Fluoride, Flu Shots, Facial Tics – PediaCast 136


  • Bisphenol A
  • Vitamin D
  • Second-Hand Smoke
  • High-School Social Skills
  • Fluoride Recommendations
  • Flu Shot Recommendations
  • Facial Tics


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 Audiobook today.
Bandwidth for PediaCast is provided by Nationwide Children's Hospital. For every child, for every reason.



Hello, everyone and welcome to PediaCast. It is Episode 136 for Thursday October 23rd 2008. Fluoride, Flu Shots, and Facial Tics. It's time to think about flu shots again this year. So we're going to go over the recommendations and talk about the different kinds of flu shots that are available and are they really important especially for healthy kids. I mean, 'Do healthy kids really need flu shots?' We're going to talk about that.
Also, have lots in the News Department today. We're going to talk about Bisphenol A or BPA in plastic baby bottles. We've talked about this before but Canada has made some decisions regarding plastic baby bottles. So we're going to discuss that. Also Vitamin D, the recommendations on how much Vitamin D babies should get has undergone some changes. Second Hand Smoke Exposure, High school Social Skills; these are all things coming up in the News Department.


You know PediaCast has always been and always will be, at least this version of PediaCast really geared toward moms and dads, but I know we do have quite a number of healthcare professionals; doctors, nurses, and x-ray techs and lab people, dentists, family practice doctors, you know all these folks who also do listen to the show in much smaller numbers than moms and dads. But I do have some news for healthcare professionals out there especially if you're an Apple fan that I think is important.
There's a service on the Internet called Skyscape, they're at Skyscape.com and a lot of you may have heard of them especially if you have had a palm device in the past 'cause you can get medical text books, medical resources to put on your PDA. Well Skyscape came out maybe six months to a year ago with iPhone compatible versions of lots of different medical references but in order to use the Skyscape product you had to be online. So in other words you had to use Safari on your iPhone and hook up to the internet and then you could look at whatever you are subscribed to.


So let's say you're a Pediatrician and you are subscribed to Harriet Lane and you wanted to look up drug doses, you could do that but it was through an Internet-type interface which had a little bit of a lag plus you had to have access to the Internet on your iPhone and if you were using your cellular plan, it might be a little bit slow. Anyway bottom line is, this last week, Skyscape unrolled their brand new feature of having native iPhone application. So no if you had Harriet Lane through Skyscape, you can actually download it to your iPhone and have it always available very quickly whether you have Internet access or not. So this is really a great resource for medical professionals.
I don't get any kickback from Skyscape, they're not a sponsor of this podcast but maybe they should be. [Laughs] So anyway, then I could get some free medical texts, no I'm just teasing.

Anyway, you might want to check them out, Skyscape.com and we'll have a link to that in the show notes.


OK, back to the regular show. We're going to be gearing more toward moms and dads now. Sorry about that, but I know I have some doctors and nurses and so on who listen to the program and I have to give a little shout out to Skyscape 'cause it's really exciting to have native iPhone applications available.
All right, don't forget if there's a topic that you would like us to discuss on PediaCast, all you have to do is go to the website at Pediacast.org, click on the Contact link, you can get a hold of me that way. You can also e-mail pediacast@gmail.com or call the voice line at 347-404-KIDS. And we're going to be having a show again in the near future where we answer all those Skype messages.


Also the information presented in every episode of 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 Agreement which of course you can find at Pedicast.org.

And with all that in mind, we will be back with News Parents Can Use right after the short break.



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.

Canada has announced it will proceed with drafting regulations to ban the importation, advertising and sale of polycarbonate baby bottles containing Bisphenol A or BPA. Measures will also be taken to reduce the amount of BPA that is released into the environment.

Tony Clement, Minister of Health, said "In 2007, we issued a challenge to industry under our Chemicals Management Plan to provide information on how they manage Bisphenol A. Today's announcement is a milestone for our government and for Canada as the first country in the world to take regulatory action."

John Baird, Environment Minister, said "Many Canadians, especially mothers of babies and small children in my own constituency of Ottawa West-Nepean, have expressed their concern to me about the risks of Bisphenol A in baby bottles. Today's confirmation of our ban on BPA in baby bottles proves that our government did the right thing in taking action to protect the health and environment for all Canadians."


The assessment states that the general public does not need to be concerned. The main focus is its impact on newborns and babies up to the age of 18 months. Nevertheless, health risks for Canadians of all ages were considered.

Scientists determined that newborns' and babies' use of polycarbonate baby bottles when they are exposed to high temperature, plus the migration of BPA from cans into infant formula, are the main sources of human exposure.

They concluded in this assessment that BPA exposure to newborns and babies is below levels that cause effects. However, as some studies raised uncertainties relating to the potential effects of low levels of Bisphenol A, Health Canada says the Canadian government is "taking action to enhance the protection of infants and young children."


According to scientists at Environment Canada, BPA is entering the environment through washing residues, waste water, and landfills. BPA also breaks down in the environment where oxygen levels are either low or non-existent. The accumulative effect of slow break down and the wide use of BPA in Canada could mean that levels may gradually build up in the country's waters and harm fish and other organisms, Health Canada informed.

A further $1.7 million has been allocated over the next three years to fund research projects on BPA. Health Canada says, "This extra money, plus major Canadian studies which are currently ongoing, will help address the key knowledge gaps in both the international and Canadian scientific community."


So my question is, just because Canada has banned Bisphenol A, does that mean all of a sudden it really is dangerous? Does this lend credibility to the question about BPA? 'No.' This is a governmental action and instead of relying on the scientific community which even in the article and the government in Canada stated that BPA exposure in babies is unlikely to cause any ill effect, because the exposure is below the level that causes problems, instead of relying on science, 'let's ban the substance because mothers of babies and small children have expressed concern.'

