already, a poll question that Saturn would like you to answer. It's very quick. It'll literally take 10 seconds, if that, of your time. It's one simple little question. And if you go to pediacast.org, I would appreciate it.
And you just answer there a little question and you'd be on your way.
All right. We're going to talk about today the candidate's views, speaking of John McCain and Sara Palin. We're going to talk about their views on sex education.
Also, we're going to talk about "Stronger Bones: A Medicine for Nearsightedness". Dry Drowning' – I have a lot of questions on this one. In fact, one of my new neighbors, Jen if you're listening, I know you had a question about "dry drowning". We met the neighbors already, folks.
So we're going to talk about "dry drowning". That's coming up in this episode and also as I mentioned before, we can't use the "penis" word in our title so "Foreskin Issues" that's we're going to talk about.
All right. Don't forget if there is a topic that you would like us to discuss, all you have to do is go to pediacast.org and click on the Contact link. You can also email firstname.lastname@example.org or call the voice line at 347-404-KIDS. That's 347-404-5437, 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 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.
And with that in mind, we will be back with News Parents Can Use, right after this short break.
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The Los Angeles Times recently examined differences between Republican presidential candidate, Senator John McCain and his vice presidential running mate, Alaska Governor Sarah Palin over whether condom use should be discussed in schools.
According to the "Times" McCain and the Republican Party platform say that students should be taught that abstinence until marriage is the only safe way to avoid pregnancy and sexually transmitted infections.
Palin in a July 2006 survey was asked if she supported abstinence-only sex education programs instead of "explicit sex education programs, school-based clinics and distribution of contraceptives in schools."
Palin said, "The explicit sex-ed programs will not find my support." In a radio interview in August 2006, Palin was asked whether programs that discuss condoms are included in "explicit" programs.
Palin said no and called discussion of condoms "relatively benign". She added "I'm pro-contraception and I think kids may not hear about it at home and they should hear about it in other avenues. So I am not anti-contraception. But yeah, abstinence is another alternative that should be discussed with kids. I don't have a problem with that. That doesn't scare me, so it's something I would support also."
The "Times" reports that such statements could raise concerns among social conservatives who have supported Palin strongly.
Leslee Unruh, president of the National Abstinence Clearinghouse and campaign manager of the VoteYesforLife.com effort, said that children should be given a "clear and concise" message on the benefits of abstinence, adding that Palin's comments in the 2006 interview are not clear and seem "disjointed".
However, Unruh two days later said that the statement was "old" and added she supports Palin "in every way".
Palin spokesperson Maria Comella said Palin stands by her 2006 statement. Although the McCain campaign did not respond to questions about whether Palin's stand on sex education differs from McCain's, a campaign spokesperson previously had said that McCain believes abstinence is the "only safe and responsible alternative".
A campaign statement said, "To do otherwise is to send mixed signal to children that, on one hand, they should not be sexually active, but on the other hand, here's the way to go about doing it.
As any parent knows, ambiguity and equivocation leads to problems when it comes to teaching children right from wrong.
The federal government has spent more than $1 billion on abstinence-only sex education programs since 1996.
In related news, "USA Today" reports that despite the national debate over sex education, there is no systematic tracking of what schools in the U.S. are teaching students about sex – "and either way, there seems to be little connection between what they're taught and their behaviors."
According to "USA Today," state and local policies "trickle down" to individual classrooms, and a study of sex education in Illinois public schools earlier this year found that 30% of those teaching the subject had never received training.
Sarah Brown, CEO of the National Campaign To Prevent Teen and Unplanned Pregnancy said, "As much as we fight about sex education, we actually know very little about it in the real world."
A new report by the Sexuality Information and Education Council of the United States found 25 states are now rejecting federal funding for abstinence-only programs and several studies have questioned the effectiveness of this curriculum.
A recent analysis by long-time researcher Doug Kirby, published in the September issue of Sexuality Research and Social Policy, reviewed studies of nine abstinence-only programs and 48 comprehensive sex education programs.
According to Kirby, a couple of the abstinence-only programs showed "weak evidence" for delaying sex, but most did not delay initiation of sex at all. On the other hand, nearly half of the comprehensive programs delayed when teens first had sex, reduced the number of sexual partners and increased condom or contraceptive use.