Let's see, do we look at well designed scientific studies or do we listen to paranoid parents? 'Let's design policy around paranoia.' Way to go, Canada. Let's clap. [Claps]
For more information about Bisphenol A, you can check out PediaCast number 125, where we really take a good objective look at the data about Bisphenol A and plastic baby bottles and microwaves and you can find link to PediaCast 125 in the show notes at Pediacast.org.

That's just great. I mean these guys get elected, so you know why not listen to the parents who are concerned and ban the stuff based on their worry. They're the ones that elect you.

OK. Because of Vitamin D deficiencies in the diet of breastfeeding mothers, the American Academy of Pediatrics is doubling the amount of Vitamin D it recommends for infants from 200 Units per day to 400 Units per day beginning in the first two months of life and the recommendation also extends to all other babies, children, and adolescents.

The new recommendation to increase the daily intake of Vitamin D for infants, children, and adolescents in a clinical report available as a PDF download from the AAP website, (which we have a link to) and it's expected to be published in the November Issue of the Journal Pediatrics.

Co-author Dr Frank Greer, who chairs the AAP Committee on Nutrition, said "We are doubling the recommended amount of vitamin D children need each day because evidence has shown this could have life-long health benefits. Supplementation is important because most children will not get enough Vitamin D through diet alone," he added.


Dr Carol Wagner, member of the AAP's Breastfeeding Executive Committee and who co-authored the report with Greer said, "Breastfeeding is the best source of nutrition for infants, but because of Vitamin D deficiencies in the maternal diet, which affect the Vitamin D in a mother's milk, it is important that breastfed infants receive supplements of Vitamin D".

Wagner said that "Until we can find out the exact Vitamin D requirement of lactating mothers and breastfed babies, the best way to make sure that breastfed babies get enough is to recommend a daily supplement of 400 Units."

The new recommendation follows a review of new clinical trials on Vitamin D that show 400 units of Vitamin D a day not only prevents but also treats rickets, the bone-softening disease.


Enough Vitamin D stops children developing rickets but dietary sources are limited and there are problems with determining what is a safe amount of exposure to the sun (which our skin needs sunlight to make vitamin D).

There are still reports of rickets in children in the US and other Western countries where the greatest risk is in babies who are exclusively breastfed and who do not receive daily supplements of 400 Units of Vitamin D a day. The peak incidence of rickets is in babies aged between 3 and 18 months, but there are also reports of the disease in older children and adolescents. Getting enough Vitamin D in childhood is also thought to reduce the risk of developing osteoporosis later in life. And new research shows Vitamin D is also important for the immune system and the prevention of a range of autoimmune diseases, diabetes and cancer.


More specifically, the new recommendation suggests the following:

Babies who are fully or partly breastfed should start having a daily supplement of 400 Units of Vitamin D within a few days of birth.

Babies who are not breastfed, and older children, who consume less than one quart or 1 liter of Vitamin D-fortified formula or milk a day should also be taking a supplement everyday of 400 Units of Vitamin D.

Adolescents should also be taking a daily supplement of 400 Units of Vitamin D if their diet does not give them this amount every day.

Some children may need higher doses, for instance if they are taking certain medications that put them at higher risk of Vitamin D deficiency.

Healthcare providers caring for women during their pregnancy should consider monitoring their Vitamin D levels, given the growing body of evidence that Vitamin D is important for fetal development.


And if you're interested in reading the full Vitamin D report, you can look for the link in the show notes at Pediacast.org. And notice that all of these recommendations are based on scientific research and not because mothers were calling the AAP and say, "You know we're really concerned our babies aren't getting enough Vitamin D."

OK, I know I'm being a smart aleck, I'm sorry.


A study presented at this year's Annual Meeting of the American Society of Anesthesiologists provides evidence that the carbon monoxide levels of children exposed to second-hand smoke are often similar to that of active adult smokers and frequently higher than levels in adults exposed to second-hand smoke.

Dr. Branden Yee and his research group from the Anesthesiology Department at Tufts Medical Center studied 200 children between the ages of 1 and 12 to assess their levels of carboxyhemoglobin, which is formed when carbon monoxide binds to the blood. Carbon monoxide binds to blood 200 times more easily than oxygen, but the resultant carboxyhemoglobin is unable to deliver oxygen to body tissues, including that of the brain, heart and muscle.


The exact ramifications of high levels of carboxyhemoglobin are not entirely known, but potential consequences of long-term, low level exposure include changes in heart and lung tissue. Although household and environmental factors such as stoves, heaters and automobiles are potential sources of carbon monoxide exposure, the most likely source of elevated carboxyhemoglobin overall is second-hand cigarette smoke.

And according to Dr. Yee's study, the younger the child, the greater the potential level of exposure. "The physiology of children – especially the youngest – is different from that of adults," said Dr. Yee. "Children breathe in a greater amount of air per body weight compared to adults."

"Another possible explanation for the youngest children having the highest levels of carboxyhemoglobin is that they are completely reliant on their parents and are thus exposed to everything their parents are, including air pollution, cooking exhaust and, of course, second-hand smoke."


Dr. Yee stressed the importance of education in helping to change parents' smoking habits, especially around children. He thinks that the right blend of physician intervention and technology could have positive benefits.

"The simple, non-invasive device we used to test exposure may encourage health care providers to ask further questions of children and their parents regarding smoking habits," said Dr. Yee. "Personalized education coupled with the act of physically showing a parent the carboxyhemoglobin measurement in a child's blood may provide a graphic and concrete message to that parent."

And who knows if enough parents voiced their concern to the government, maybe Canada will do something really crazy like banning the production, distribution, and sale of something we know for sure is bad like cigarettes. Sure ban the BPA but let the parent smoke, that's great.