Also about one-quarter of the comprehensive programs reduced the frequency of sex.
Valerie Huber of the National Abstinence Education Association said, "You can't expect that one class is going to undo all the misinformation teens are receiving from the other sources. It needs to be reinforced, and parents should be the primary sex educators of their children."
Elizabeth Schroeder of Answer, a New Jersey-based group that supports comprehensive sex education said, "For any kind of behavior change or healthy maintenance, it has to be an ongoing program."
All right. So I ask you moms and dads, what does your school teach? Is it abstinence only or do they have a comprehensive sex education program? If you don't know, shame on you. It's our responsibility as parents to know what school's are teaching to augment that information where appropriate and to instil our family's values into the equation.
And my own personal opinion on McCain and Palin differing a little bit on what they think appropriate sex education in the schools is, it's not important for me, personally, for candidates and the same party to have a "cookie cutter" outlook on things. To have difference of opinions is good even in the same political party.
And I apologize. This article did focus on John McCain and Palin.
So in order to be fair, in the future podcast, we'll talk about Barrack Obama's look on sex education which is from the headlines involves kindergarteners. But again, no jumping to conclusions on who I support with that, OK, some of you may already know.
Jumping for joy – high-impact activities such as jumping and skipping benefit bone health in teenagers. That's according to a recent article in the Journal of Bone and Mineral Research, a 10-minute school-based intervention, provided twice a week for eight months, significantly improved bone and muscle strength in healthy teenagers compared to regular low-impact warm-ups.
Physiotherapist Ben Weeks said the high-impact group, which included tuck jumps, star jumps, side lunges and skipping with gradually increasing complexity and repetitions, was specifically designed to apply a bone-stimulating mechanical load on the skeleton. Students worked up to about 300 jumps per session by the end of the study.
Eighty percent of bone mass is accrued in the first 20 years of life and especially around puberty to the circulating hormones. This study targets a window of opportunity in adolescence to maximize peak bone mass with high-intensity, weight-bearing activity.
The study of 99 adolescents with a mean age of 14 years found boys in the intervention group improved whole body bone mass while the girls' bone mass specifically improved at the hip and spine.
Boys in the bone-friendly warm-up group also lost significantly more fat mass than the other boys.
Mr. Weeks said the gender-specific response to the exercise program may be related to the different rates of physical development with girls reaching maturity at an earlier age than boys.
Peak height velocity is at different ages in boys and girls. Most boys in the group were right at that stage while most girls in the study were past puberty.
He said the improved bone strength at the hip and spine in girls was promising as those were the typical sites for osteoporotic fractures in the elderly.
While the study showed that a simple, practical exercise intervention can result in worthwhile skeletal benefits in adolescents, Mr. Weeks said larger, longitudinal studies are required to determine whether the beneficial effects persist into adulthood and reduce the risk of future bone fractures.
So jumping, skipping – all important things even for teenagers and from jumping to nearsightedness, this one is interesting. Daily treatment with a medication called Pirenzepine can slow the rate of progressive of myopia or nearsightedness, in children.
The report in the Journal of American Association for Pediatric Ophthalmology and Strabismus found that this is true.
Myopia is a condition in which focus on near objects is good but distant objects appear blurry. It's caused by a problem with the length of the eyeball or the curvature of the cornea, and it gets worse over time in many children.
In the study, children with myopia were randomly assigned to treatment with Pirenzepine gel or an inactive placebo gel.
After a year of treatment, the average increase in myopia was significantly less for children using Pirenzepine.
The new study presents the final results in 84 patients who continued treatment for a total of two years, 53 with Pirenzepine and 31 with placebo.
Although myopia worsened in both groups of children, the rate of progression was slower with Pirenzepine. At the end of two years, myopia increased by an average of 0.58 diopters in children using Pirenzepine versus 0.99 diopters with the placebo.
All children initially had "moderate" myopia, with an average refraction error of about -2.00 diopters.
New glasses are generally prescribed when myopia worsens by at least 0.75 diopters. During the study, 37% of children using the Pirenzepine met this cut-off point compared with 68 percent of the placebo group.