Ten years after graduation, high school students who had been rated as conscientious and cooperative by their teachers were earning more than classmates who had similar test scores but fewer social skills, shows a recent study of Illinois published in the Journal Social Science Research.

The findings challenge the idea that racial, ethnic, and socioeconomic gaps in educational attainment and earnings can be narrowed solely by emphasizing cognitive skills, said Christy Lleras, a University of Illinois Assistant Professor of Human and Community Development.

"It's important to note that good schools do more than teach reading, writing, and math. They socialize students and provide the kinds of learning opportunities that help them to become good citizens and to be successful in the labor market," she said.

"Unless we address the differences in school climates and curriculum that foster good work habits and other social skills, we're doing a huge disservice to low-income kids who may be entering the labor market right after high school, especially in our increasingly service-oriented economy."


She cited responses to employer surveys that stress the need for workers who can get along well with others and get along well with the public.

The report analyzed data from the National Educational Longitudinal Study, which followed a diverse group of 11,000 tenth graders for 10 years, tracking not only their scores on standard achievement tests but teacher appraisals of such qualities as the students' work habits, their ability to relate well to peers, and their participation in extracurricular activities, a proxy for the ability to interact well with both students and adults.

The teachers' assessments were then compared with the students' self-reported educational attainments and earnings 10 years after high-school graduation.
Even after controlling for students' achievement test scores, family socioeconomic status, and educational attainment, Lleras found that such social skills as conscientiousness, cooperativeness, and motivation were just as important as test scores for success in the workplace.


"You could argue that the reason these behaviors matter is that kids who display them are more likely to obtain a college degree and in turn have higher earnings. Certainly that is part of it, but even after I controlled for educational attainment, there were still significant effects," she said.

To measure conscientiousness, the researchers ranked teacher responses to such questions as; Does this student usually work hard for good grades? How often does the student complete homework assignments? How often is this student tardy to class?

To measure cooperativeness and sociability, she ranked teacher assessments of how well a student related to other students. Teachers were also asked to rank a student's motivation or passivity.

Participation in sports and school organizations also had strong effects on a student's future educational and occupational success.


"For African American and Hispanic students only, participation in fine arts led to significantly better earnings compared to whites. This suggests that different activities teach kids different kinds of skills and learned behaviors."

Lleras also emphasized the importance of improving school quality. "Low-income and racial minority students continue to be concentrated in lower-quality schools with fewer opportunities for extracurricular participation, large class sizes, and lower teacher quality, all factors that are correlated with poorer school-related attitudes and behavior."

"If the few resources that low-performing schools have are used solely for testing and preparing students to take tests, which is what many schools are doing to meet the requirements set forth in No Child Left Behind, these schools will continue to face challenges."

Lleras reports or findings show that the most successful students are those who have not only high achievement test scores but also the kinds of social skills and behaviors that are highly rewarded by employers in the workplace.


You know I think an interesting expansion of this kind of research would be to compare home school kids with public and private school kids in terms of workplace and earnings potential in the future. Because there are questions, and we home school actually so I probably should qualify that right up front. But I would be interested in the study that did look at home school kids versus institutionalized school kids to see what the differences are in terms of socialization and attainment in the workplace. So there's a call for research from me, which you know doesn't really matter. [Laughs] Then the researchers aren't listening to me, oh well.

Let's go ahead and take a quick break and we'll be back to answer your questions right after this.



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OK. We are back and ready to tackle our Listener Segment this week.

First up we have John in Rancho Cucamonga California. John says, "Hi, Dr. Mike. I've been listening to the show since my wife and I found out we were pregnant. Just this past week we took our sweet baby girl to her six month check-up and our our pediatrician prescribed fluoride drops once a day until she's about two years old or until we are brushing her teeth on a regular basis. My wife and I are unsure of this and can't make a decision. I remember hearing that all water has been fluorinated since the early 80's so does our girl need this extra dose or not? What are the possible side effects of this and what are the positive outcomes? Thank you for the show, it's very informative and I look forward to hearing your response. John and Nicole."


All right, so let's talk a little bit about fluoride. We've tackled this before but let's go through it again 'cause it has been a while. Fluoride becomes incorporated into a enamel which makes it more resistant to decay. And this can be accomplished by brushing with a fluoride toothpaste, so you have external exposure to fluoride and it can also be accomplished by ingesting fluoride so that we have an internal way to get fluoride to the teeth.

Now for infants, ingestion of the fluoride is going to be more important because their teeth haven't erupted yet. And even in small children the adult teeth erupted yet so ingestion of fluoride continues to be important so that it becomes incorporated in the growing adult teeth. And if fluoride becomes incorporated in the baby teeth and adult teeth, as they develop up inside the gum, there are many studies to show that the resulting teeth are more cavity and decay resistant than are teeth that are not exposed to fluoride. And that there have been many studies showing this, they date back even to the 1940's and 1950's and they showed that population with exposure to fluoride have a much lower incidents of tooth decay.


And that's good thing because tooth decay causes lots of problems, it's painful, it is cosmetic issue, it can introduce infection into the gums and up into the bones and eventually into the bloodstream. So tooth decay is not a minor thing, it can be serious. But like all things, too much of a good thing is bad. So if you get too much fluoride, that's not good and a condition that we called Fluorosis sets in. And this is a condition which too much fluoride is incorporated into the enamel. Now these teeth are strong, they're highly resistant to decay but they become very unsightly. Mild Fluorosis; you start to get some white specks in the enamel of the tooth, so there's some discoloration and they're white in color. As you progress to moderate Fluorosis the white specks turn into yellow and brown stains and then with severe Fluorosis you get pitting of the tooth surface.


So we know that too much fluoride makes the teeth decay-resistant but the teeth become very unsightly. We also know that extreme exposures to fluoride is likely responsible for some types of bone cancer. So again like most things, too much of a good thing is very bad. So there are a lot of anti-fluoride groups out there who claim we are poisoning our kids and they talk about where the fluoride comes from and how toxic it is. But it's kind of silly because there's no evidence to suggest that small amounts of fluoride is harmful in any way and while large amounts is dangerous, large amounts of other metals like iron and calcium are deadly but you don't hear anti-iron and anti-calcium fortification groups out there, you know people like something to complain about and fluoride is a good target.


OK. So we've established that small amounts of fluoride is beneficial and too much fluoride is not something that you want.
So let's quantify exactly how much fluoride that we're talking about. Well in terms of supplementation, the amount of fluoride that you need depends on how much fluoride your infant or child is getting from other sources because we don't want to overdo it.

So the first thing we have to look at is what are the potential sources of fluoride before you consider whether your want to supplement or not. The biggest source is going to be of course drinking water; babies aren't drinking lots and lots of water, but if you use your home water supply to make formula from concentrate or powder, then this is a source that you need to know about. So you want to know how much fluoride is in your water, and to find that out you can contact your local water department or you can have your water's fluoride content tested and most health departments will do that for you.


I should mention John, no not all communities add fluoride and not all communities add the recommended amount of fluoride. Some water sources have natural fluoride and if you add fluoride to that then you have too much fluoride in the water. Some may have natural fluorides, the community will say, "Well we don't add it because it already has fluoride in it'" but it's not enough fluoride and they should be adding some, so you don't really know unless you call your water department and ask them, "Hey, what is the parts per million of fluoride in our water?" And if you want to really be sticler on this, then you can have your water tested and find out what the parts per million content of the fluoride is and again you don't necessarily want to trust that it's the right amount because some communities don't put fluoride in the water, some add it and that makes it too much, some don't add enough. So you know your best bet is probably to have it tested if you're really worried about this.


Also if you have a well, if you have well water, don't assume that there's no fluoride because you may have natural amounts of fluoride. In fact you might have an amount that's too high and again your local health department can help you out here to let you know exactly how much fluoride is in your water.
Also keep in mind if you use ready-to-feed formula or you breastfeed or you use bottled water to make the formula and that bottled water does not have fluoride in it, then your infant is getting minimal fluoride exposure so you definitely want to provide a supplement in that case.


OK. So how much supplement do you need? Again it depends on the water's fluoride content that your child is otherwise exposed to and it also depends on your child's age. Now rather than give you a bunch of numbers, I'm going to put a link in the show notes to a nice chart that's from the American Dental Association and if you know your child's age and you know how much fluoride is in the water that they get, you know if you have fluoride in your water but you're using ready-to-feed, it don't really matter because your baby's not drinking the water that comes out of your tap. So you want to know your child's age and how much fluoride is in the water that they drink or the water that you use to make up their formula and knowing those two things, you can determine exactly how much fluoride supplement is recommended.

So we'll have a link in the show notes to that for you. And for those of you with a deeper interest in the topic, I'll also put a link to the text of the full policy statement on fluoride supplementation from the American Academy of Pediatrics Committee on Nutrition. So there will be a link to that as well in the show notes and it is the most up to date version of that policy statement.


So summing things up and answering John's questions here, I think fluoride supplementation is a good thing. There are many, many studies that have shown that it works and it's safe if the right quantity is given and to know how much to give, you have to take into account your child's age and how much fluoride they are otherwise exposed to in their formula or drinking water. Not all cities add fluoride and not all cities add the right amount of fluoride, so you want to find out how much in parts per million your water has and the best way to know that is to have it tested, and if you use un-fluorinated bottled water or ready-to-feed or breastfeed, then the answer is zero amounts of fluoride

Then with this information in hand, go to the show notes, look for the link to the fluoride supplementation chart and see if your doctor's recommendations are the correct ones.

So thanks for your question, John. Hope that helps and we'll move on right now to our next question.


Laura in Grand Rapids Michigan says, "Hello, Dr. Mike. I'm wondering if you can address the recommendations for the flu shot again. Now that the flu and cold season is upon us, I have heard there are new recommendations that all children get vaccinated not just those under five. I hear so much misinformation being spread about the flu shot causing the flu vaccines not being safe etcetera. Many people seem to think the flu is no big deal. Can you help remind everyone that the flu is dangerous for young children and the elderly and even if you get through the flu just fine, you may pass it on to someone who is vulnerable. Also I heard a new story on Good Morning America this morning that New Jersey has made it mandatory for all children to get a flu shot in order to attend school, other States are also considering of passing similar laws. Do you think this is a good idea or should it be up to parents to decide? Love the show. Thanks."


And also Elaine in Rocky Mountain North Carolina said, "Dr. Mike, love your show and look forward to more regular upcoming podcasts. I have a question about the flu shot for children and toddlers. Should all children get a flu shot? Is there an age that a flu shot isn't recommended? As a working mother with two children under age five I have had the flu shot every year. However, my five year old is old enough now that just saying the word shot gets a fight. When is the FluMist recommended and is it effective? I hate to force a painful shot that isn't necessary but I also hate to see them sick unnecessarily. Thanks for your info in advance."


OK. So what are the current flu shot recommendations? Well they're easy this year.

All children ages six months to 18 years should receive a flu vaccine.

Children who are six months to eight years of age should receive two vaccines. Their first year ever getting a flu shot and if they only received one vaccine the previous year when they should have had two, maybe because you didn't go back and get them their second one or the supply ran out, that sort of thing; so if they should have gotten two vaccines last year because last year because last year was their first year getting the flu shot, then they should get two this year.

And these two doses should be separated by four or more weeks. Any child getting their second flu shot and if they are between six months and eight years of age and they only received both of them last year, then they only need one flu shot.

So does that makes sense? I hope that makes sense to everyone.