With glasses, all children had about 20/20 vision at both the beginning and end of the study.
Pirenzepine treatment was generally safe, although 11% of children stopped using it because of side effects such as eye irritation. The drug also causes mild dilation of the pupils. The amount of change in the length of the eyeball was not significantly different between the groups so researchers aren't really sure why it works, but suffice to say that it does.
Myopia is the leading cause of vision loss worldwide, affecting at least 25% of U.S. adults. Effective to prevent or delay progressive myopia may reduce the risk of serious complications – which are rare – such as detached retina and glaucoma.
Treatment to slow worsening myopia may also have important quality-of-life benefits, for example, while children with -1.00 diopters of myopia need glasses only part-time, those with -2.00 diopters will probably need glasses for all activities, including school and sports.
Previous studies have suggested that a drug called atropine can delay progression of myopia.
The new results show that Pirenzepine, a drug related to atropine, has fewer side effects and is also safe and effective for this purpose. Of course, more research will be needed before Pirenzepine can be widely recommended for children with myopia.
Key questions include the long-term effect and optimal length treatment. In addition, more convenient and practical methods of drug administration may help overcome some of the disadvantage of Pirenzepine gel.
I do want to mention that this shows that it delays the progression of myopia but still may be inevitable.
All right. We're going to take a quick break and we will come back and answer your questions right after this.
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Caroline:& Hey, Dr. Mike. This is Caroline from Maryland and I am wondering if you could possibly cover the subject of "dry drowning" in one of your podcasts. I've not caught up with all back podcasts so I don't know if you've already covered this.
But I've listened to the recent ones and I haven't heard anything about it. And it's been on the news so much recently because of a little boy, and I think South Carolina, who went to the pool, walked home and then apparently died about an hour later while taking a nap. I think there's a lot of confusing information on the topic.
I have a young daughter who can't swim yet but she likes to splash around in the water and I'm scared now that she will swallow too much water and I won't know it. So if you could please give us some information that would be greatly appreciated?
Thanks so much for the podcast. It's really informative and great especially for us new parents. So thanks a lot. Bye!
Dr. Mike Patrick: So Caroline from Maryland wants me to talk about "dry drowning" so thanks for the phone call, Caroline. She did use the Skype line which is really easy to do.
So dry drowning, it's been in the news a lot lately. There was a young boy in South Carolina, a couple of months ago who went swimming, walked home, took a nap and died, all within a couple of hours.
There is lots of confusing information out there about dry drowning. And Caroline's young daughter likes to splash around in the water so mom's worried will she drink too much of the water and mom won't know it.
OK. There has been a lot of press on this phenomenon so let's talk about it. There are a few ways that swimming water can be dangerous. So just to define what dry drowning is, we can compare that to, I guess, you would call it "wet drowning" and this one's easy enough to understand.
Large amounts of water enter the lungs. The body is deprived of oxygen because we have lungs not gills so we can't extract oxygen from the water. And this lack of oxygen leads to cellular death, which leads to unconsciousness, cardiac arrest and the death of the person.
Now unfortunately, wet drownings happen about 4,000 times each year in the United States with 1,400 of those incidents each year involving children.
So swimming lessons and more importantly, water safety practices and constant parental supervision when children are around water is extremely important.
OK. So what is dry drowning? Dry drowning is basically death caused by water but the death occurs at the time distant from the actual exposure and after a period of time that the child appears healthy.
So how can this happen?
There's several ways. One is going to be ingestion of the water so basically drinking a lot of pool water. Now this is going to require really large amounts of water ingestion. And what happens is that all this water gets absorbed in the stomach, into the bloodstream, and it dilutes the electrolytes in the blood.
And if these electrolytes become too diluted, if the sodium becomes very diluted, it can cause seizures. And if the potassium becomes very diluted and then low potassium, that can cause some cardiac conduction, electrical conduction abnormalities, and that may lead to death.
Now the amount of ingestion needed to do this is going to be really large. And it does primarily depend on a person's total blood volume. So the less blood volume you have the less water it's going to take to create a dangerous situation.
So babies are really the ones who are most prone to this thing happening so you do want to watch babies closely and younger children, too, and don't let them drink too much water while they're swimming.
Now a couple of mouthfuls of water aren't going to be a problem. It takes a lot of water ingestion. It's rare but it can happen but probably is not going to happen without you knowing that your child drank a lot of pool water, as long as they have constant supervision.
So a little water, swallowing it from the pool is not going to be a problem. This is when you drink very large amounts of water.
I do remember a car dealership. It's been a few years ago now. I think they had a contest. Basically, you see who can stand the car the longest and not have to go to the bathroom and get out, whoever the last person sitting in the car would win.
And at one point, they made him drink a lot of water but they didn't let him go pee. I think they passed away actually because they had messed their electrolytes up from drinking too much water.
But it does take a lot especially in an adult. It takes not quite as much in infants but still you would probably notice as long as you're paying close attention.
OK. So ingestion or drinking water into the GI tract is going to be one way. Now the other way is with aspiration. So in this case, the water enters the lungs but it's a small amount of water. It's not such a large amount that it's a wet drowning.
So a smaller amount of water enters the lungs but the amount of water or the length of exposure does not cause an immediate problem with oxygenation.
So the child appears to be doing well. Now the water may still irritate the upper airway and it can lead to laryngospasm, which basically is muscular contraction of the upper airway and that muscular contraction and swelling can obstruct the airway, deprive the body of oxygen and this still is going to occur relatively soon after exposure.
Now the next thing that can happen is the water may irritate the lower airway. And this usually takes a little longer so you get some inflammation set up in the lower part of the lungs and this leads to swelling in the smaller airways and that's going to result in wheezing and severe swelling.
And wheezing can lead to oxygen deprivation just like in asthmatics. In fact, asthmatics and those with a history of respiratory allergies are more prone to the sequence of events happening.
Severe small airway inflammation can then lead to vascular or leakage from the blood supply into the airway so body fluid can overwhelm the lungs. And this is oversimplifying it a little bit.
So instead of the pool water causing a problem, the inflammation caused from the small amount of water and possibly chemicals in the water that's been aspirated causes the body to have this massive inflammatory or immune system response, and then you can get plasma leaking from blood vessels and from surrounding tissue into the airways. And this is called adult respiratory distress syndrome or ARDS.
Even though it's called adult RDS, it can happen to children and babies. It's just called adult RDS to contrast it to neonatal respiratory distress syndrome which we see in premature infants who are born early and don't have a surfactant in their lungs to help them pop open.
ARDS, adult respiratory distress syndrome, is ominous. And the mortality rate with that is extremely high.
It's also rare in kids who just have a little bit of aspiration of water. You are much more likely to see that scenario in a person who really has a "wet drowning" but then they are revived but then they develop over the next couple of days, adult respiratory distress syndrome and still pass away a few days later.
But it's possible that you could get something like that happening with a small amount of aspirated water but it's pretty unusual and very rare.
The next thing is absorption of aspirated water so if you aspirate some water into the lungs, it takes a less water volume to dilute the blood compared to drinking too much water because the stomach regulates how much water that you are – not the stomach – more the large intestine.
But in any case the GI tract, I guess, we should say "regulates" osmosis of water across that membrane so how much of the fluid actually gets into the blood.
And it does a little bit of a better job regulating that compared to the lung where a lot of it gets into the blood. So direct absorption of aspirated water into the blood stream directly from the lung can also dilute electrolytes, lead to electrolyte disturbances, which can lead to seizures, cardiac arrhythmias and death.
So there's several ways the so-called "dry drowning" can occur so death that's distant from the time of water exposure, can be from too much ingested water through the GI tract which can cause electrolyte disturbance and then seizures and, or death.
It can come as aspiration or water going down into the lungs which can also cause electrolyte disturbances, can cause bronchospams can cause lower airway inflammation which ranges from wheezing to the more severe adult respiratory distress syndrome.
I also want to point and this is really, really important. Sudden death can occur for other reasons and it might just be a coincidence that a child was swimming, went home, several hours later took a nap, and died.