So you need two of them the first year, if you're between six months to eight years. And if you never had two of them in one year then you do need to do that. Once you've had two of them in one year, then you only need one each year. And if you're over the age of eight, even if it's your first year, you only need one.

Now what is FluMist? That's the nasal spray form, so instead of a needle shot, it's a nose spray in the nose and that can be given to healthy persons ages two through 49. It's not recommended however for kids two through five who have asthma or other lung problems or serious, chronic illnesses that affect the airway and lungs. And kids under two should only get the shot, not the FluMist and adults over the age of 49 should only get the shot not the FluMist.

And we'll have a link in the show notes to these current recommendations so you don't have to memorize them from the podcast. You can go online Pediacast.org, we'll have the link up for you and then you'll be able to see exactly what we're talking about in terms of these recommendations.


Now do I think that you should get the flu shot? I just want to remind everyone that the flu can be deadly. And even though think, "Nah the flu's no big deal." Complications from the flu can kill you. And each year in the United States of America, more than 200,000 people are hospitalized from flu complications and 36,000 people die from the flu each year in the USA. So just because you don't know someone who's been hospitalized for the flu or died from flu complications doesn't mean it doesn't happen and it doesn't mean that it couldn't happen to you or your children. So I think it is important for everyone to get a flu shot.


Just from personal experience, there was a time in my life when I was a younger doctor that I thought, "You know the flu is not big deal. Get the flu, you have natural immunity to the flu which probably last longer and is more beneficial than artificial immunity that you get from a vaccine and so you know it's no big deal." But you know there was one year that I didn't get a flu shot and I did get the flu, missed a week of work for the flu, then I got pneumonia and I was wheezing; I don't have asthma, never had pneumonia in my life and if I weren't a doctor, I probably would have ended up in the hospital. I probably should have been in the hospital but I didn't. I treated it at home. All in all, I missed two weeks of work, had to use and Albuterol Inhaler and I've gotten a flu shot every year since that happen. So it can happen, it does happen and it's not just the people who have bad immune systems or chronic illnesses that it happens to, it happens to normal, healthy people who have good immune systems and have never been really sick all that much. You still can get the flu, get pneumonia and die from your pneumonia. It is possible. So I do think flu shots are important.


Now what's the difference between the flu shot and the FluMist?

The flu shot is a killed virus. The FluMist is a live virus. The FluMist probably gives you a better protection that last a little bit longer against more strains of the flu than the shot does.

The flu enters your body through the upper airway and so the FluMist makes a certain type of antibody that's sort of your first line defense against the flu, so you're more likely to stop the flu as it enters the body rather than once it is already incorporated into the body.

So I think ideally the FluMist at least on a theoretical level is a better product. However, it is a live virus vaccine. So if you are immunocompromised, it is possible to get the flu from the FluMist although it is extremely unlikely. It is impossible; it cannot happen that you get the flu from the flu injection because it is not a live virus that is in that immunization.


Now you can feel sick after you get the flu shot and you can get a fever after you get the flu shot but that does not mean that you have the flu. What's happening is that your body recognizes that a foreign substance has entered whether it's the injection or the FluMist and so it says, "Hey, we need to make antibodies against this," and so it gears up and it starts to make antibodies which is what we want, right? We want you to have antibodies against the flu so that then when the real flu comes along, you have the antibodies that you need to fight it off.


Along with making antibodies, certain chemicals are released into the blood because it thinks that you have the flu and that's what makes you feel sick and gives you a fever. So basically those are side effects not of the flu shot or the FluMist, those are the side effects of your body making a reaction against what we've injected so that when the real flu comes along, you are protected.

The thing with that is, when it does happen, it usually just last a couple of days. Take it from someone who's experienced this, the flu lasts lot longer than a couple of days. It usually last one to two weeks and the complications beyond that. So if you get a little fever and you feel kind of bad for a day or two after the flu shot, don't be a sissy about it and say, "Oh it made me sick." OK it's worth it. It's worth it to prevent real flu which the shot cannot give you and the FluMist is extremely unlikely to give you.


OK let's move on. Again there'll be a link in the show notes for those recommendations. But I recommend everybody gets flu shot six months of age through the end of your life that you should get flu shots every year. 'Cause it's an easy thing to prevent and they're safe.

OK. Facial tics, you know I say they're safe. Are they 100% safe, no. You know you can have issues, there's the mercury deal. Is that a big deal? Do you have to have the mercury preservative-free vaccine? Probably not a bad idea for infants. Although again it's unlikely that that really amounts to much of anything, kind of like the BPA issue but it's easy enough to get a hold of preservative-free vaccine.

Also there are some cases where your immune system can sort of way over react and you can get Guillain-Barre Syndrome, again this are all really, really rare things and the chances of you getting hit by lightning or being in a bad car accident are much greater than having those kind of side effects happen to you.


So I still think when you're looking at risk versus benefit that the flu shot for everybody age six months up to the end of your life, benefit outweighs risk.

Why not get flu shots below the age of six months?

Well it's because number one; they have mom's antibodies already kind of floating around in their system so they're semi-protected against the flu as long as mom has had it. Also you don't get as good of an immune response at that age and it's not been clearly studied to show it to be beneficial so that's why it's not recommended.

If you have a kid at home who's less than six months of age, you definitely want to get the rest of the family protected against the flu so they don't pass it along to the two month old.

OK. Now we really are going to move on.


Lynn in Muskego Wisconsin says, "I have a question about facial tics. Last February my six year old son started opening and closing his mouth like he was going to yawn while playing basketball. I thought it was odd and asked him about it, he told me he just liked doing it. he continued doing this throughout the day and everyday for about two months. During this time I went online and did some research and I contacted my son's pediatrician. I was videotaping him during his basketball game, so I showed his doctor the tape and she recommended a pediatric neurologist. I tried chiropractic care hoping that would help."