It might not be from the water at all. So when you hear about these cases in the news, keep that in mind, too. An autopsy eventually will be performed. The results of which may not be made known to the news media so you may never know the child, if they actually had a congenital heart problem, if that was the issue; if they had a history of a seizure disorder that the news media didn't know about.
This all comes into the privacy issues so it could be that this particular child had some underlying problem we don't know about and the parents didn't tell the news media. And the doctors certainly aren't going to tell the news media.
So from the public standpoint, you just hear that this kid was swimming and died a few hours later. But it doesn't mean that the death really was from the swimming. There may have been some other issue. There may also be abuse issues and/or foul play involved.
And these are all things of course that doctors and the coroner will have to consider. So back to Caroline's question – does she need to worry about this?
If her young daughter splashing around in the pool, does she need to really stay up at night worrying about this? Probably not, I mean, lots of kids ingest pool water. Lots of kids aspirate a little bit of pool water and the vast majority have no problems.
Obviously, you want to provide a swimming and water safety lessons. You want constant supervision. But beyond that, I think the benefit of swimming in a safe and supervised setting, at least in my opinion, outweighs the relatively low risk of these events happening.
I also point out that most of these situations do not lead to abrupt death out of the blue. You're going to have some coughing, wheezing, maybe some shortness of breath, some chest pain, alterations in consciousness.
These are all warning signs that something bad is going to happen. And then in the case of the boy in South Carolina, you do have to worry also about that nap.
Was it really a nap? Or had the child passed out? Was the child prone to napping at that time of day or was that out of the ordinary? Now don't get me wrong. I'm not blaming the parents for not recognizing a problem.
I'm just using this as an example of the thing you have to look for. So that's the scoop on so-called "dry drowning". I hope that helps, Caroline.
I do have a good Internet resource for you from WebMD concerning dry drowning and I'll be sure to include a link to that in the Show Notes. And of course, you can find those over at pediacast.org.
OK, so now for the infamous foreskin issues because we can't use the big P word in our title, so here we go.
Valerie:& Hi, Dr. Mike. This is Valerie calling for Mean Mommies Club. First of all, I just wanted to thank you for PediaCast Episode 126 especially when you talked about "Crying It Out" because that happens to be our first topic for our very first episode. So we want to thank you for that.
And of course, myself, Erin and Megan just love you. So anytime we mention Dr. Mike on Mean Mommies Club, we're like little school girls "We love, Dr. Mike. Yay!"
Anyway, I am calling because I have a question about my two-and-a-half-year-old son. First of all, my son has what looks like an inverted penis. It looks like it, almost like innie belly button. It hides. They call it a little turtle penis because it goes back into his body.
And I always try to make the point of popping it out and pointing it down so that when I put the diaper on it doesn't accidentally go up and cause it to stuck.
But I noticed that when I hold the skin of the shaft down, it popped the penis out. I noticed that he has three rather large, what I assumed are like "pus pockets" along the rim of the head and also it looked like the skin from the shaft was attaching itself to the head of the penis.
And I cleaned out the pus pocket and what was in there wasn't like runny pus but it had more of the consistency of thick and grainy like that and so I kind of kept an eye on it.
Also I work on a little bit. I was able to get some of the skin to unattached from the head. My son never flinched so I assumed it did not hurt and he never made a sound. So I did take him to my pediatrician the other day and I was really quite satisfied with him what he had to say.
Actually it was the first time ever that I felt like I was a parent or a mom.
The pediatrician gave me that "feeling" that I was wasting his time. And I love this pediatrician and we've never had a problem with him. So I want to have a second opinion. He told me that the substance that I found in his little slit in my son Smith were still the first soap. And I mean I can understand that might be an issue because of bubble baths and things.
But he didn't really think too concerned about the fact that the skin was re-attaching. He just said it was a little bit of friendly pus leaking. You just kind of work on it each time. But my concern is how long do I have to be with one, is it going to correct itself?
He made a joke, "Oh, when he becomes a man, and other things happen with that area." But at the same time I still didn't get an answer. I can understand how I can do it now while changing his diaper and I told him that I do have to touch that area of him in order to keep it clean because it's important.
The doctor said, "We have to keep your penis clean but at the same time we're going to start the potty training soon.& And I feel a little weird at the end of day though I'm OK when we see your penis. Let me check and make sure it's OK because I still want to open that ‘can of worms'….
He already understands that mom and dad and the doctor are the only ones who are allowed to touch him down there. But I went pondering from ground and I don't have access to that area every couple of hours.
What do I do? I'm a little concerned and I'd like a second opinion. I'm concerned about this little pus pocket. Is it really a built up of soap or what else could it be? And also, what can I do to prevent his penis – the shaft of the skin from re-attaching to the head because his penis wants to hide inside his body.
So, Dr. Mike, I appreciate any input you have. I appreciate your show so much.
I love it. I got Erin to listen to it. Megan got me to listen to it. So we love you and we love listening to your podcast. Thank you so much. Bye-bye!
Dr. Mike Patrick: OK. So Valerie from the Mean Mommies Club which is an excellent podcast and we'll have a link in the Show Notes at pediacast.org so you can find that very easily. You can tell that Valerie does a podcast because she likes to talk. [Laughter]
So yours was a little prolonged [Laughter]. It's OK, Valerie, because if I were calling and I'll do the same thing because you know me in tangent. So it's all good.
So Valerie has a two-and-a-half-year-old son and he has what she calls an "inverted penis". It's like an innie belly button. She calls it the turtle penis [Laughter]. And mom noticed that there are three, what she calls pus pockets, at the rim of the head or the glans of the penis.
And the foreskin was starting to attach there and then where it's attaching, as it comes apart, some white substance comes out.
And mom's not real satisfied with her pediatrician's explanation. He seemed rushed, just told her it was soap. It's going to fix itself. Don't worry about it. But she wants a second opinion. She wants to know what she should do. When will it correct itself?
She's worried about constantly asking him about his penis. And she basically wants to know what I think. Is it really soap? How can she prevent this? When will this stop being a problem? And in the mean time, what do you do especially as the child gets older?
They're all excellent questions, Valerie, and I think I can help explain this.
The key to understanding what's going on is to remember that there's a difference in the level at which the penis is attached and where the foreskin is attached. And I'm talking about the base down by the body.
So the base of the foreskin is attached at the level of the body wall, OK, or the external skin that covers the abdomen and pelvis.
The base of the penis itself is deeper. It's down by the pubic bone. Now the reason that this is important is because when you do a circumcision you're lining things up. You're taking off foreskin. You want everything to line up but where the penis and where the foreskin is attached is at a different spot, with the penis being down deeper.
Now when circumcisions are done shortly after birth, there's not a lot of subcutaneous fat. So the base of the foreskin and the base of the penis are pretty close to one another. But as time goes on, many baby boys develop a fat pad overlying the pubic bone.
And if you have a baby with a fat pad overlying the pubic bone you know what I'm talking about. There's basically a hump of fat under the skin just below the base of the penis. But the thing to keep in mind is this, the penis is still attached deep, down by the pubic bone and the hump of fat actually sort of grows up around the penis, not under it.
And this gives the impression that the penis is sinking down into the fat but it's not. The position of the penis doesn't really change. It's just this fat is engulfing the penis around it underneath the skin.
Now the foreskin is a different matter. It's attached at the level of the skin. So the fat pad really is under the base of the foreskin which is a continuation of the outermost layer of skin around the penis.
So the fat pad elevates the foreskin and pushes the foreskin beyond the head of the penis. So you have a stationary penis surrounded by fat and an elevated foreskin that extends passed the glans penis or the head of the penis.
And this is why these boys who previously looked like they were circumcised now look like they never had the procedure done.
It seems like there's this extra foreskin that's hanging over the end and you wonder what's going on. The good news is, as boys grow, they often lose this fat pad as long as they watch their calorie intake. They get plenty of physical exercise. And as they lose this fat pad, the foreskin returns to its original position.
Now the bad news is, while the foreskin is extended passed the rim of the glans penis, it often becomes attached. So the two layers, the foreskin and the head of the penis, stick together. Now these are both layers of skin and skin as you know renews itself.
You make new skin and you sloughed off old skin. But if the layers are stuck together, that sloughed skin doesn't have anywhere to go. It gets trapped between the stuck together layers and then that dead skin begins to decay or break down.