OK, so Lynn  your doctor says, "See a pediatric neurologist." You say, "Nah, let's see a chiropractor instead." Let me guess, it didn't help. Lynn, Lynn, Lynn, Lynn, Lynn. Hello, earth to Lynn. What do you think I'm going to say about this? All right let's finish the question first.

"He continued to have facial tics, nose twitching, frowning, finger stretching, neck stretching, throat clearing. I could never pinpoint a cause since he would do this not only while active he plays a lot of sports but also while just sitting and watching TV. Over the summer the tics seem to subside then just last week they started up again with the original one, the jaw stretching and throat clearing. I know he can't control it. My question for you is, what would a neurologist do and recommend? I'm afraid to put him through the stress of invasive testing if this is just something he'll eventually outgrow without intervention. Then again if I can do something that may help aside from medication, I would like to try. I looked into magnesium deficiency being a possible cause of tics, do you have any knowledge of this? I do a lot of research online. I am also pro nutritional supplements. Is there a test that can determine this deficiency? Do you have any knowledge of this type of tic and tests that can determine how, why it started and if it will be a lifelong thing or if it will be outgrown? I know I'm asking a lot, I'm just a concerned mom. Thanks for your consideration and time, Lynn."


You know Lynn, it's fine to do research online as long as you're looking in the right places. I mean there's a huge validity gap in the places where you can look online. And a lot of the things, questions that I get on PediaCast, I'll be honest with you, I sort of double check myself. I want to give you good knowledge and as a pediatrician I have lots and lots of knowledge base, but on a show like this, I want to make sure that you're getting the up to date current things and so I do a lot of online research too. Double checking myself, seeing what the latest recommendations are; which then keeps me up to date as a doctor and as another reason that the show is a benefit to me personally.


But I guess the advantage that I have is knowing where to look. And so when you do a Google search for tics and magnesium, you're going to get a lot sites that suggest they're related but their anecdotal relationships, it's parents who say, "Oh there was this issue, we tried some magnesium, it seemed to get better." Not really well done scientific trials, recommendations from the people in-the-know on these things. And the problem with just trying something or believing someone who tried it and it worked is that things extinguish and it doesn't mean there's a cause and effect relationship between what they gave or did and the resolution of the problem. You know a virus gets better in about 10 days, right?


If you take an antibiotic because it's not going away after day 7 and three days later you're feeling better, does that mean the antibiotic worked? No, 'cause if you hadn't taken it, three days later you would have started to get better. Tics come and go. So you give a kid magnesium, you tell them, "Hey this is going to make it go away," and it goes away. Does that mean the magnesium worked? Not necessarily, so you got to be careful with this sort of thing.


So let's talk about tics. First what are they?

Tics are stereotypic, voluntary movements of muscles. Now what does that mean? Stereotypic means they follow a pattern and that pattern can be simple or they can be complex but they basically involve the same muscle groups over and over again. And voluntary where as the person makes the motion happen. So you say your child doesn't have any control over it, that's really not true. They do have control over it and they're making this tic happen. It's not an involuntary motion like you would see with the seizure.


From the perspective of the person having a tic, basically they feel this overwhelming need to make that stereotypic movement or sound, tension and stress build up and this tension and stress is relieved when they make the motion or make the sound but then the tension and stress start to build up again.

The underlying issue here is in the brain and it comes down to a complex interaction of electrical impulse pathways and chemical neurotransmitter. So there's a behavioral component and there is a chemical component to this. We know that tics appear worse during times of stress and anxiety and they help relieve tension, so that makes sense.

And they also tend to be seen more during times of maximum concentration; so during sports when you're playing games, during school, you're doing work. And they tend to come and go over time.


We also know that they get worst with some types of ADHD medication which again suggest a chemical component involving neurotransmitters in the brain.

Unfortunately as much as you want the issue to be something simple like a magnesium deficiency, that's extremely unlikely to be the case, and why? Well magnesium works at the level of the muscle and not so much at the level of the brain. And since magnesium is equally distributed throughout the body, you would expect that any kind of muscle twitches due to low magnesium would be in muscle groups everywhere, not just the face.

Also those kind of twitches are going to be involuntary; so they happen randomly, really have no control over this. They are not complex stereotypic behaviors of the same muscle groups over and over again, they're just simple twitches.


And also you can do an easy blood test to find low magnesium. Supplement the magnesium, if the magnesium level in the blood comes up and the problem goes away and stays away, then you could say, "Well maybe it was from a low magnesium level." If you just give magnesium and it goes away, you don't know that for sure 'cause you don't know if they have low magnesium to begin with.

And it could be you check the magnesium level, give them magnesium, the body says, "Hey, this is too much magnesium. I already got enough," gets rid of the extra magnesium from the urine and so you're giving magnesium but the magnesium level stays the same and the problem goes away, then it's probably not the magnesium that cause the issue to resolve.


So you mean, you can look for low magnesium and the magnesium level in the blood is an easy thing to look to see if it's low, I doubt that's your problem, Lynn. I know you want it to be the problem but it's unlikely. And you got to look at the truth here. So I don't think that's going to work for you.

So what work, what will work?

Well often, simply ignoring the tic will help it to go away. The more you talk about it, the more you draw attention to it, the more stress and anxiety build up around it and the more likely it is for the person to go ahead and do the tic to relieve the stress that you are causing by talking about it. So a lot of times, you just want to ignore it and eventually it'll go away.


Now of course that only goes so far, I mean sometimes you do have to intervene and when is that?