And then that decaying skin that's trap between the two layers of the foreskin and the head of the penis turns into this white cheesy substance that we call "smegma". OK. It's a little gross but you asked me to talk about it.
So, Valerie, I don't think the white stuff you saw was soap. It doesn't sound like it's infection or pus pockets. I think it was just the collection of decaying skin, cog between the foreskin and the rim of the glans penis or the head of the penis.
This is actually a common issue and I'm sure there are plenty of moms and dads out there who know exactly what I'm talking about.
So the next question becomes, what do you do about the foreskin and glans being stuck together? We call this foreskin adhesions and this is one of those things in medicine where there's no agreed upon definite right or wrong answer here.
There is in fact some controversy surrounding this. Someone argues you do nothing, and as time goes by, the adhesions will spontaneously resolve.
Others would argue that you want to reduce the adhesions during infancy and young childhood by providing traction, separating the two layers then covering the area with some Vaseline to keep the layers from sticking back together.
Now why would you want to do that? If you leave the adhesions, there are some potential issues. You can get infection in the stuck together region, although that is rare. You can get abrupt detachment of the adhesion that can be painful and cause some bleeding and that can be emotionally traumatic to older kids.
And then rarely what we call a skin bridge can occur and this is where a new layer of mature skin forms over the stuck together area, permanently bridging the foreskin to the glans and this can cause problems down the road as the penis grows.
If the fat pad goes away, then the foreskin become detached that can cause some curvature of the head of the penis and this can require surgical repair.
But the good news with that is it's rare. OK. It does not happen very often at all. So keeping all these in mind, here's the policy that I personally take.
If I see a young infant with adhesions, I usually reduce some in the office. And I show parents how to pull the foreskin back with each diaper change to prevent re-attachment. Why? Because there are potential issues with leaving the adhesions and I think that the benefit of reducing the adhesions or pulling them apart, in my opinion, outweighs the risk of complications in just leaving them there.
Now, in toddlers and older kids, I generally leave them unless they're causing pain, recurrent infection or some other problem like the development of a skin bridge. Now why? Because in these older kids, reducing the adhesion hurts, it's traumatic, the adhesions likely will recur, and in older kids, the adhesions usually, most of the time, resolve on their own at the time that the kids go through puberty.
And the complication rate in these kids is low. So in my opinion, in the older kids, including toddlers, the pain and trauma involve in reducing the adhesions no longer outweighs the benefit.
And then I should say with these older kids, if they do experience complication which again is rare, but they have pain or they have infection, I might try to reduce the adhesion gently. But more often than not, especially with the skin bridge, they're going to require surgical intervention to get that taken care of.
So what's the bottom line for you, Valerie? I wouldn't worry about this too much in a two-and-a-half-year old. If the white stuff leaks out, clean it. Pus is yellow, green and mucusy like snot. It's not white and cheesy or soap-like.
So what you were describing sounds like decaying skin that had sloughed off and got just in the normal way. The body makes new skin, gets rid of the old, makes new.
This skin that was trying to get rid off was cut between the two layers. That dead skin started to decay and that's what you're seeing and what we call smegma. And all I need to do is wipe it off when it appears and that may take a few days for it to work its way out.
And as long as it is not painful, if there are adhesions there, as long as they're not painful, they're not bleeding, there's no sign of infection, I would just let them be. And over the course of a couple of years, they'll likely go away on their own, definitely by the time of puberty.
More often than not they go away. They come back. They go away. They come back. And during that process if there's a problem such as infection, pain or bleeding, then you want to let your doctor know.
And a two-and-a-half-year old, Valerie, when private parts are starting to become a sensitive issue, I agree with you. I wouldn't keep pulling it back and keep making a big deal about its penis and his mom doing this.
So I think in a two-and-a-half-year old, I'll probably just let nature take its course. And if problem arises then you deal with it but it's unlikely that a problem is going to arise.
So I hope that helps, Valerie. Thanks for writing in. Thanks for listening and thanks for adding great material to the podcast road with the Mean Mommies Club. And be sure to check out Valerie and her friends at the MeanMommiesClub.com.
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