The criteria that I personally use in my practice is if the tic is interfering with the quality of your child's life; kids are making of them, teachers and adults are constantly bringing it up, they're having poor school performance, poor athletic performance, they seem depressed; then I think it's a tic that needs to be dealt with. If the tic is not interfering with the quality of your child's life; no one's really mentioning it, they're doing fine in school, athletic performance is fine; then probably that's a tic you just want to leave alone.

And my own kids both of them in the course of their lives and I have an 11 and 14 year old, both of them in the course of their lives have had tics that have come and gone; sniffling, making a little clicking noise here and there and it goes away. It's there for a few weeks and then it goes away.


And you know as a parent, "Stop that. What are you doing? Stop making that noise." But we find then they don't stop and when you start not bringing attention to it, most often extinguishes on its own.

So let's say that the tic is interfering with the quality of their life, what can you do?

A good thing to start with is just to try some relaxation techniques so that when they are having the stress, when they feel like making the movement, feel like making the noise, then you do some biofeedback sort of thing. You imagine some sequences or some thoughts to relieve the stress. You know instead of making the noise, imagine a blue balloon and gradually the blue balloon turns red and it pops and when it pops your anxiety and stress are going to go away.

I mean you can try something like that, but honestly that seldom works and it's very, very difficult to achieve with young kids. But you know you can try some relaxation techniques, biofeedback, try to deal with the stress and anxiety without making the noise or with making the noise in your mind.


And always make an appointment to see a psychologist or a counselor to deal with it in that sort of way, if you don't feel comfortable doing it yourself. But honestly, that's probably not going to work very well.

So, what is going to work?

Well honestly Lynn, we're left with medication. And I have to snicker a little bit about your resistance to medication, Lynn.

What is a medicine?

It's a bioactive substance, you put it in the body and it acts at the cellular level and causes something to happen. If nutritional supplements that you are in to and that you promote, if they make something happen in the body, then they're bioactive; they are in fact a medication. Nutritional supplements are medication. Otherwise, they would just be digested and not make something happen.


The only real difference is that approved medications, what you would call a medication rather than a supplement, they're designed by really smart people, they are tested like crazy to make sure that they are generally safe and do what the manufacturer says it's going to do and every known or likely side effect is clearly marked for you and your doctor to read, and these substances are regulated by the government to make sure all these testing is done and the education really does happen.

Now, do they sometimes miss some possible side effects? Sure and last week we talked about Motrin and Stevens–Johnson Syndrome and how rare that is. But again when you're talking a one in a million chance, I wouldn't call that a known or likely side effect because it could still be coincidence and it just is not something, I mean you could take too much salt and if you're one in a million people who can't handle sodium regulation in the body, then you could have an increased amount of sodium that can cause a seizure. I mean there's weird things that can happen on an individual person to person basis with anything that we do including normal things that you just think about as being food.


I mean you know, some people die from eating a peanut, right? 'Cause they have an allergic reaction to it. So, I mean not everything is 100% safe. But at least with approved medications, it's been tested, it's been shown to do what it's supposed to do and if it doesn't or it becomes unsafe because things are happening with irregularity, they pull it off the market.

And again, I compared that sort of system to nutritional supplements which may still be bioactive, but they're made by Bob in his garage and they're sold in a bottle and you know the only information on the label is untested claims. And in fact you'll be surprised, take a nutritional supplement and look at the address of the company that makes it, and then do like a Google Map search, a lot of these places literally, they're people's homes. I mean these things are made and packaged in someone's garage. I'm not kidding you. I mean check that out sometime.


Look and see on the label of a nutritional supplement, Google the address and just see where it is. I think you'll be surprised. I've done it several times and I always have to snicker. There's one I'm not going to mention, I don't want any trouble. But there was one that I looked at that I found at Whole Foods, that was Flaxseed or something and I Googled the address to see where they were located and the company is in a house in a very, very expensive multimillion dollar house in a country club community in Central Florida.

I mean, "Yeah this guy wants you to buy his nutritional supplement, man." Is he using it? I don't know, I doubt it. OK, I digress. So I wouldn't be resistant to medicine or I wouldn't be as resistant to medicine as you are Lynn, especially if my son or daughter's quality of life was truly being compromised by the tics and behavioral and biofeedback-type strategies weren't working. But that's me and I guess to me it makes sense that if a problem is chemical, even though it's in the brain, you still have to treat it as a chemical problem.


You know, you have high blood pressure; you have no problem treating it with anti-hypertensive medication, you have diabetes; you have no problem with insulin, you have hypothyroidism; you take Synthroid. Why is it so different when the chemical issues in the brain, because it's the brain you think we have self control over it? But that's not necessarily true and I just don't agree with that. I don't get that.


So what would I do here?

Again if the tics aren't compromising quality of life, I would ignore them and likely they'll go away. If they are interfering with quality of life, I would treat them. You know might try some relaxation, biofeedback, stress control techniques first. And when that doesn't work, notice I said 'when' not 'if', then I would try medication.

By the way, if your doctor thinks the tics are exacerbated by a medication like an ADHD medicine, you might want to try different one like Strattera for instance. The classic CNS stimulants like Ritalin, Concerta, Adderall; they can make tics worst and again this does suggest the chemical nature to the problem to begin with.


So if they weren't on anything, if they weren't on any of those medicines, then that's not an issue. But if they were on an ADHD medicine, you might want to stop that and see if the tics go away.

So beyond that, I think medicine is useful. And if the medicine significantly improves the quality of a person's life by making the tics go away, the I think they are worthwhile. As long as that medication whichever one we're talking about has a good safety profile and few side effects and risks. And a good one that I've had luck within my own practice is a medicine called Clonidine, so that's something you can ask your doctor about.


But you know that's me, and it's something that as a parent you need to decide for yourself. Me, I would give it a try then again I'm a doctor, I prescribe medication, I see lots of people on this kind of medications whose life is drastically improved without side effects.

So even though in the literature you say, "Oh well Clonidine can cause low blood pressure." In the reality of my life as a doctor in prescribing it, I see good outcomes all the time, poor outcomes extremely rarely. So you got to cut me some slack here 'cause I'm coming at it from a little bit of a different perspective. And Lynn, I'll cut you a little bit of slack 'cause I understand you're coming at it from a different perspective.


Although I will still criticize you Lynn for going to a chiropractor when your doctor advised a neurologist. Why are you even going to this doctor? I mean I don't get that. You go see a doctor to get advice and if you don't take the advice of your doctor, then maybe you need to find a different doctor whose advice you trust. And I even see people who a doctor will tell them one thing, they don't like what the doctor said so they go to a second doctor and independently not knowing what the first doctor suggested, they suggest the same thing. Well then they go to a third doctor who suggests the same thing. So they've got three doctors suggesting something and you still don't want to do it. Why in the world did you even go to a doctor in the first place? I just, I don't get that.


OK let's move on. I'm not sure why you're scared of the neurologist. And I'm not even sure, Lynn what invasive test that you're talking about. They might do an MRI to make sure that there are no structural brain issues that could be causing these movements that are contributing to the problem, but I wouldn't call an MRI invasive. They might do an EEG where they hook electrodes up to the scalp to look at brain waves and see if there might be a seizure type issue, not like a grand mal you know you pass out and everything shaking kind of seizure; but there are temporal lobe seizures, complex partial seizures that can cause involuntary movements that are the same movements over and over, kind of like a tic would be. Again it's much more common, much more likely to be a tic but there are some seizure disorders that could present that way. It is possible, but an EEg would be a good thing to rule that out.


Again, electrodes that are glued with adhesive to the scalp, not permanently glued, not talking super glue, but you know they're stuck to the scalp. Is that invasive? I don't think so.

They might want to check some blood work. OK, now a needle is involved, but come on a needle; it's minimally invasive. If you don't want to go see a neurologist 'cause you're afraid they'll get blood work, that's just crazy. You got to teach your kids to live their life. There're some unpleasant aspects to that, you know like the lady in the previous question who didn't want to give her kid a shot, so the kids freaked out because they're going to get a shot. Look, it's life. Paying taxes freaks me out, there's things that are going to freak you out, you got to deal with it. And as parents we don't want to see our kids harmed, we don't want to see them uncomfortable, but dock on it, they're going to be uncomfortable during their life and you got to teach them how to deal with this comfort not how to completely 100% avoid it.

OK. Again, I digress.


So, I guess I'm not understanding where this fear of invasive test come in, Lynn. I mean they're not going to stick a probe through the skull and move around inside the brain to figure this out. I mean MRI's, EEG's, some blood work; those aren't really that invasive.

So I would get the appointment, Lynn. You know I would go see the neurologist, make sure it's a pediatric neurologist; a neurologist who deals with kids who have tics. And if these tics are interfering with your son's quality of life, I think you owe him the opportunity, get them looked into and help them go away in an appropriate manner.

OK, so that's my take on it.

Let's go ahead and take one more break here and then we'll be back and wrap up the show right after this.



As always, I'd like to thank all of our sponsors today; Nationwide Children's Hospital for providing the bandwidth for our show this week.

Also all of this week's sponsors; Vlad Studio who provides the artwork for the website and the feed. We appreciate Vlad over there at Vlad Studio. Medical News Today for helping us out with the News Department.

And of course my family for letting me spend the hours and hours that takes to put the show together each week, without a lot of income [Laughs] generation from it. This show does not pay the bills, folks.


Also of course, thanks most of all to the listener's like you who take time out of your busy schedules to listen to our program.

The Pediascrbe blog, I do have to give my family some shout outs here for putting these blogs together and so in order to help you see that it's there, helps drive their readership up and then they want to keep doing it because of the comments and the community, as that form around the blogs.

My wife's blog is called Pediascribe which goes along with the PediaCast and she calls a recent blog post. I still can't incorporate it all which talks about setting up shop and adjusting to life in a new city.


Speaking of adjusting to life in a new city, we're in a rental home; we've owned two different homes over the past 13 years. So this is the first time in 13 years that we've been in a rental. Let me tell you, everything – well I shouldn't say everything, things that can go wrong, they go wrong and it's easier when you own the house, you can just call someone get it fixed. Then when you got to go through a real estate management company who then has to go to the landlord and get permission to tell this person and everything just takes a lot longer and it's extremely frustrating, but we're building a new house. This is only a six month thing; I know these things will pass. But in the course of this show, I actually have to interrupt the recording of it at one point because the bottom of our refrigerator had a stream of water pouring out of it and it had to be dealt with. So you got to love the rental situation.


Anyway, I still can't incorporate it all. Check that out, Pediascribe blog, Pediascribe.com. You can also find the link in the show notes at Pediacast.org.

Also Lovely, we might be missing the fall leaves back in Ohio, but check out these blooms, pictures of some plant material here in Central Florida at late october. So Lovely is another blog post. And again both those links are in the show notes at Pediacast.org.

My 14 year old daughter's blog, Bagga Chips as in all that in a 'Bagga Chips', Baggachips.com. This is a funny story about a waitress in a Charlotte North Carolina pizza shop, it's called, She Dyes Her hair Brown. So you want to check that out.


Also don't forget the PediaCast shop is open for your shopping pleasure. We have t-shirts with the PediaCast logo, also we have duffle bags, totes; those sorts of things. So please check that out and support the show.

We do not make any money off the t-shirts and bags in the PediaCast shop, but it does help spread the word by using those items out and about.

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So here we are back with weekly shows, I'm excited about it. I really am and this is great. So I appreciate all of you again taking the time and until next week, this is Dr. Mike saying, "Stay safe, stay healthy, and stay involved with your kids." So long everybody.


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